Provider Perspectives on Screening for Social Determinants of Health in Pediatric Settings: A Qualitative Study

Abstract

Pediatric settings often screen children and/or caregivers for social needs associated with social determinants of health (SDH). Although SDH awareness rose with COVID-19, questions remain regarding best practices for SDH screening in pediatric settings. We assessed pediatric providers’ perspectives on integrating SDH screening into patient care. Semi-structured interviews were conducted with pediatric providers (n=13) from 10 clinics. Interviews were transcribed and themes analyzed using the constant comparative method. Themes highlighted providers’ awareness of structural limitations to address social needs identified by SDH screening; implementation concerns; unique role of pediatric providers for child and family health and well-being; provider comfort with assessing patients’ social needs; patient considerations; importance of relational health between pediatric providers and families, and between providers and community supports for effective screening; and unintended consequences. Pediatric providers endorse the need for SDH screening, but barriers to doing so in pediatric settings may hamper the process and reduce efficacy.

Introduction

Negative effects of childhood adversity and social need, some related to growing up in conditions of poverty, can extend to a variety of lifelong health and well-being outcomes, including poor mental health, sleep disturbances, violence and trauma exposure, obesity, and poor nutrition.^1,2 In response, child-serving settings across the United States have increasingly started screening children or their caregivers for social determinants of health (SDH).^3–7 SDH are the conditions in the environments in which people are born, live, learn, work, play, and worship that affect a wide range of health, functioning, and quality-of-life outcomes.⁸ Examples of SDH include life circumstances such as access to safe and stable housing, job opportunities, and transportation options. Although extensive research links various SDH to poorer health outcomes along numerous dimensions,^1,2 much remains unknown regarding the best practices for SDH screening in health care settings—particularly from the perspectives of pediatric health care providers. To best meet the needs of underserved children and families who have social needs related to SDH, it is essential to determine how SDH works in practice and to not only identify barriers, but also opportunities to optimize SDH screening practices.

Various models exist for pediatric SDH screening and referral systems, including some which have been the subject of rigorous evaluation and have documented success in linking parents to needed resources.^4,5 Less is known about how well-intentioned SDH screening and referral systems translate to real-world settings and across a variety of different types of pediatric practices.^7,9 Recent qualitative work examining providers’ perspectives on SDH screening in the context of a clinical efficacy trial [WE CARE] suggested that understanding providers’ perspectives on SDH screening will be critical for buy-in and tailoring processes as needed for different sites.^10–12 Prior research has found that most medical providers support screening families for social needs in theory,^13,14 but less research has been published on the insights from pediatric providers who are implementing social needs screening in practice across different clinical settings that may vary in population served, provider experience, and available resources in the practice and surrounding community.

As the vast majority of SDH screening has occurred within pediatric clinics,⁶ pediatricians and pediatric nurse-practitioners can contribute valuable perspectives regarding real-world application of SDH screening with families. Identifying barriers or concerns raised by such providers is important in order to make SDH screening effective and sustainable across various pediatric settings, outside of rigorous screening efficacy trials. In the present project, we interviewed pediatric providers to evaluate if and how they integrate knowledge of patients’ SDH into practice, and to gather information on their perspectives regarding the benefits, barriers, and unintended consequences of asking parents and guardians in a pediatric setting about these non-medical conditions that influence health.

Methods

Participants and Recruitment

Participants were pediatricians and nurse-practitioners recruited from different pediatric clinics. Participants were initially a convenience sample recruited from a Midwest healthcare system. We used snowball sampling to contact additional participants. Inclusion criteria were that participants were pediatric providers in clinic settings. Participants completed informed consent processes and were compensated for their time. In total, we recruited practitioners from 10 different clinics, across 9 independent health systems. The study was approved by the University Institutional Review Board (HUM00174067).

Procedure

Semi-structured Interview.

The interview guide was developed by the authors with expertise in pediatrics, public health, and developmental psychology and was designed to capture pediatric providers’ views on SDH screening in practice and understanding of processes regarding screening for SDH in their clinic settings, including workflow, benefits, barriers, and unintended consequences. Specific tools used for SDH screening were not assessed. Providers were also asked to provide information regarding demographics, subspecialty training, and any specialized training in SDH. The interview guide included both open-ended questions and probes, for example, “What do you think should happen after a pediatric clinic screens a patient for social determinants of health?” Probe: “What recommendations, if any, do you have for clinics after they screen their patients for SDH?”

Data Collection.

Interviews were conducted in two waves between February and July of 2020 (during the onset of the COVID-19 pandemic; questions were added to reflect COVID-19 considerations, for example whether SDH screening practices had changed with the onset of the pandemic). A trained undergraduate or master’s student conducted interviews following the interview guide either in-person or by phone or video. Interviews lasted between 13 and 30 minutes. Interviews were audio-recorded and later transcribed and double-checked by a third-party.

Analysis

Transcripts were analyzed using the constant comparative method.^15,16 Five readers, two of whom had conducted the interviews, reviewed the transcripts and independently generated themes. All readers were first instructed to identify themes from the same corpus of transcripts, attending to nuances, and to repeatedly evaluate whether new themes emerged in each subsequent interview (i.e., until saturation). Readers highlighted quotes from each interview transcript to illustrate each theme. After completing this independent process, readers met to compare themes. Themes were presented sequentially by each reader. The group then discussed how best to classify and combine themes, and reviewed the identified quotes. Themes were member-checked with a pediatric provider.¹⁷

Results

Thirteen interviews were conducted. Participants (Table 1) were 10 MD-trained pediatricians, 3 of whom had subspecialty training (developmental-behavioral pediatrics, child abuse), and 3 Nurse-Practitioners. Participants were drawn from 10 different clinic settings, ranging from large hospital systems to smaller private practices representing 9 health systems, in the Midwest and in California.

Table 1 -.

Participant Characteristics (n = 13)

Participant Characteristics	n (%) or mean (SD, range)
Female	9 (69.2%)
Age	45.55 years (12.37, 29-67)
Race
Asian	3 (23.1%)
White	7 (53.8%)
Unknown or prefer not to say	3 (23.1%)
Ethnicity
Hispanic or Latino	1 (7.7%)
Not Hispanic or Latino	9 (69.2%)
Unknown or prefer not to say	3 (23.1%)
Degree
Doctor of Medicine (MD or MD/PhD)	10 (76.9%)
Pediatric Nurse Practitioner (PNP) or Registered Nurse (RN)	3 (23.1%)
Speciality
Pediatrics	13 (100%)
Subspecialty
Yes	3 (23.1%)
No	8 (61.5%)
Unknown	2 (15.4%)

Seven major themes were identified (Table 2): 1) structural challenges in addressing identified social needs; 2) considerations for SDH screening implementation; 3) the unique role of pediatric providers in the relationship between child, family, health, and well-being; 4) provider comfort with assessing patients’ social needs; 5) patient considerations for SDH screening; 6) the importance of relational health for effective screening; and 7) unintended consequences of SDH screening.

Table 2.

Themes and sample quotes derived from pediatric provider interviews

Theme Description	Sample Quotes
1) Structural Challenges included limited ability to follow up on identified social needs due to multiple and interconnected needs but fragmented systems; insurance barriers; setting and resource constraints; and COVID-19 impacts.	“If a clinic that wasn’t well connected to a good social work support team or other resources like that, I would be hesitant to have them implement a social determinants of health screening. Because… what are you gonna do with that information?” “Are they [Social Workers] actually able to keep up with those referrals? Are they actually able to provide resources that are valuable and important to families? Because I think it’s really important that you don’t screen for something if you don’t have a way to provide some good counseling or good support around it.” “We created our own food pantry on site because we were like, ‘This is becoming a chronic problem and patients and families can’t go other places to get food so why don’t we like build that here.’ So I would love to…see more capacity built in those areas so that we could address more of the needs here on site, while patients are here.” “There are some situations where screening and offering resources can’t really make things better. Like if you have unstable housing, you know, there’s some resources out there that help people with housing but it’s not something that happens in a week or a month, um, so that ultimately is just a difficult situation ‘cause we have a lot of families who just lack a lot of resources… it’s a little bit distressing to kind of feel like you can identify needs that you can’t really, um, adequately address… and that’s the reason we didn’t screen for a little while cause we’re all like what are we going to do about it.” “At this point I understand it, at least in my practice: every single one of my families is experiencing a trauma right now. Every single one of my families that may have been at risk for social determinants of health prior to COVID are now fully, fully saturated with those.”
2) Implementation Considerations included the need for efficient workflow and established protocols to minimize time constraints; value of screening all patients; strategies to reduce barriers to follow-up and ensure connection to services; need to identify optimal screening frequency and rationale, and to communicate expectations for screening to patients.	“We’re busy clinicians and have fifteen minutes to take care of something in a visit. But, I think if you’re not reminded that these are all important factors, then it would be easy to forget. I also think external appearance is really deceiving and so you can’t really just screen based on what someone looks like or what zip code they live in or where you think they’re coming from. So it’s sort of like an equalizer that it’s given to all patients. “ “In that setting, to be able to meet with the patient, offer resources at that moment…when you have sort of proximity from when they filled out the survey and you actually have them there I think is the ideal time.” “I think having that kind of warm hand-off every time would be ideal… Rather than trying to communicate with somebody over the phone… even a day later, or a couple weeks later.” “There needs to be some psychoeducation to the families around why you were asking these questions [which] unfortunately, traditionally [has] not been part of the medical visit. Um, and so having, whoever the most trusting relationship is between that patient and that practice, whether it’s the provider, or the medical assistant, the nurse, the front desk, I would recommend like that be the person who can communicate that out.” “I really appreciate and understand that these are factors that can change with a lot of frequency, but I also hear a lot from patients and families…especially on pediatrics we have a lot of forms and questionnaires that we ask them to fill out…. Some of them are…really crucial and important for like what’s going on with the child’s development -they need a physical form for school - and so…I wonder if like especially in that first year of life if the frequency could be decreased a little bit, maybe just like two times or something like that. And then I think annually at the health supervision visit seems appropriate because there’s so much that could change in that time-frame.”
3) Unique Role of Pediatric Providers included appreciation for the impact of SDH on child health; connection with parents and knowledge of family context; long-term, influential relationships with families and communities; and ability to reach children early in development.	“I have a bias because I am a pediatrician and my patients don’t get to determine their social determinants. It’s more up to the parents so I think it’s completely appropriate to screen for those things.” “The social determinants that would affect their medication adherence or their ability to make appointments, nutrition, lifestyle factors, things like that. So, I guess I’m someone who takes it for granted and believes it’s just so intertwined with peoples’ health outcomes. And also, being a clinician who focuses on behavior and child development and family relationships…we have to ask about all those things, cause otherwise we may be giving guidance that’s really hard for families to follow.” “I wouldn’t say I was trained in this but certainly we’ve learned that pediatricians tend to be the catch-all for a lot of starting points. It’s for mental health, it’s for…education. It’s for a variety of things ‘cause we have a relationship with our patients and families and they come to us and ask…. I feel like a lot of what I do is triage and…then seek out resources.” “One of the nice things about being a pediatrician is that you get to follow a kid as they grow and…I enjoy it…. Summer months, for example, my older kids are coming back and we could talk about their school and their sports and their college plans and all different sorts of things.”
4) Provider Comfort with assessing social needs included provider training in SDHs; emotional readiness to discuss challenging and relevant topics; and sense of efficacy in perceived role.	“Fear of having to report is a big barrier…fear of not having sufficient or like sufficiently robust resources on site is a big barrier.” “I think that the area that’s probably the least comfortable to me is like intimate partner violence or domestic violence…. I think a lot of that is because, as a pediatrician, I am really focused on the child and so not necessarily always thinking about that.” “I feel less comfortable with racism induced stress… that’s something I often would, if a parent brings it up…I want to hear what they think about their experience…. I don’t want to seem like I made assumptions about what they may have experienced, being black, or being an immigrant, or other experiences like that.” “There are social determinants of health that I know are affecting my patients and families that I have no control over and that feels really crappy.” “I think it’s more that just when we’re not able to connect all the dots, and get resources in place for families, that’s where we continue to struggle.”
5) Patient Considerations included linguistic and cultural barriers; fears and concerns about confidentiality; stigma and shame; comfort and trust in sharing personal information; negative experiences with social services in the past; and beliefs that SDHs aren’t relevant in a healthcare setting.	“That feeling of like we’re prying into their lives. I also think that like patients… often feel like they’re being targeted to do social determinants of health screening because of where they live…. They’ve been like targeted many times for things like this and so…you don’t know, because you’re a patient here, that like everyone across the health system is getting the same screener.” “I’ve had some families who have had negative experiences with social workers in the past and have likened social work involvement with CPS involvement, and so that might raise worries for families to be honest. And I think that some families…perceive or have had experiences with clinicians trying to connect them to outside services that have been negative.” “I can understand if patients are less trustful of their PCP. There’s cultural barriers in the sense of the healthcare system’s not [being] universally trusted.” “I think a lot of people in general are like, ‘Why are you asking me these questions?…this is not relevant to why I’m here today.’” “Our patients get so much paperwork when they come to these visits and so I think they’re getting this paper screening amongst a lot of other paper forms…. Some of them are not really…paying attention to it or…often it’s empty, it’s not filled out. Or parents, people, may feel like I’m supposed to write, “No, no, no, no, no,” for everything. So they don’t actually fill it out correctly.”
6) Relational Health concerned the importance of parent-provider trust in order for SDH screening to be effective, and what can undermine that trust. The relational health between the pediatric provider and community resources was also seen as important in order to structure follow up recommendations for families.	“You have to engender a trust situation in the parents [that] …gives you license to express your concerns… ‘How is this going, you know, are there other ways that you think we can do this’. And, that’s the art of the pediatrician. If you don’t build relationships, you got no ground to be able to pursue things that you think need some work and some change.” “The means by which you do it has to be done in an incredibly respectful way so that, uh, the folks who are, who are struggling aren’t seen as being alienated or discriminated against because of the situations that they’re in and I-so I think there are some real challenges on how to do that in a respectful way.” “A lot of these services make…parents feel — um, they themselves can be demoralizing. If you’re like, here I am getting handed around to all these service providers, that aren’t really connecting with me on a human level.” “There are… some trust issues? […] I think there still may be some stigma… in some populations…. There are patients who will screen positive or may answer that they don’t have needs when you kind of know they have needs and don’t want to be contacted because they have mistrust of institutions…you know because they’ve had run-ins with CPS or different agencies in the past. And so, I think we do have some patients, some families, who are not really either not answering honestly or don’t’—are hesitant to be, you know, open [to] that line of true communication.” “Working with them to make the call with them, or for them, or warm hand off, or knowing a person like specifically at that outside organization and having that connection with them so that you could um, prepare both the family and that other organization to really connect properly. Um, so that goes back to relationships. So, not just a list but relationships across organizations, um to really facilitate those kind of connections.”
7) Unintended Consequences of SDH screening included families becoming overwhelmed or frustrated; provider worries about damaging extant relationships with families or missing other medical concerns; and about insufficient resources for post-screening follow-up.	“Let’s say you live in a city where there are no social services, and there is um nothing at your disposal to do to like help the family with like this particular social problem. IS it ethical to them to like raise up that conversation, if there’s nothing that can be done about it?” “I think that sometimes we have families that get frustrated because they, you know, there are limits to what we can do, and then they think they realize there are limits to what we can do and so they kind of, you know, get—become a little skeptical, lose faith in the ability of what we can do for them.” “Some people are either ashamed or shy or…, um, not sure that…coming out publicly with that information is [okay], particularly in our practice. We have a lot of undocumented families so I think there’s fear that goes along with it but there’s also shame…. To say you don’t have enough food for your kids or to say you don’t have transportation…for a lot of people, it is a tough thing to say so I think it definitely people either appreciate it or…maybe it makes them feel worse.” “The consumption of people’s time, particularly when, you know, a good share of your practice are probably not having any of the major social determinants of health issues…. I think there’s hills to climb.” “There’s a bit of a balancing act in a sense…pediatricians have to, you know, leave some time for ourselves to do the things that we were trained to do in medical school…. If we transfer our emphasis too much to those social concerns… because everybody only got so much time and energy to deal with stuff, it can cut into, you know, the other things we’re supposed to be doing, like not missing a leukemia diagnosis or something like that. “

Structural Challenges.

Although all providers noted the importance of SDH screening, structural challenges in addressing identified social needs emerged as a central theme. Providers noted that for screening to be effective, supportive resources must be available and accessible in the community to meet identified family needs. Yet, not all practice settings were adequately set up to provide connections to such resources, and/or the resources did not exist: “we need more social workers… in more settings.” Participants also described the interconnected nature of structural challenges, with one participant stating that “housing insecurity or green space in their neighborhood, or access to healthy foods, that’s all intertwined” and another that the COVID-19 pandemic “has amplified what we see” (e.g., food insecurity magnifying at-home learning challenges). Participants also reflected on structural barriers associated with family insurance status, with one provider noting, “a big barrier is which health plan they have” and “certain insurances we can help more than others.”

Implementation Considerations.

Another theme concerned processes in implementing screening. Most providers acknowledged time-management barriers, and many noted the benefits of having systematic screening incorporated in their workflow (e.g., electronic medical record checkbox). Providers reflected on the value of screening all patients as opposed to on a case-by-case basis from an equity perspective; “screening has helped… pick up patients that don’t feel comfortable advocating for themselves…verbally.” Providers appreciated being able to act on concerns as they arose when processes were in place to connect immediately with social workers or other resources such as educational handouts or contact information for community-based assistance to provide a warm hand-off for families. Although there was no consensus on specifics, providers also emphasized the need to establish explicit processes for SDH screening frequency and rationale so that expectations were transparent to families.

Unique Role of Pediatric Healthcare Providers.

Pediatric providers identified their unique position to address SDH during key developmental windows that allow for prevention of long-term health impacts. Providers shared multiple examples of how SDHs like unstable housing, lack of access to educational supports, and family factors shaped children’s lives and health, with one participant noting, “I don’t think all providers are aware… of the importance of social determinants of health on the children.” Providers also remarked on how pediatric visit timing (e.g., frequent well-child checks during the first year of life), length of their relationships with patients, and connection with families were factors that provided a unique context for SDH screening. One provider summarized this unique role as, “pediatricians tend to be the catch-all for a lot of starting points. It’s for mental health, it’s for…education. It’s for a variety of things because we have a relationship with our patients and families and they come to us and ask.”

Provider Comfort.

Provider comfort with SDH screening also emerged as a theme among interviews. This included whether the provider had training in discussing non-medical needs with patients, providers’ readiness to engage in such discussions, and providers’ sense of self-efficacy regarding their ability to help families. Although some hesitancy was due to structural limitations regarding insurance and/or community resources to address key needs, other tentativeness was due to providers’ own comfort levels discussing social issues. For example, multiple providers endorsed feeling less comfortable discussing intimate partner violence and expressed concern about how to ask about SDH topics in a respectful, non-offensive manner.

Patient Considerations.

Providers noted various patient-related factors that were important to consider in SDH screening. Beyond the clear need to address linguistic and cultural barriers related to screening, providers mentioned the importance of reducing patient shame, stigma, and/or worries regarding confidentiality, described by one provider as “that feeling that we’re prying into their lives.” Patients may not understand why these issues are being discussed in the visit. Providers noted that patients who have had negative experiences with social services in the past may be appropriately skeptical regarding whether the SDH screening process would help. Providers themselves professed concerns regarding the level of supports that are needed to ensure that patients can follow through on recommendations to address multifaceted needs.

Relational Health.

Multiple providers discussed relational health, or having adequate trust between providers and patients to share personal information related to SDH. Providers emphasized the importance of sharing with families the reasons for screening and why screening was important for their child’s health. Providers suggested that their own direct involvement in SDH screening and structuring follow-up recommendations was important for promoting trust and encouraging parents to engage with services for their child’s care. Beyond the patient-provider level, providers also noted the importance of their own personal connections with community resources to facilitate successful referrals. In contrast, issues of cultural bias, lack of respect, and discrimination were noted as potentially undermining relational health between patient and provider.

Unintended Consequences.

Finally, providers noted the possibility that SDH screening could have negative consequences for families. Such negative repercussions of screening included families becoming overwhelmed, frustrated, or offended; damaging an existing positive relationship with the family; and missing or not having time to address other medical concerns. The inability to fully address patient needs was also mentioned, with one provider noting, “[Families] realize there are limits to what we can do” and other providers suggesting that an inability to address identified needs could lead to increased mistrust and/or negative outcomes for children and families.

Discussion

Despite well-established associations between SDH in childhood and long-term negative health outcomes^1,2 and increasingly widespread implementation of SDH screening in pediatric settings,^6,7 relatively few studies have investigated the challenges and considerations for SDH screening in practice. Studies suggest that pediatric patients^18,19 and their families^12,20 generally endorse clinic-based SDH screening and referrals. Yet, much remains unknown regarding best-practices for these systems, as fewer studies have considered pediatric provider perspectives across a range of practice settings. Understanding providers’ perspectives on SDH screening in practice is essential in order to develop effective SDH screening processes to help reach families and children in need and address the challenges of experiencing harmful adversities early in development. We examined pediatric providers’ perceptions of the process, barriers, and benefits of screening for SDH. Although we interviewed providers across a range of pediatric clinic settings from a large hospital system to small private practices, themes were generally consistent across providers. Findings yielded several new insights, including the importance of relational health between pediatric providers and families, as well as relational health between providers and community supports and access to resources, that can inform future work and next steps in SDH screening.²¹

Although providers generally endorsed the value of SDH screening, they noted that screening could not necessarily address the multifaceted needs of families. Prior work on pediatric SDH screening found that fewer pediatricians routinely screened for SDH than endorsed its importance,^13,14 yet that actions taken as a result of SDH screening can address patients’ social needs.²² Current results confirm and expand on these findings. Specifically, providers described structural challenges regarding insufficient availability of comprehensive, coordinated services to meet identified patient needs as a key limitation of screening. Consistent with prior work, providers emphasized that SDH screening should not be conducted in isolation of established processes for connection to available, effective community resources.^23,24 The COVID-19 pandemic has exacerbated family needs, illuminated the interconnected nature of such needs, and highlighted the importance of expanding non-medical services to address identified SDH.²⁵ Not all families can access such services, however; providers in the current study expressed frustration about not being able to address the complex challenges facing families, including barriers due to insurance and/or immigration status. Family eligibility for services has previously been noted as a barrier to screening.²⁴ It is thus essential for pediatric practices to anticipate how they will address issues related to interconnected structural barriers when preparing to implement SDH screening.

As in other studies of pediatric screening for social needs, providers described implementation challenges.^11,13,26 These included limited time during encounters, determining optimal screening frequency, and the varied nature of screening questions. Integration into existing processes (e.g., electronic health record) has been shown to facilitate SDH screening.^27,28 Prior work has also shown that simply receiving relevant referral information can be beneficial to families.^12,29,30 Thus, despite limited services, maintaining up-to-date information on available community resources and eligibility criteria is an administrative task that may promote screening success. Providers viewed the ability to provide on-site services and an immediate “warm handoff” to social workers as important for effective implementation, although this was not always possible for all providers in this study given varied clinic flow, access to social workers, and workload across settings. Clinics with limited access to social workers may consider remote patient navigators as a possible model.³⁰ It will be important for future work to integrate perspectives of social workers and others providing such support across varied pediatric settings, as confusion regarding roles and priorities of clinic staff has been described in clinical trials of SDH screening efficacy.¹¹ Another implementation consideration among these pediatric providers across settings concerned the frequency and timing of screening, particularly given the high number of pediatric visits during the first year of life. Establishing optimal developmental windows and clarifying the rationale and plans for timing of SDH screening in general pediatric settings (e.g., should screenings be conducted at each well-child visit? at all urgent care visits?) is important not only in order to manage workflow, but also to communicate expectations about screening to families. Given increased family needs and delays in regular well-child visits during the COVID-19 pandemic,²⁵ developing such plans across various pediatric clinic settings, particularly those that serve children and families living in poverty, is increasingly urgent.

Beyond barriers related to structural and implementation processes, findings identified key challenges in SDH screening related to provider comfort, patient considerations, and unintended consequences, each of which could have implications for pediatric clinics planning to undertake SDH screening in their unique settings. Provider comfort has previously been noted as a key driver of screening behavior.^13,14,22 To promote provider comfort with screening, it may be helpful to integrate into training programs not only the importance of SDH in child health, but also strategies for how to manage potentially difficult screening-related discussions, for example around interpersonal violence, in a respectful manner. The American Association of Pediatrics recommends that all pediatric providers be educated on SDH and continuing education around this issue.³¹ Although some work suggests parents look to their pediatricians for help with social needs³² and that many patients and families view SDH screening as appropriate,^12,19,20 there remains potential for stigma and/or skepticism among patients that screening will make a difference,¹² particularly among families from historically marginalized groups.³³ Families have noted concerns about privacy, bias, and not being treated with respect and highlight the need to ensure compassion when screening for SDH.¹² Providers in the current study also described being sensitive to these types of family concerns about screening and noted that many such concerns were valid, for example, if families had had prior negative experiences with social services. Regularly screening all families across pediatric clinic settings may be an equitable way to normalize discussion of challenging topics and reduce stigma related to SDH screening.^22,23 Provider observations about unintended consequences such as family frustration, mistrust, insufficient resources, and/or the level of effort patients would need to address recommendations based on SDH screening further reflected the structural challenges inherent in conducting this work. Providers’ perspectives centering on the importance of family-centered decision-making around addressing SDH needs also paralleled findings from prior work showing family preferences for patient-centered approaches to SDH screening.¹²

Relational health, or the existence of a trusting and supportive relationship between patient and provider, has been noted in prior work^10,23 and was confirmed in the current study as a key factor that could facilitate acceptance and overall effectiveness of SDH screening, connecting many themes. Providers noted the importance of relational health between themselves and their patients, and further described how pediatric providers can play a unique role given their often long-lasting relationships with families, need to connect with parents on behalf of children, and appreciation of how social contexts shape child development and health. Current study findings also newly highlighted how providers’ relational health with community resources could benefit families. Specifically, respondents reflected on the benefits of providers’ knowledge of available resources and direct involvement in the “warm handoff” to social services as ways to foster screening uptake and follow up. Increasing provider knowledge and comfort and collaboration with such services in the community may therefore be an important approach to facilitating these opportunities for families.^14,21,34

Implications for Health Care and Practice

SDH screening cannot directly address the root causes of SDH, but it is important in addressing the ways in which SDH manifest in children and families’ lives.^7,22 Despite pediatric provider recognition of the importance of SDH screening in pediatric clinical settings, structural issues including limited effective resources for referrals and fragmented systems unable to address the interconnected needs of patients were identified as significant barriers. Providers felt that, given their role with patients during sensitive developmental windows, and with the opportunity for frequent interactions during a child’s early life, they were in a unique position to address SDH and interrupt long-term negative health impacts. Yet, providers also cited both their discomfort with screening, such as amount and type of training needed to conduct SDH screening, and patient considerations such as fears surrounding consequences of reporting based on screening outcomes, as challenges. Fostering relational health between providers and their patients (and families)—and between providers and community resources—emerged as fundamental for mitigating potential unintended consequences of screening and promoting patient health and well-being. Pediatric practices seeking to implement new SDH screening efforts should carefully consider the timing and integration of SDH screening into extant mechanisms, solicit and clarify staff and patient understanding of and expectations for screening, and establish and clearly communicate processes for screening, referral, and follow-up.

Strengths and Limitations

We interviewed pediatric providers across a range of pediatric practices, outside of efficacy trials, in order to better understand their perceptions of SDH screening in practice. Although a strength of the study was the inclusion of perspectives across a range of clinic settings, providers were taken from a convenience sample and we were unable to assess clinic characteristics, which may limit generalizability of results. Provider characteristics were not considered in the generation of themes, although themes were consistent across providers and health systems. Themes related to patient concerns should be interpreted with caution as these are provider, rather than family, perceptions. Additionally, as interviews were conducted across 9 different health systems, ranging from larger university-affiliated systems to private practice, we do not have information on the specific SDH screening and referral processes occurring in each system or the broader social context. Future research would benefit from study designs that include assessments of perspectives from patients (both parent/guardian caregivers and older children themselves), a range of providers and staff, and measurement of contextual elements of clinic settings that may shape screening implementation processes, in order to best characterize key elements of pediatric SDH screening experiences for all stakeholders.

Conclusion

Effective SDH screening is an urgent public health priority to address the significant social and financial costs of harmful adversities early in development. Current study results highlight the intertwined nature of considerations for SDH screening, many of which relate to the structural factors that can impinge on providers’ capacities to meet the needs of the children and families they serve.

Abbreviations:

SDH

Social Determinants of Health