School‐Based Health Providers' Approaches to Social Risk Screening for Pediatric Asthma: A Qualitative Study

ABSTRACT

Background

Asthma has a high prevalence among children and is associated with negative outcomes and extreme costs. Asthma exacerbations, often preventable, have been associated with social determinants of health and social risk factors. It is unclear whether school‐based health providers consider social information for asthma, possibly related to a lack of knowledge or data availability.

Objective

Describe the information‐gathering behaviors and approaches for social risk screening for patients with asthma exacerbations performed by school‐based health center providers.

Methods

We conducted a qualitative descriptive study with a purposive sample of school‐based health center medical providers. We conducted four focus group sessions (total participants = 16 nurse practitioners) and employed thematic analysis to generate themes.

Results

We identified four major themes: (1) Information‐gathering tactics, (2) diligence, (3) challenges accessing and assessing social determinants of health information, and (4) uncertainty. Major findings include: (1) There is a variety of information‐gathering tactics used; (2) there are missed opportunities for social risk screenings in schools; (3) social risk screening is feasibly challenging; and (4) there is continued need for resources and increased awareness of screening.

Conclusion

This study highlights the lived experiences of school‐based health center providers in gathering information about social determinants of health and social risk factors. Challenges limit the ability to provide effective screening and referral to resources, particularly for school‐age children with asthma. Our findings can be used for further research and development of informatics resources to promote effective social risk screening in school‐based health centers.

Abbreviations

EHR

electronic health record

REDCap

research electronic data capture

SBHC

school‐based health center

SDoH

social determinants of health

1. Introduction

Asthma is one of the most common chronic conditions in schools, affecting more than 4.9 million children in the United States [1]. Asthma exacerbations in children are preventable and costly [2], resulting in over 270,000 emergency department visits and 27,000 hospitalizations [3] each year. There is strong evidence that asthma exacerbations are influenced by social determinants of health (SDoH), social risk factors, and individual social needs [4]. Often used interchangeably, there are slight differences between these SDoH concepts (Figure 1), leading to confusion and misunderstandings amongst healthcare providers [5].

Figure 1.

Definitions of social determinants of health, social risk factors, and social needs [5]. Often used interchangeably, there are slight differences between social determinants of health concepts, leading to confusion and misunderstandings. Clarity on these terms is needed to provide effective social risk screening and intervention [5]. [Color figure can be viewed at wileyonlinelibrary.com]

For children, asthma is often managed within a school‐based health center (SBHC), which are separate entities providing healthcare services in or near schools. Working collaboratively with the school nurse, SBHC providers are able to promote communication with primary care providers, families and schools and are readily accessible [6, 7]. Therefore, SBHCs are ideally placed to facilitate identification of SDoH, social risk factors and social needs and decrease the burden of asthma exacerbations associated with increased medical expenditures and student absenteeism.

Unfortunately, available social risk screening tools are underdeveloped or used inconsistently, or are still undergoing psychometric analysis or interoperability [8]. Screening practices vary, with providers voicing discomfort and a lack of confidence performing screenings [9, 10]. Additionally, there are misunderstandings regarding SDoH, social risk factors, and social needs, and experts continue to define terminology and interoperability of data to build consensus‐driven standards [11]. Therefore, there is a need to raise further awareness of SDoH and further develop informatics resources that may promote data sharing and improve the prevention of asthma exacerbations [5, 12].

While we know SBHCs address community concerns through comprehensive health services [13]. it is unknown what social risk screening or data is used in SBHCs [14, 15, 16, 17]. Similar to other providers [18], it is unclear whether SBHC providers consider SDoH or social risk factor information, particularly for asthma, possibly related to a lack of SDoH knowledge or data availability. Hospital systems and state agencies are increasingly combining data from heterogenous sources into preliminary SDoH dashboards; however, these informatics are often used only within large health systems, inaccessible to SBHCs [19, 20]. Feedback from SBHC providers is critical to understand if available SDoH data is being used or how it influences prioritization of social risk screening among patients with asthma, especially since SBHCs have the advantage of being connected to schools and communities.

Using a qualitative approach, we sought to understand SBHC providers' information‐gathering behaviors and approaches for social risk screening for patients with asthma exacerbations. Ultimately, knowledge gained from this study can be used to develop informatics resources that integrate SDoH and social risk factor data into asthma care guidelines to promote early, targeted screening, to identify social needs, and offer improved resources for asthma management within SBHCs.

2. Methods

2.1. Study Design and Participants

We conducted a qualitative descriptive study using focus groups, enrolling a purposive sample of SBHC medical providers (nurse practitioners) throughout the state of Connecticut. Focusing on a single state allowed for reduced heterogeneity, and improved study feasibility as the Northeast United States has higher emergency room use for asthma [2, 3]. Recruitment methods included disseminating study flyers through the Connecticut Association of School‐based Health Centers and the National Association of Pediatric Nurse Practitioners' Connecticut‐based online forum. Inclusion criteria included advanced level providers with recent SBHC work (within 2 years), and use of electronic health records (EHR). Participants were required to speak and understand English. A total of 21 participants responded, of which 16 met the inclusion criteria. The Vanderbilt University Medical Center Institutional Review Board determined the study was minimal risk to participants (45 CFR 46.104 [d] category [2]) for Exempt Review under submission number 222170.

2.2. Data Collection

Data collected was reported using consolidated criteria for reporting qualitative research (COREQ) guidelines [21]. We collected and managed study data using the Research Electronic Data Capture (REDCap) tool [22]. We collected SBHC provider demographics (age, biological sex, race/ethnicity, education, years of experience) and SBHC factors (type, population served, EHR system).

2.3. Focus Group Interviews

The semi‐structured interview guide was developed from a literature review, the primary investigator (PI)'s clinical experience, and consultation with experts and collaborators. After pilot testing with two SBHC providers and after each focus group, we reviewed the guide with small adjustments as agreed upon with the research team. Questions focused on perspectives regarding SDoH and social risk factor usefulness, information‐gathering, access to data, use of current tools, and barriers to social risk screening. We used the term “SDoH” as that was the term most consistently used at the time of development of the interview guide. We also introduced our intended next step to create an informatics resource that displays publicly available data regarding SDoH and social risk factors most important to asthma. We asked participants open‐ended questions about what they would desire in an informatics resource and how they might envision using it in practice.

We conducted focus groups with semi‐structured interviews via encrypted online teleconferencing (Zoom [23]). Each focus group session was video and audio‐recorded, transcribed, deidentified, and stored in a HIPAA‐protected cloud‐based drive with access only to the research team. Sessions lasted approximately 60 min, concluding when participants had no further responses to questions or probes. Debriefing and reflection occurred immediately with reflexivity for the moderator as an SBHC provider and the housekeeper. We stored field notes on the same protected drive, including observations, methodological notes, and theoretical concepts. Further details on qualitative methods are available in the Supporting Information Material.

2.4. Data Analysis

For our descriptive qualitative method, we applied Braun and Clarke's [24] six‐phase framework for a step‐by‐step approach to theme‐based content analysis. For understanding of the overarching context, the PI listened and read verbatim transcripts fully for accuracy, and a second member of the research team independently confirming accuracy. Next, we focused on descriptive, level 1 coding, with consideration of a limited number of a priori themes derived from relevant literature related to our research question of social risk screening and data collection methods, and established during pilot‐testing [25]. We used whiteboard software to draft a diagram of themes and computer‐assisted qualitative analysis software (Dedoose) for the codebook and audit trail [25, 26]. We critically reviewed transcripts to identify themes, and used bracketing for reflections and thinking processes, and compared themes to field notes and existing literature. Emphasizing reflexivity, we analyzed the implications of the PI's role as an SBHC provider [25] (see Supporting Information Material). After four focus groups, we reached a point of saturation where no new codes or themes were arising, and no further insights or meanings were found [27].

3. Results

3.1. Description of Participants

Of the 21 participants who completed the demographic survey, two were excluded as they were not medical providers, and three were unavailable for any focus group times (citing work or family conflicts). We conducted four focus groups with a total of 16 participants from February to April 2024. Descriptive statistics are summarized in Table 1.

Table 1.

Self‐reported demographics of participants and Connecticut school‐based health centers (N = 16).

	n (%)
Age (years)
25−34	3 (18.7)
35−44	4 (25.0)
45−54	5 (31.3)
55−64	3 (18.7)
65−74	1 (6.3)
Ethnicity
Not Hispanic or LatinX	13 (81.3)
Hispanic or LatinX	2 (12.4)
Prefer not to say	1 (6.3)
Race
White	15 (93.7)
Non‐White	0 (0.0)
Prefer not to say	1 (6.3)
Gender
Male	0 (0.0)
Female	15 (93.7)
Prefer not to say	1 (6.3)
Years experience working in healthcare
< 2 years	0 (0.0)
2−5 years	1 (6.3)
5−10 years	1 (6.3)
> 10 years	14 (87.4)
Years of experience working as school‐based nurse practitioner
< 2 years	2 (12.5)
2−5 years	8 (50.0)
5−10 years	2 (12.5)
> 10 years	4 (25.0)
Patient populationa (age group served)
< 3 years old	0 (0.0)
Preschool (3 to < 5 years old)	2 (12.5)
School age (5−11 years old)	9 (56.3)
Adolescent (12−17 years old)	16 (100)
Young adult (18−24 years old)	5 (31.3)
Type of school‐based health center
Traditional (fixed location at the school)	14 (87.4)
School‐linked (fixed site near school campus)	1 (6.3)
Mobile (van/bus parked near school)	0 (0.0)
Telehealth only	0 (0.0)
Unknown (not reported)	1 (6.3)
Year center was established
Within the last 2 years	3 (18.7)
Within the last 2−10 years	4 (25.0)
> 10 years ago	7 (43.8)
> 25 years ago	2 (12.5)
Type of organization/agencya
Health center (federally qualified or community health center)	12 (75.0)
Hospital or medical center	2 (12.5)
Local health department	1 (6.3)
Mental health agency	0 (0.0)
Non‐profit/not‐for‐profit agency	3 (18.7)
School system	1 (6.3)
Tribal government	0 (0.0)
University	0 (0.0)
Services provided by partnered agenciesa
Behavioral health	1 (6.3)
Primary care	1 (6.3)
Vision services	1 (6.3)
Unknown (provider: “I don't know”)	3 (18.7)
None	12 (75.0)
Electronic health record systema
Athena	3 (18.7)
eClinicalWorks	11 (68.8)
EPIC	3 (18.7)
Evolv	2 (12.5)
Standardized screener in use
Accountable health communities screening tool	0 (0.0)
iHELP pediatric social history tool	0 (0.0)
PRAPARE (protocol for responding to and assessing patients' assets, risks, and experiences)	0 (0.0)
WE CARE (well child care, evaluation, community resources, advocacy referral, education)	1 (6.3)
SDoH pre‐programmed questions in the EHR/EMR system	2 (12.5)
Tool developed and/or modified by the SBHC or sponsor agency	5 (31.2)
None, we don't use a screener for social needs	8 (50.0)

	Median [IQR]
Number of students at school	760 [518−1075]

^aProportions can sum to more than 100% because respondents could select more than 1 response.

3.2. Themes

We identified four themes: (1) Information‐gathering tactics, (2) diligence, (3) challenges accessing and assessing SDoH information, and (4) uncertainty. Representative quotes for each theme are displayed in Table 2.

Table 2.

Themes with representative quotes.

Theme	Representative quotes
Information‐gathering tactics	We have a school liaison, and we have social workers and you know, and they're just a wonderful resource for us. But so I certainly partner with the school and try to learn all the resources there, for sure. In respects to the community that was definitely trial by fire. There's no question, you know, trying to just personally reach out to them, trying to figure out what's in my area.…talking to families, seeing who they use. So yeah, there was nothing formal about that just would have to just kind of figure it out.
	…calling the parent and saying, you know, is there a reason why you didn't pick the med up? Is there something I can do to help? And finding out, they have no way to get the med. …But there's no formal screening. There's no place that it lives in the EHR. There's no way to score somebody's social determinant health risk. Like there isn't anything like that that we have that I know of.
Diligence	I see that sort of thing happening where they're not being followed consistently. So they're not getting good management. And that's when school based can really step in, too. And if we can go the extra step and communicate with the Pcp. Or get them a Pcp that can be really helpful.
	that makes such a difference, being able to see them frequently and check in. And then they trust you that you're not trying to undermine and wiggle and do something that you shouldn't be doing.
Challenges to accessing and assessing SDoH information	I'm split between 2 schools. So I kinda worry sometimes. Am I missing things? Cause I'm not here all the time. You know I miss what happens, or you know a student's been out for a few days, and you know the nurses talk to them or talk to their parent. But I wasn't privy to the information, so I might not find out and start asking, you know, drilling down on those questions because I didn't know what happened.
	If we can help get those things, or at least get them someone that can help them with those things, then I feel like I can get to more medical interventions. But if you don't address those things first, then I think they sort of like, listen to you with glassed over eyes thinking, like, I have so many other things that I have to deal with before I can go get an inhaler refilled.
Uncertainty	I think a lot of times, because the families with poverty and with not as many social supports, are struggling with a lot of other things at the same time, in the families I've worked with. They are dealing with prioritizing things, you know. It's like Maslow's hierarchy, the food, shelter before they're getting to, you know, asthma follow up appointment.
	And my next question is, okay. Now we do the screening. What tools do we have to help support the problems that come up? Because screening is not enough.

3.3. Information‐Gathering Tactics

Information‐gathering tactics describe the variety of ways SBHC providers access information about children and their families. Participants indicated they sought information from health history, social history, and prior notes in the EHR. During physical examinations (required for school clearance), providers usually asked questions about social risk factors and social needs. Participants mentioned EHR templates or forms that populate questions for the providers, that “you plug in the answers” or “you just have to verify it.”

Sometimes, providers delved deeper and asked further questions after subtle clues, using phrases such as “it just usually comes about in conversation” or “it's situational.” For example, when a medication was not picked up at the pharmacy, providers asked follow‐up questions, whether using a formal screen or an informal process. The frequency of how often a child came to the SBHC also prompted providers to ask further follow‐up questions.

Participants noted that they also relied on other staff to relay information (Figure 2). Through collaboration, providers obtained information and provided referrals for a social need if warranted. Participants connected to a larger health system, such as a health center or local children's hospital, had easier access to information from other staff or outside providers.

Figure 2.

Potential staff assisting in information‐gathering. School‐based health providers rely on information from many different sources and collaborators. Not an all‐inclusive list, these groups are the people described by this study's participants. [Color figure can be viewed at wileyonlinelibrary.com]

While some providers performed universal screening, most used an informal, nuanced approach, using words like “discovering” or “connecting dots” to explain how they identified social needs. They described “adding on questions,” e.g., “Do you have access to food?” during a visit at the SBHC. Participants often used a storytelling style to share patient stories and interactions with family members, emphasizing the role of the SBHC providers in making connections.

3.4. Diligence

Defined as careful and persistent work or effort, diligence describes how providers were dedicated to discovering SDoH, social risk factors, and social needs. Providers indicated they “troubleshoot” and “work through those different types of things.” For example, one participant assisted with insurance applications with the family, a process that took approximately 30 min of additional time. Providers searched for resources, sometimes discovered through word of mouth, colleagues in the school or community, or from other SBHCs.

Participants were diligent when providing access to care and fulfilling the role of school‐based health to provide accommodating services in school, saving time, and costs for families [14]. Participants expressed a sentiment of pride in that role, valuing access, connection, and discovering family concerns. Conversely, participants expressed frustration when they could not fulfill that role (e.g., failed attempts to connect families with needed resources or the inability to bill for coordination of care).

Diligence also created a relationship in which rapport was built, facilitating greater information sharing over time. When providers tactfully asked questions about social needs, patients and families were “open” or “honest.” Participants used words such as “trust” and “feeling comfortable” to describe when patients and families shared information about their social needs. Participants expressed they valued this trust, and shared stories whereby being a consistent presence over time, providers developed connections, increasing the willingness of their patients to share their social needs.

3.5. Challenges to Accessing and Assessing SDoH Information

A third theme was challenges to accessing and assessing SDoH information. Foremost challenges were related to immigration status, reliance on other staff, issues with the EHR, communicating with families and caregivers, and complexity.

3.5.1. Recently Immigrated

When providing care for families who recently immigrated, participants voiced that information may come from an unreliable source (e.g., when an immigrated child refers to someone as “family,” but they are not a primary caregiver or related to the child). One participant described newly immigrated caregivers as being “suspicious,” afraid that by interacting with the health system, it increased the immigrants' risk of “being reported.” Language and culture barriers required additional time to support the family and gain trust, which participants described as “we can't quantify that service” or “it is non‐billable.”

3.5.2. Relying on Fellow Staff

Collaboration with school staff or community members also presented a challenge, as others brought information to the SBHC and asked for assistance, but the relayed information was incomplete. Participants shared the sentiment that they felt they were “missing something,” especially when a provider was only part‐time or served multiple schools. Participants reported they have little to no access or awareness of any data schools collect.

3.5.3. Challenges Within the EHR

Participants described entering SDoH, social risk factors, and social needs information in new areas of the EHR, areas that no longer mirror paper forms. Information could only be added to a progress note rather than accumulated together, requiring providers to search through prior visits. When notes were written by another staff (e.g., a social worker) using the same EHR, the provider had to consider whether the note should have restricted access in respect of privacy or confidentiality. Prebuilt EHR forms also lacked specific questions, and one participant shared that they can only mark “SDoH screening as either positive or negative.”

3.5.4. Difficulty Reaching Caregivers to Provide Education and Resources

Participants described how children and families lacked understanding of their asthma care, for example, had multiple inhalers, were unaware of the differences between inhalers, and had “poor asthma management.” Participants were unable to communicate consistently with caregivers. For example, when caregivers were unable to afford cellphones or transportation, providers could not reach parents for more information or to refer to resources. Participants shared that even free resources using Wi‐Fi for calling are unreliable, and communication was complicated further by language barriers and literacy issues.

3.5.5. Complexity

Participants also voiced the complexity of factors contributing to social needs. One participant used “combination” and “mixture” to describe major issues facing one patient, including caregivers' inability to take time off from work, financial status, transportation needs, and lack of insurance. This complexity was especially true for acquiring medications, as for example, when pharmacies were not within walking distance, and public transportation was unreliable or unavailable, a patient would not get their asthma medications.

3.6. Uncertainty

A final theme was uncertainty, defined as doubts or reservations, and refers to when participants expressed being uncertain about what constitutes SDoH, and how or when to screen. Participants mentioned other variables, including genetics or asthma triggers, and cited questionnaires that screen for variables besides SDoH, social risks, or needs. No validated social screening tools were verbalized by participants during the focus groups, and on collected demographics, only one participant reported one tool. While participants shared examples of SDoH and social needs (Figure 3), they expressed uncertainty about the relationship to asthma exacerbations, and how care should be prioritized.

Figure 3.

Word cloud: Social determinants of health and social risk factors reported by focus groups [28]. The word cloud is a visual representation of the most frequently used words during our focus groups. These social determinants of health and social risk factors were described by our participants, with those more frequently used appearing larger and bolder. [Color figure can be viewed at wileyonlinelibrary.com]

Participants expressed uncertainty about whether they should screen, especially during acute exacerbations, or if there is a lack of resources or referral options. When managing acute exacerbations, participants were uncertain whether to forgo screening or address a social need that likely contributed to exacerbations. Providers voiced uncertainty if they felt they did not have consistent, reliable options for referrals or community resources (i.e., “access to care workers” who assist in obtaining insurance that are only available during business hours).

3.7. Envisioned Informatics Resource

We intend to use our results in development of an informatics resource that displays publicly available data regarding SDoH and social risk factors. Participants voiced interest and shared factors they desired in an informatics resource (Table 3). They also shared how they might envision using the resource in clinical practice with patients with asthma, indicating that having information, such as map or location‐based would be interesting. Providers also shared they felt a resource could also be helpful to adolescents, suggesting a phone app to check every morning. Participants indicated that having access at their fingertips would be helpful and exciting to use and share with their school‐age patients with asthma.

Table 3.

Responses to what may desire in an informatics tool (listed alphabetically).

Air quality

Community locations to access resources

Family economics

Formal social risk screening tool

Locations of cheaper after‐school care

Locations of discount pharmacies, online pharmacies, or free delivery services

Pollen counts

Referral services for resources: both what exists and how to refer

Safe places for Immigrants to obtain assistance or medical care

Safe spaces

Walkability of neighborhoods

4. Discussion

In our study, we examined the perspectives of SBHC providers regarding their information‐gathering behaviors and methods for SDoH and social risk factors for prevention of asthma exacerbations. Our major findings include: (1) There is a variety of information‐gathering tactics used in SBHCs; (2) there are missed opportunities for social risk screenings in schools; (3) screening for SDoH, social risk factors, and social needs is essential but challenging; and (4) there is continued need for resources and increased awareness in schools. While many studies make associations between SDoH and exacerbations of asthma, this descriptive, qualitative study highlights the lived experience of practicing SBHC providers.

4.1. Variety of Information‐Gathering Behaviors

The lack of a consistent, agreed‐upon, best practice clinical tool leads to extra work [15] and individualized practice. SBHC providers have individual styles and preferences, with no clear consensus for a single screening tool or which social needs are of highest priority [12, 19]. There is little agreement on which SDoH domains to screen or when is the best timing to perform screenings, especially during acute exacerbations [16, 19]. Overall, our findings are consistent with prior research that emphasizes providers' lack of confidence in addressing social needs, related to lack of time, resources, training, and increased documentation burden [18]. We acknowledge the need for further development and validity testing of comprehensive, practical tools for consistent and universal screening in SBHCs, with access to screening data performed by collaborating providers.

4.2. Missed Opportunities and the Need to Involve Providers

There remain missed opportunities in schools, and providers struggle with documentation and application of screening tools into clinical workflows, lacking a systematic approach [10, 17]. Our findings highlight that while practices for screening and referral exist, most SBHC providers perform screenings during well‐child visits, and not regularly at others, including asthma exacerbation visits [29]. SBHC providers particularly may be siloed, unable to access data in the community or collected by the school. There continues to be a gap between the desire and diligence to address social needs of children and families with the ability to do so. Further study should ensure appropriate communication, workflow, staff engagement, and community partnerships.

4.3. The Challenges of Social Screening

Providers are willing and understand the importance of social screening; however, screening is not always feasible [10, 17]. Providers report positive experiences if they have screening tools and resources but voice barriers including the time limitations of screening and referral [17, 19, 30]. There are insufficient resources, especially for the complexity of social needs and heterogeneity of patient populations and staff [20, 30]. Providers are limited to local resources, which are often maxed out quickly, or rely on providers to enter the resources and maintain lists. Our findings are also consistent with prior literature that identifies the reliance on strong relationships with others, especially school nurses. SBHC providers rely on community collaboration and infrastructures for the coordination of care to address social needs [31].

4.4. The Need for Resources and Awareness of SDoH

Our participants identified screenings for mental health, developmental‐behavioral, or risk assessments, which are not comprehensive social screenings and are often age‐specific. Providers desire tools and social assessments that yield actionable information that will inform care decisions, and our findings demonstrate providers are unaware of available screening tools or are uncertain of definitions for SDoH concepts. Providers struggle evaluating if referrals and/or interventions effectively address social needs and overall child well‐being [16, 32, 33], even when evidence supports social risk interventions reduce asthma‐related emergency room visits and hospitalizations [34]. Clinical guidelines should consider universal social risk screening and implementation of social risk–based interventions, particularly for patients with asthma [34].

Furthermore, providers must use a variety of information sources, which are often incomplete, lacking detail, or in EHRs that are separate from other providers [15]. Although in early stages, there is evidence that demonstrates population‐level data can be used to predict asthma exacerbations [35, 36]. Data derived from nonclinical sources (i.e., deidentified local and national data sets) can be incorporated into care and increase social risk awareness. Our findings add to the body of knowledge that challenges with SDoH data quality, reliability, and accessibility create the need for increased awareness, education, and informatics resources and technical support for providers, especially those in schools [15].

4.5. Strengths of the Study

We maintained methodological rigor of trustworthiness, authenticity, and auditability through use of Dedoose [26], which allows for field notes and memos to be linked throughout excerpts and codes. Another strength of this study was the focus group methodology that increased the likelihood of participants providing candid responses and building on each other's ideas [37]. Using a semi‐structured interview with consistent data collection ensured objectivity and dependability. Use of a qualitative expert and full research team review of coding and theme interpretation also ensured dependability. Consistent with prior research, we feel our findings are a credible and valid interpretation of the lived experiences of SBHC providers.

4.6. Limitations

Our study also had its limitations. Conducting our study in one state and enrolling a predominant number of White, non‐Hispanic female participants limits transferability; however, our demographic data is consistent with the demographic of Connecticut licensed nurse practitioners from the 2022 National Sample Survey of Registered Nurses: female (86%) and White non‐hispanic (78%) [38]. A purposive snowball sampling approach may cause certain groups to be underrepresented. We acknowledge that the PI's beliefs, interests, and experiences as an SBHC provider may affect facilitation of interviews and interpretation of findings; however, our use of a housekeeper and reflexive field notes methodologically minimized this bias.

4.7. Implications and Future Research

This study highlights the opportunity for further education, awareness, and research to provide practical, social risk‐based interventions to prevent asthma exacerbations. Based on our findings, especially in SBHCs, providers can benefit from informatics resources and awareness of available community partners that can address barriers to SDoH information‐gathering. Guidelines that include increased awareness of SDoH and training with validated tools can assist providers in prioritizing social risk screening, identifying social needs, and offering more education and community resources.

5. Conclusion

While SBHC providers are very aware of social needs and their importance to their patients and families, they are faced with challenges that limit their ability to provide effective screening and referral to resources. Our findings are a step to improving targeted social risk factor screening and assessment of social needs in SBHCs, increasing SDoH awareness, and improving the lives of school‐age children with asthma.

Author Contributions

Vera Borkowski: conceptualization, methodology, data curation, investigation, validation, formal analysis, funding acquisition, visualization, project administration, writing – original draft, writing – review and editing. Mariann R. Piano: conceptualization, methodology, data curation, supervision, formal analysis, validation, investigation, writing – review and editing, funding acquisition. Erin D. Maughan: conceptualization, funding acquisition, validation, writing – review and editing. Stacy Curry‐Johnson: conceptualization, validation, funding acquisition, writing – review and editing. Alvin D. Jeffery: conceptualization, methodology, data curation, investigation, validation, formal analysis, supervision, writing – review and editing.

Ethics Statement

The Vanderbilt University Medical Center Institutional Review Board determined the study was Exempt from review under submission number 222170. It was determined that the study poses minimal risk to participants. This study meets 45 CFR 46.104 (d) category (2) for Exempt Review.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Supplemental Material Methods.

Supplemental Semi‐Structured Interview.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.