From office tools to community supports: The need for infrastructure to address the social determinants of health in paediatric practice

Abstract

Previous research has highlighted the importance of addressing the social determinants of health to improve child health outcomes. However, significant barriers exist that limit the paediatrician’s ability to properly address these issues. Barriers include a lack of clinical time, resources, training and education with regard to the social determinants of health; awareness of community resources; and case-management capacity. General practice recommendations to help the health care provider link patients to the community are insufficient. The objective of the current article was to present options for improving the link between the office and the community, using screening questions incorporating physician-based tools that link community resources. Simple interventions, such as routine referral to early-year centres and selected referral to public health home-visiting programs, may help to address populations with the greatest needs.

The social determinants of health (SDOH) are the conditions in which people are born into, grow, live, work and age (1). SDOH include early childhood development, education, employment and working conditions, family income, food security, housing, health care services, social support, neighbourhood safety, inequities among economic groups and racism (1–3). Marginalized individuals experience the highest levels of disease and premature death (1,2). Approximately 15% to 19% of Canadian children live in poverty and are more likely to experience low birth weight, learning difficulties, mental health problems, iron deficiency anemia, asthma, burns and injuries, obesity and hospitalization than their more affluent peers (4,5). Exposure to prolonged stress (known as toxic stress) negatively impacts the development of the neuroendocrine-immune system (6). Infants living in poverty have a 60% higher mortality rate (2). Children are particularly vulnerable because they are dependent on their families for basic needs, social support, socialization and life skills (7). The number of social risk factors and length of exposure demonstrate a cumulative and increased vulnerability to poorer health status over the years, which impact ‘life-course developmental health’ (6–8).

Although awareness is increasing, a significant proportion of paediatric patients and their families have unidentified or poorly managed psychosocial concerns (9–11). Barriers for physicians to address the SDOH include a lack of time, resources, training, awareness of community resources and case management capacity to promote change (12). Additionally, the SDOH have a disproportional burden on immigrant families, emphasizing the importance of providing culturally competent care (9).

The American Academy of Pediatrics recommends expanding the role of paediatric providers to include screening, assessment and referral of parents for social problems (7). There must be greater focus on implementing a practical, synergistic and systematic approach for clinicians that includes the following:

• screening directed at the broader needs of patients;

• provision of referral to appropriate resources;

• assured follow-up and support.

To achieve this, a virtual or real service navigator, case manager or health advocate may be required (12). Several innovative initiatives from the development of screening tools and community resources to comprehensive hospital- and clinic-based programs that attempt to address these disparities will be reviewed.

NOVEL INITIATIVES FOR ADDRESSING THE SDOH

Improving screening methods

The majority of information regarding the social circumstances of a child is collected through the social history. While the comprehensive HEADSS (home and environment, education and employment, activities, drugs, sexuality, suicide/depression) assessment is used in adolescent medicine, such questioning has often otherwise been limited (3). A useful mnemonic, ‘IHELLP’, revised here as ‘ITHELLPS’, is one method for physicians to comprehensively approach social history issues such as income and food security, transportation, housing/utilities, education, legal status/immigration, literacy, personal safety and support (Table 1) (3). The original published mnemonic provides a coherent way to explore a breadth of SDOH that can readily link to available interventions such as legal support. Garg and Dworkin (12) recommend tailoring screening tools to the most commonly identified problems in the communities being served, while global screening tools can identify more basic family problems such as food and employment. They recommend conducting routine screening with initial intake, for newborns within the first six months, and regularly thereafter at well-child care visits. Screening should be increased according to the burden of psychosocial issues in the community (12).

TABLE 1.

Social history domains for exploration using the ‘ITHELLPS’ mnemonic to address basic needs

Domain/area	Examples of questions
Income
General	Do you ever have trouble making ends meet?
Food income	Within the past 12 months did you worry whether your food would run out before you got money to buy more? Within the past 12 months did the food you buy last and did you have money to get more?
Transportation
Public transportation	Do you have trouble paying for public transportation?
Long distance travels	Are you able to access basic needs from your home (ie, food, health services, job, school) in manageable time?
Housing
Housing	Is your housing ever a problem for you?
Utilities	Do you ever have trouble paying your electric/heat/telephone bill?
Education
Appropriate education placement	How is your child doing in school? Is he/she getting the help to learn what he/she needs? Are you able to speak to the teacher and go to parent-teacher meetings? Does your child use the breakfast programs, have after-school programs at the school?
Early childhood program	Do you go to the Early Years/Best Start Child and Family Centers? Does your child go to other preschool, or other early childhood activities?
Legal status
Immigration	Do you have questions about your immigration status? Do you need help accessing benefits or services for your family?
Literacy
Child literacy	Do you read to your child or tell stories around pictures in the book every night? Singing and speaking with your child as much as possible is really good too – are you able to do that?
Parent literacy	How happy are you with how you read?
Personal safety
Domestic violence	Have you ever taken out a restraining order?
General safety	Do you feel safe in your relationship? Do you feel safe in your home? In your neighbourhood?
Support
Personal	Do you have a close network of supportive family and friends?
Support services	Are you aware of social programs available to you? Do you use them?

Adapted from references 3 and 27

A novel Canadian (Ontario) screening tool encourages family physicians to ask ‘seven simple questions to help patients living in poverty’ with the purpose of linking patients to appropriate financial interventions (Table 2) (13). Their questions – eg, inquiring whether all patients have completed their tax forms, whether families with children receive the Child Benefit each month, whether individuals with disabilities receive payments from various disability programs and whether social assistance recipients have applied for extra income supplements – are simple but high-yield steps toward helping patients achieve maximum support based on their individual needs. Once patients have been screened, they can be directed to specific resources to assist them in addressing their income security using the resources available on the tool (www.ocfp.on.ca/cme/povertytool). Furthermore, a novel Canadian paediatric poverty tool was developed at The Hospital for Sick Children (Toronto, Ontario), which parallels poverty screening questions to specific community resources (14).

TABLE 2.

Examples of national and local (Toronto, Ontario) resources

Concern	Where to refer
Benefits and support	Three easy-to-use guides to government benefits:
	1. Service Canada: www.servicecanada.gc.ca
	2. Canada Benefits: www.canadabenefits.gc.ca
	3. Ontario Benefits Directory: www.ontario.ca/benefitsdirectory
	Community income tax clinics
	www.cra-arc.gc.ca/tx/ndvdls/vlntr/clncs/on-eng.html, telephone 1-800-959-8281
	Social support programs
	http://www.mcss.gov.on.ca/en/mcss/programs
	St. Christopher House for Financial Advice
	www.stchrishouse.org, telephone 416-848-7980
	Disease-specific financial advice
	Wellspring: www.wellspring.ca, for individuals with cancer.
	Persons with AIDS Foundation: www.pwatoronto.org, for individuals with HIV.
	Wellspring Money Matters Resource Centre
	www.wellspring.ca, telephone 416-961-1493. Cancer patients can access financial consultation and clinics.
	Income Security Advocacy Centre
	www.incomesecurity.org
	Local employment and social services
	www.toronto.ca/socialservices
Access to food	Daily Bread Food Bank
	www.dailybread.ca, telephone 416-203-0050
	School-based nutrition
	Breakfast for Learning: www.breakfastforlearning.ca
	Breakfast Clubs of Canada: www.breakfastclub.ca
	Start2Finish: http://start2finishonline.org
Prescription drug coverage	Ontario Drug Benefit Program
	www.health.gov.on.ca/en/public/programs/drugs/, telephone 416-314-5518, 800-268-1154
	Trillium
	www.health.gov.on.ca/english/public/pub/drugs/trillium.html
Child benefits	Service Canada
	www.servicecanada.gc.ca/eng/goc/cctb.shtml, telephone 800-622-6232
	Canada Revenue Agency
	www.cra-arc.gc.ca/bnfts/menu-eng.html, telephone 800-387-1193. Search for and download RC66, Canada Child Benefits Application
Legal and immigration clinics	OCASI-Settlement
	www.settlement.org, telephone 416-322-4950
	Community Legal Education Ontario
	www.cleo.on.ca, telephone 416-408-4420
	Legal Aid Ontario
	www.legalaid.on.ca, telephone 416-979-1446, 800-668-8258
	Access Alliance
	www.accessalliance.ca, telephone 416-324-8677
	ARCH Disability Law Centre
	www.archdisabilitylaw.ca
	Advocacy Centre for the elderly
	www.advocacycentreelderly.org
	Where to refer
	Aboriginal Legal Services of Toronto
	www.aboriginallegal.ca
Safety	Assaulted Women’s Helpline
	Telephone 416-863-0511
	Domestic violence women
	www.schliferclinic.com, telephone 416-323-9149
	Emergency shelters
	Telephone 877-338-3398
	Toronto Homeless Services
	www.toronto.ca/housing

When you do not know where to turn: 2-1-1 (telephone) or 211ontario.ca. This is a free, complete directory of supports and services in Ontario including housing, employment and other social supports. It is available 24 h/day, in 150 languages, and is confidential and unrecorded

Screening is an essential first step in addressing the SDOH. It provides a foundation for physicians to understand the family context, and also helps to direct their patients to appropriate interventions (3). Development of a standardized screening tool and more extensive training for physicians can help to incorporate SDOH into daily office practice.

Improving methods of referral to appropriate resources

Following screening, the patient should be connected to the appropriate resources and programs. The development of comprehensive community resource listings is imperative for meeting the needs of patients and their families, and enabling health care teams to provide appropriate referrals (Table 2). Many city wards provide a listing of local resources. In Toronto, the 211Toronto.ca resource provides a search engine for resources such as housing, low-cost dental services and family literacy centres (15); the 211 telephone service is provided by a live Resource Specialist year-round, 24 h per day, confidentially, unrecorded and in 150 languages. Internet-based government resources, such as Canada Benefits (www.canadabenefits.gc.ca), Service Canada (www.servicecanada.gc.ca) and Service Ontario (www.ontario.ca/serviceontario), offer user-friendly guides to government-run social support programs (16–18).

However, identification and appropriate allocation of community services to patients is a challenge for many health care providers due to the overwhelmingly large number of services and potential barriers with regard to knowledge of existing programs (12). For example, a report found that community-based food initiatives reach only a very small proportion of low-income Toronto families characterized as food insecure or insufficient, and called for a more effective way for food-insecure families to reach community food resources (19). Further research is needed in this area to better understand how resources can best reach families in need.

Development of comprehensive programs including screening, referral and follow-up

The following review of three novel programs demonstrates management initiatives for primary care and hospital-based physicians. These initiatives require physicians to screen their patients, and refer either directly or indirectly, through case management workers or specialized volunteer services, to social supports. Overall, these programs are successful at addressing the SDOH for families using the three essential steps discussed above.

First, Garg et al (20) conducted a randomized controlled trial involving 200 parents at an urban hospital-based paediatric clinic to evaluate the implementation of a psychosocial screening and referral program. The team developed a brief self-report survey written at the third-grade level in English, assessing 10 psychosocial issues (lack of high school education, unemployment, smoking, drug abuse, alcohol abuse, depression, intimate-partner violence, child care need, homelessness and food security) and the family’s motivation for addressing each issue. In the intervention group, parents of children two months to 10 years of age were asked to complete the questionnaire before their clinical visit and submit it directly to the resident during their appointment (20). The authors also developed a ‘family resource book’ containing information about available resources for the screened items, with copies available for families. Paediatric residents in the intervention group were trained and informed about the family resource book. Participants received a postappointment visit and one-month follow-up interview to assess outcomes. Overall, the intervention group demonstrated statistically significant improvements in outcomes: families had discussed more psychosocial topics; there were fewer unmet needs for discussion during their clinic visit; more referrals were made for community resources (job training, housing, General Education Development classes, food resources, smoking cessation classes and child care); and there was a greater likelihood of contacting the resource. Moreover, approximately 90% of residents reported that the tool lengthened the visit by <5 min.

Second, Garg et al (21) evaluated the effectiveness of Project HEALTH, which used undergraduate volunteers to screen at-risk families for psychosocial concerns, connect them with community resources, followed-up at least bimonthly, and provide the physician with feedback. Family help desks were run for several hours per day in a clinic for low-income paediatric patients from birth to 21 years of age. Providers referred patients to the help desk, but families could also access this service without referral. A self-report intake questionnaire, written at the sixth-grade level in English, screened for 15 psychosocial concerns: employment, education, food insecurity, homelessness risk, childcare, after-school programs, utilities public benefits, health insurance, smoking, drug abuse, alcohol abuse, intimate partner violence, child school failure and safety equipment (21). Approximately 64% of families who accessed the service contacted a suggested resource, and 32% subsequently enrolled in a community program. The majority of families enrolled in these community programs were satisfied with the services. It was speculated that the discrepancy between referral and utilization of the community resource was due to multiple social barriers such as time constraints and household demands. Project HEALTH, founded in 1996 as a small student-driven campus organization, has since evolved into Health Leads, a fully staffed, $10 million organization with programs in 15 hospitals and clinics across six major cities in the United States, which has served >23,000 patients. Families visit either a partner hospital or health centre where they are screened for basic needs such as food or heating. Patients then bring their prescriptions to the Health Leads Desk where college students, trained as health leads advocates, assess patients’ eligibility for health insurance, food pantries and food-assistance programs, gas and electric turn-off assistance and discounts, job training and day-care subsidies. Health Leads advocates help patients to navigate through the complexities of accessing resources by assisting them in finding telephone numbers, completing applications, finding transportation and printing maps (22).

Third, in 2011, The Hospital for Sick Children conducted an in-hospital Settlement Services Pilot Program to gain an understanding of the barriers faced by newcomers (new immigrant and refugee families) in accessing quality health care and navigating the hospital, and to test an intensive case-management model in mitigating these barriers. For newcomers to Canada, language barriers combined with poor health literacy are significant impediments to access to health care (23). A registered nurse and social worker provided case management services. Thirteen families encompassing 26 children and 32 adults were referred to the program. The families came from ethnically, culturally and linguistically diverse backgrounds, and the children had a broad range of acute and chronic health conditions. A semistructured interview involving a needs and intake assessment was conducted with each family. Key needs were identified in the following areas: hospital navigation and wayfinding; understanding of diagnosis and treatment; financial assistance for medications and food; and anxiety about the child’s health. The interventions of the case management team included: advocating for appropriate resources (including medical interpreters); helping the families navigate the hospital and health care system; coordinating care; role modelling and coaching families on how to have their voices heard in health care interactions; providing emotional support; and providing health education. Follow-up evaluation interviews with participants demonstrated that families had a better understanding of their child’s diagnosis and medical regimens, were able to access health care, community and government resources as a result of the services provided, and expressed a high degree of satisfaction with the case management support provided (24).

These programs highlight key components essential for the effective management of SDOH: specialized screening and referral tools; strong community partnerships; adequate training of health care professionals and volunteers in managing the SDOH; and sound follow-up using physicians, case managers or volunteers, and continuous support programs. In addition, there needs to be support for cases that are more complex from a legal, mental health risk perspective. Building this link with community resources is critical for empowering families to overcome the SDOH and have better health outcomes (25,26).

RECOMMENDATIONS FOR ADDRESSING SDOH IN MEDICAL PRACTICE

Optimizing the health of children requires identification and effective management of psychosocial risk factors. Paediatricians are in a unique position to improve care of the entire family by partnering with family medicine, public health, nursing, social work and community services (7). An effective program requires approaches for screening, referral and follow-up. Development of an infrastructure supportive of medical management and addressing the SDOH is crucial to the success of holistic medical care. Physicians within an appropriate practice context have a responsibility to play a larger and more consistent role in addressing the SDOH through screening for needs, provision of appropriate referrals to resources, and assurance of follow-up and support. Addressing SDOH in office practice was reported as lengthening the interview by <5 min (20).

First, physicians must become comfortable with screening for SDOH, as with any other risk factor. It is essential that both physicians and medical trainees receive proper training on screening, best referral methods and sensitivity in discussing such concerns. Trainees who have taken a new social paediatrics elective at the University of Toronto have published their reflections on how their experience has positively changed their approach to care. It has also led to the development of other advocacy projects at the postgraduate level (25). The ITHELLPS mnemonic (Table 1) or novel screening tools, such as the poverty tools (14,15), appropriately direct providers toward interventions for patients in need, similar to HEADSS.

Second, physicians must become familiar with community resources and programs (Table 2) in their respective neighbourhoods to best direct and empower their patients to seek help when needed. Some simple interventions that make a difference can now be recommended routinely. These connections can be made using the suggested tools, telephone lines, the Internet, trained personnel or by care providers. Support could also be provided through a health navigator such as a Health Leads advocate (21).

Finally, physicians must take time for follow-up to ensure support and effective use of resources. Ensuring consistent follow-up and continuous support for patients is essential for proper management of the SDOH. Follow-up can be provided via the physicians themselves, or case managers or volunteers; however, there are definite challenges. Case-manager programs are costly and, thus, long-term follow-up may not be feasible (24). Noncontinuous volunteers or high turnover may result in poor follow-up and patient frustration. Key factors for the success of Project HEALTH included the capacity for appropriate training, and coordination, maintaining and conducting follow-ups with volunteers (21). Therefore, ways to improve the sustainability and feasibility of case management and/or volunteer support must be further examined to ensure fluid care and support for patients. Further research investigating the SDOH using some of these strategies regarding recognition, connection and follow-up will help to address recognized barriers.