Addressing social determinants of health at well child care visits: a cluster RCT

A family-centered approach to social needs awareness in the pediatric emergency department

Objective

We aimed to understand family preferences around reporting and receiving health-related social needs (HRSN) information by assessment modality during pediatric emergency department (PED) visits.

Methods

Families were randomized into paper (control), cell phone, or tablet modality groups by their child's exam room. Nurses alerted families to complete a single HRSN assessment during routine workflow. We used logistic regression and McNemar's test to assess discordance in modality preference.

Results

Forty-seven percent of families disclosed at least one HRSN across a total 611 assessments. Disclosure of HRSN was similar by modality. Twenty-three percent of those assigned tablet preferred cell phone (p < 0.001). Two-thirds of families preferred receiving digitally formatted community resources (email or text). There was no difference in preferred timing of HRSN assessment completion.

Conclusions

Assessment modality did not appear to influence family HRSN disclosure. Families were generally satisfied with all HRSN assessment modalities but demonstrated a particular preference in using personal cell phones over tablets. Digitally formatted community referrals also pose numerous advantages over conventional paper handouts.

Innovation

Use of personal cell phones is a novel, streamlined method of HRSN interventions in the clinical setting, performing similar to more conventional modalities, with a preference among families when compared to tablets.

Federally Qualified Health Centers' Screening for Social Risk Factors and Health Outcomes

Federally Qualified Health Centers (FQHCs) are ideally positioned to identify and address health-related social needs, but little is understood about the relationship between social risk factor (SRF) screening and health outcomes. We studied 1352 FQHCs from the 2019 Uniform Data System. Ordinary least squares regression was used to estimate the relationship between SRF screening and the percentage of patients with adequately controlled diabetes and hypertension. Results show 71% of the FQHCs in the sample collected SRFs. FQHCs' screened for SRFs had higher percentages of patients with adequately controlled diabetes (69.5% vs 67.0%, P < .001) and hypertension (63.8% vs 59.4%, P < .001) relative to FQHCs not collecting SRFs.

Addressing food insecurity in the inpatient setting: Results of a postdischarge pilot study

BACKGROUND AND OBJECTIVES

With a growing interest in screening for food insecurity (FI) during pediatric hospitalization, there is a parallel need to develop interventions. With input from caregivers experiencing FI, we sought to identify interventions to assist with short-term FI after discharge and evaluate their feasibility, acceptability, and appropriateness.

METHODS

We first employed qualitative methods to identify potential interventions. Next, we conducted a pilot study of selected interventions for families experiencing FI. Seven days postdischarge, caregivers rated the intervention's feasibility, acceptability, and appropriateness. We also assessed for ongoing FI. We summarized the median and proportion of "completely agree" responses to feasibility, acceptability, and appropriateness questions, and we compared in-hospital and postdischarge FI using McNemar's test.

RESULTS

In the qualitative stage, 14 caregivers prioritized three interventions: grocery store gift cards, grocery delivery/pick-up, and frozen meals. In the pilot study, 53 caregivers (25% of those screened) endorsed FI during their child's hospitalization and received one or more of the interventions. Every caregiver selected the grocery gift card option; 37 families (69.8%) also received frozen meals. Seven days after discharge, most caregivers rated the intervention as "completely" feasible (76%), acceptable (90%), and appropriate (88%). There was a significant decrease in caregivers who reported FI after discharge compared to during the hospitalization (p < .001).

CONCLUSIONS

This study demonstrates the feasibility, acceptability, and appropriateness of inpatient interventions to address FI, particularly at the time of pediatric hospital discharge and transition home. Randomized trials are needed to further evaluate the efficacy of interventions employed during hospitalization.

Comparison of Caregiver and Provider Food Insecurity Screening Preferences Within a Health System

Food insecurity is a public health concern associated with poor health. Evidence guiding how to best implement screening for food insecurity across a pediatric health care system is lacking. We performed a single-center, multi-department, cross-sectional study of caregivers and health care providers in outpatient and inpatient settings to describe the beliefs, barriers, preferences, and preferred food insecurity screening location. Most providers and caregivers underestimated the pervasiveness of food insecurity while acknowledging the benefit of screening. Caregivers are overall receptive to food insecurity screening and disagree with feelings of discomfort or shame when disclosing food insecurity status. Providers acknowledged perceived caregiver discomfort, lack of community food resources, and lack of a validated screening tool as barriers to screening. Both caregivers and providers identified the primary care setting as the preferred screening setting.

Implementing Inpatient Social Needs Screening in an Urban Tertiary Care Children's Hospital

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends screening for unmet social needs, and the literature on inpatient screening implementation is growing. Our aim was to use quality improvement methods to implement standardized social needs screening in hospitalized pediatric patients.

METHODS

We implemented inpatient social needs screening using the Model for Improvement. An interprofessional team trialed interventions in a cyclical manner using plan-do-study-act cycles. Interventions included a structured screening questionnaire, standardized screening and referrals workflows, electronic health record (EHR) modifications, and house staff education, deliberate practice, and feedback. The primary outcome measure was the percentage of discharged patients screened for social needs. Screening for social needs was defined as a completed EHR screening questionnaire or a full social work evaluation. Process and balancing measures were collected to capture data on screening questionnaire completion and social work consultations. Data were plotted on statistical process control charts and analyzed for special cause variation.

RESULTS

The mean monthly percentage of patients screened for social needs improved from 20% at baseline to 51% during the intervention period. Special cause variation was observed for the percentage of patients with completed social needs screening, EHR-documented screening questionnaires, and social work consults.

CONCLUSIONS

Social needs screening during pediatric hospitalization can be implemented by using quality improvement methods. The next steps should be focused on sustainability and the spread of screening. Interventions with greater involvement of interdisciplinary health care team members will foster process sustainability and allow for the spread of screening interventions to the wider hospitalized pediatric population.

Measures of nutrition status and health for weight-inclusive patient care: A narrative review

In healthcare, weight is often equated to and used as a marker for health. In examining nutrition and health status, there are many more effective markers independent of weight. In this article, we review practical and emerging clinical applications of technologies and tools used to collect non-weight-related data in nutrition assessment, monitoring, and evaluation in the outpatient setting. The aim is to provide clinicians with new ideas about various types of data to evaluate and track in nutrition care.

Changing contexts of child health: an assessment of unmet physical, psychological and social needs of children with common chronic childhood illness

BACKGROUND

We assessed the biopsychosocial needs and key health drivers among children living with a common chronic illness, as baseline for a cluster randomised controlled trial of a child health system strengthening intervention.

METHODS

Cross-sectional data were analysed from a large population sample of children from South London with asthma, eczema or constipation, as exemplar tracer conditions of a new integrated care service. Descriptive and regression analyses, accounting for sociodemographic factors, investigated social needs, psychosocial outcomes and quality of life associated with poor symptom control.

RESULTS

Among 7779 children, 4371 children (56%) had at least one uncontrolled physical health condition. Across the three domains of physical health, mental health and social needs, 77.5% of children (n=4304 of 5554) aged 4-15 years had at least one unmet need, while 16.3% of children had three unmet needs. Children from the most socioeconomically disadvantaged quintile had a 20% increased risk of at least one poorly controlled physical condition (risk ratio (RR)=1.20, 95% CI: 1.11 to 1.31, p<0.001) compared with those from the least disadvantaged quintile. There was an 85% increased risk of clinically important mental health needs among children with uncontrolled asthma (RR=1.85, 95% CI: 1.65 to 2.07, p<0.001), 57% for active constipation (RR=1.57, 95% CI: 1.12 to 2.20, p<0.01) and 39% for uncontrolled eczema (RR=1.39, 95% CI: 1.24 to 1.56, p<0.001). Health-related quality of life was associated with poor symptom control.

CONCLUSIONS

There is a large burden of unmet biopsychosocial needs among children with chronic illness, signalling an urgent need for prevention, early intervention and integrated biopsychosocial care.

Quality of life of caregivers at the end of their child's pediatric cancer treatment: cancer-specific worry and material hardship

OBJECTIVE

Emerging research suggests that completion of pediatric cancer treatment can be challenging for caregivers given shifting roles and responsibilities. Lower caregiver quality of life (QOL) has been associated with cancer-related variables, higher cancer caregiving strain, and more household material hardship during pediatric cancer treatment. Caregiver QOL at the end of treatment has not been fully investigated but has implications for child and family well-being. Using a psycho-oncology framework, this study aimed to understand the cumulative burden of household material hardship and cancer-related factors on caregiver QOL at the end of treatment.

METHODS

Caregivers (N = 143) of children (Mage=10.51 years) within 1 year of ending active cancer treatment completed self-report questionnaires assessing their QOL, cancer-specific worry, and material hardship (e.g., housing, insurance). Total months of active cancer treatment were extracted from the medical record. Hierarchical linear regression was used to test the relative effects of length of treatment, material hardship, and cancer-specific worry on caregiver QOL.

RESULTS

Cancer-specific worry was significantly associated with and accounted for significant variance in caregiver QOL, above and beyond the length of treatment and material hardship. Caregivers who endorsed more cancer-specific worry had poorer QOL. Material hardship was also significantly associated with caregivers' QOL, but length of treatment was not.

CONCLUSIONS

Caregivers with sufficient resources and less worry about cancer have higher QOL. Findings highlight the importance of end-of-treatment screening of caregivers' subjective cancer-specific worry in addition to material hardship, irrespective of their cancer-related stressors, for ongoing psychosocial support.

Assessing and addressing social determinants of health in school-based health centers in King County, Washington

Objective

School-Based Health Centers (SBHCs) can reduce barriers to accessing care for school-aged children and adolescents. However, current practices related to screening for and responding to social determinants of health (SDOH) in SBHCs are unknown. Our study sought to understand SBHC staff's knowledge related to SDOH, and their screening and referral practices for addressing SDOH.

Methods

This study was conducted with all SBHCs in King County, Washington (n = 30 clinics operated by n = 8 agencies) between January-March 2022. Data were collected using a web-based questionnaire, distributed to all provider and clinical care staff (n = 222) in these SHBCs.

Results

While respondents had strong generalized knowledge regarding SDOH and how they impact health, they were less confident about the specific SDOH impacting the students they serve. Many health limiting and promoting factors are screened for by respondents; however, there was no standardization related to screening and referral practices across SBHCs or agencies. Respondents had suggestions on how to improve screening methodology and ensure that existing practices adequately assess the SDOH impacting student's lives. There was no clearly identified mechanism for making and following up on referrals. Respondents felt that there were either not or only sometimes enough resources available to meet student's needs.

Conclusion

SBHCs advance health and educational outcomes for students, yet SDOH are inconsistently assessed and addressed within SBHCs in King County. Standardizing processes for SDOH assessment and referral can help SBHCs develop practices that are in the best service of equity for their student populations.

Social Determinants of Health and Cancer Care: An ASCO Policy Statement

ASCO's new policy statement on SDOH supports practices that sustain and advance cancer health equity.

Spanish-Speaking Caregiver Preferences for Social Determinants of Health Screening

Equitable social determinants of health (SDOH) screening has been recommended by the Centers for Medicare & Medicaid Services and the Joint Commission; however, little is known about Spanish-speaking caregiver preferences on how they would like to be screened. We conducted a cross-sectional study at 3 pediatric clinics (October-December 2019). Caregivers completed (in English or Spanish) an SDOH screening preferences survey. Three hundred eighty-two of 443 caregivers approached (response rate = 86.2%) completed the survey. Most were female, preferred Spanish, and completed only high school. Spanish-speaking caregivers had greater odds of preferring verbal SDOH screening (odds ratio: 4.1; 95% confidence interval, 1.8-9.2) than English-speaking caregivers. Verbal SDOH screening should be a consideration in families who speak Spanish. Future studies should utilize qualitative methods to further explore Spanish-speaking caregiver preferences for SDOH screening.

Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review

OBJECTIVE

The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective is to identify implementation strategies and indicators being used to integrate and measure health equity.

INTRODUCTION

To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system.

INCLUSION CRITERIA

This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies).

METHODS

This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were assessed followed by a full-text review. The information extracted consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data have been quantitatively tabulated and presented according to 5 review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings are visually presented in charts and diagrams or presented in tabular format.

RESULTS

Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (113 peer-reviewed, 9 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity and we found that both indicators and strategies were lacking adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems.

CONCLUSIONS

Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally.

REVIEW REGISTRATION

Dal Space dalspace.library.dal.ca/handle/10222/80835.

SUPPLEMENTAL DIGITAL CONTENT IS AVAILABLE FOR THIS REVIEW

http://links.lww.com/SRX/A45.

Biocultural and social determinants of ill health and early mortality in a New Mexican paediatric autopsy sample

RESULTS.

Hispanic children have higher odds of growth stunting than non-Hispanic White children. Native American children die younger and have higher odds of respiratory diseases and porous lesions than Hispanic and non-Hispanic Whites. Rural/urban location does not significantly impact age at death, but housing type does. Individuals who lived in trailers/mobile homes had earlier ages at death. When intersections between housing type and housing location are considered, children who were poor and from impoverished areas lived longer than those who were poor from relatively well-off areas.

CONCLUSIONS.

Children's health is shaped by factors outside their control. The children included in this study embodied experiences of social and ELS and did not survive to adulthood. They provide the most sobering example of the harm that social factors (structural racism/discrimination, socioeconomic, and political structures) can inflict.

Athletic Trainers' Observations of Social Determinants of Health in the Collegiate Setting: A Card Study

CONTEXT

Addressing social determinants of health (SDOH) in all populations improves patient outcomes, leading to better patient-centered care. Despite known influences of SDOH, little is known about the ability of athletic trainers (ATs) to observe SDOH in practice.

OBJECTIVE

To explore ATs' observations of SDOH and describe actions taken at the point of care in collegiate and university settings.

DESIGN

Descriptive via an observational card study.

SETTING

Athletic training facilities.

PATIENTS OR OTHER PARTICIPANTS

Collegiate and university ATs (23 participants across 20 institutions).

DATA COLLECTION AND ANALYSIS

The ATs used a modified observation card to document observations of SDOH during patient encounters in the collegiate or university setting. The cards contained instructions for completion and a table with 4 columns: (1) a list of 19 predetermined SDOH, (2) a checkbox for observed SDOH, (3) a checkbox for the perceived negative influence of observed SDOH on patient health, and (4) an open box to write in what actions, if any, were taken to address the observed SDOH.

RESULTS

Overall, 424 cards were collected. Of 725 observed SDOH, access to social media (153/725, 21.1%), academic stressors (131/725, 18.1%), and behavioral health issues (71/725, 9.8%) were the most commonly observed. Nearly 39% (281/725) had a perceived negative influence. Of those, academic stressors (49/281, 17.4%), behavioral health issues (46/281, 16.4%), and transportation issues (32/281, 11.4%) were most common. For the 23.0% (166/725) of SDOH acted upon, ATs used counseling and education (73/166), provided additional resources (60/166), referred to others (29/166), or communicated with others (4/166).

CONCLUSIONS

Because ATs are positioned to accurately assess SDOH, they can promote better patient-centered care and improve patient outcomes. Our results suggest that many SDOH observed by ATs in the collegiate or university setting have a negative influence on patient health. Better support for patients with academic stressors and behavioral health issues is important because of these SDOH.

Using quality improvement to address social determinants of health needs in perinatal care

There are unacceptable racial inequities in perinatal outcomes in the United States. Social determinants of health (SDOH) are associated with health outcomes and contribute to disparities in maternal and newborn health. In this article, we (1) review the literature on SDOH improvement in the perinatal space, (2) describe the SDOH work facilitated by the Illinois Perinatal Quality Collaborative (ILPQC) in the Birth Equity quality improvement initiative, (3) detail a hospital's experience with implementing strategies to improve SDOH screening and linkage to needed resources and services and (4) outline a framework for success for addressing SDOH locally. A state-based quality improvement initiative can facilitate implementation of strategies to increase screening for SDOH. Engaging patients and communities with specific actionable strategies is key to increase linkage to needed SDOH resources and services.

Evaluating the Impact of a Pediatric Inpatient Social Care Program in a Community Hospital

OBJECTIVES

To evaluate the impact of implementing a stakeholder-informed social risk screening and social service referral system in a community hospital setting.

METHODS

We implemented a stakeholder-informed social care program at a community hospital in April 2022. The evaluation included patients aged 0 to 17 years admitted to the pediatric unit between April 2021 and March 2022 (1 year preimplementation) and between April 2022 and March 2023 (1 year postimplementation). For a random subset of 232 preimplementation and 218 postimplementation patients, we performed manual data extraction, documenting program process measures and preliminary effectiveness outcomes. We used χ square and Wilcoxon rank tests to compare outcomes between the preimplementation and postimplementation groups. Multivariable logistic regression was used to assess the preliminary effectiveness of the social care program in identifying social risks.

RESULTS

Screening rates were higher in the postimplementation group for nearly all social domains. Compared with preimplementation, the postimplementation group had higher rates of social risks identified (17.4% vs 7.8% [P < .01]: adjusted odds ratio 2.9 [95% confidence interval 1.5-5.5]) on multivariate testing. Social work consults were completed more frequently and earlier for the postimplementation group (13.8.% vs 5.6% [P < .01]) and median (19 hours vs 25 hours [P = .03]), respectively. Rates of communication of social risks in discharge summaries were higher in the postimplementation group (46.8% vs 8.2% [P < .001]).

CONCLUSIONS

The implementation of a stakeholder-informed social care program within a community hospital setting led to the increased identification of social risks and social work consultations and improved timeliness of social work consultations and written communication of social risks in discharge summaries for primary care providers.

Rural Veterans' Experiences with Social Risk Factors: Impacts, Challenges, and Care System Recommendations

BACKGROUND

Social risk factors, such as food insecurity and financial needs, are associated with increased risk of cardiovascular diseases, health conditions that are highly prevalent in rural populations. A better understanding of rural Veterans' experiences with social risk factors can inform expansion of Veterans Health Administration (VHA) efforts to address social needs.

OBJECTIVE

To examine social risk and need from rural Veterans' lived experiences and develop recommendations for VHA to address social needs.

DESIGN

We conducted semi-structured interviews with participants purposively sampled for racial diversity. The interview guide was informed by Andersen's Behavioral Model of Health Services Use and the Outcomes from Addressing Social Determinants of Health in Systems framework.

PARTICIPANTS

Rural Veterans with or at risk of cardiovascular disease who participated in a parent survey and agreed to be recontacted.

APPROACH

Interviews were recorded and transcribed. We analyzed transcripts using directed qualitative content analysis to identify themes.

KEY RESULTS

Interviews (n = 29) took place from March to June 2022. We identified four themes: (1) Social needs can impact access to healthcare, (2) Structural factors can make it difficult to get help for social needs, (3) Some Veterans are reluctant to seek help, and (4) Veterans recommended enhancing resource dissemination and navigation support.

CONCLUSIONS

VHA interventions should include active dissemination of information on social needs resources and navigation support to help Veterans access resources. Community-based organizations (e.g., Veteran Service Organizations) could be key partners in the design and implementation of future social need interventions.

Caregiver Perceptions of Social Risk Screening in Pediatric Liver Transplantation: From the Multicenter SOCIAL-Tx Study

BACKGROUND

The social determinants of health contribute to adverse post-liver transplant outcomes. Identifying unmet social risks may enable transplant teams to improve long-term outcomes for at-risk children. However, providers may feel uncomfortable asking about household-level social risks in the posttransplant period because they might make their patients/families uncomfortable.

METHODS

We conducted a mixed-methods analysis of caregiver participants (ie, parents/guardians of pediatric liver transplant recipients) in the Social and Contextual Impact on Children Undergoing Liver Transplantation study to assess their perceptions of provider-based social risk screening. Participants (N = 109) completed a 20-min social determinants of health questionnaire that included questions on the acceptability of being asked intimate social risk questions. A subset of participants (N = 37) engaged in an in-depth qualitative interview to share their perceptions of social risk screening.

RESULTS

Of 109 participants across 9 US transplant centers, 60% reported financial strain and 30% reported at least 1 material economic hardship (eg, food insecurity, housing instability). Overall, 65% of respondents reported it very or somewhat appropriate and 25% reported being neutral to being screened for social risks in a liver transplant setting. In qualitative analyses, participants reported trust in the providers and a clear understanding of the intention of the screening as prerequisites for liver transplant teams to perform social risk screening.

CONCLUSIONS

Only a small minority of caregivers found social risk screening unacceptable. Pediatric liver transplant programs should implement routine social risk screening and prioritize the patient and family voices when establishing a screening program to ensure successful implementation.

Trajectories and correlates of mental health among urban, school-age children during the COVID-19 pandemic: a longitudinal study

BACKGROUND

The COVID-19 pandemic posed numerous obstacles to psychosocial wellbeing for children. We conducted a longitudinal study to evaluate child mental health and social risks during the pandemic.

METHODS

Participants were 172 caregivers of children aged 6-11 years old who attended well child visits within 6 months before pandemic onset at an urban safety net hospital in the US. Prepandemic data was extracted from the electronic medical record, and surveys were administered at three time points between August 2020 and July 2021. We measured mental health symptoms with the Pediatric Symptom Checklist-17, social risks (e.g., food and housing insecurity) with the THRIVE questionnaire, and school modality (in-person, hybrid, remote).

RESULTS

Compared to pre-pandemic, children had significantly higher PSC-17 total scores (overall mental health symptoms) and THRIVE total scores (total burden of social risks) at all three mid-pandemic waves. Using longitudinal mixed models accounting for time, social risks, and school modality, both social risks (B = 0.37, SE = 0.14, p < 0.01) and school modality were significantly associated with PSC-17 scores (B = - 1.95, SE = 0.63, p < 0.01). Children attending in-person school had fewer mental health symptoms than those attending remote or hybrid school.

CONCLUSION

Mental health symptoms and social risks remained significantly higher fifteen months after the onset of the COVID-19 pandemic compared to prepandemic. In-person attendance at school appeared protective against persistently elevated mental health symptoms.

A Randomized Controlled Trial to Improve Unmet Social Needs and Clinical Outcomes Among Adults with Diabetes

BACKGROUND

Adults with type 1 or type 2 diabetes often face financial challenges and other unmet social needs to effective diabetes self-management.

OBJECTIVE

Whether a digital intervention focused on addressing socioeconomic determinants of health improves diabetes clinical outcomes more than usual care.

DESIGN

Randomized trial from 2019 to 2023.

PARTICIPANTS

A total of 600 adults with diabetes, HbA1c ≥ 7.5%, and self-reported unmet social needs or financial burden from a health system and randomized to the intervention or standard care.

INTERVENTION

CareAvenue is an automated, e-health intervention with eight videos that address unmet social needs contributing to poor outcomes.

MEASURES

Primary outcome was HbA1c, measured at baseline, and 6 and 12 months after randomization. Secondary outcomes included systolic blood pressure and reported met social needs, cost-related non-adherence (CRN), and financial burden. We examined main effects and variation in effects across predefined subgroups.

RESULTS

Seventy-eight percent of CareAvenue participants completed one or more modules of the website. At 12-month follow-up, there were no significant differences in HbA1c changes between CareAvenue and control group (p = 0.24). There were also no significant between-group differences in systolic blood pressure (p = 0.29), met social needs (p = 0.25), CRN (p = 0.18), and perceived financial burden (p = 0.31). In subgroup analyses, participants with household incomes 100-400% FPL (1.93 (SE = 0.76), p < 0.01), 201-400% FPL (1.30 (SE = 0.62), p < 0.04), and > 400% FPL (1.27 (SE = 0.64), p < 0.05) had significantly less A1c decreases compared to the control group.

CONCLUSIONS

On average, CareAvenue participants did not achieve better A1c lowering, met needs, CRN, or perceived financial burden compared to control participants. CareAvenue participants with higher incomes achieved significantly less A1c reductions than control. Further research is needed on social needs interventions that consider tailored approaches to population subgroups.

CLINICAL TRIALS REGISTRY

ClinicalTrials.gov ID NCT03950973, May 2019.

Social determinants of health and treatment center affiliation: analysis from the sickle cell disease implementation consortium registry

BACKGROUND

Adults with sickle cell disease (SCD) suffer early mortality and high morbidity. Many are not affiliated with SCD centers, defined as no ambulatory visit with a SCD specialist in 2 years. Negative social determinants of health (SDOH) can impair access to care.

HYPOTHESIS

Negative SDOH are more likely to be experienced by unaffiliated adults than adults who regularly receive expert SCD care.

METHODS

Cross-sectional analysis of the SCD Implementation Consortium (SCDIC) Registry, a convenience sample at 8 academic SCD centers in 2017-2019. A Distressed Communities Index (DCI) score was assigned to each registry member's zip code. Insurance status and other barriers to care were self-reported. Most patients were enrolled in the clinic or hospital setting.

RESULTS

The SCDIC Registry enrolled 288 Unaffiliated and 2110 Affiliated SCD patients, ages 15-45y. The highest DCI quintile accounted for 39% of both Unaffiliated and Affiliated patients. Lack of health insurance was reported by 19% of Unaffiliated versus 7% of Affiliated patients. The most frequently selected barriers to care for both groups were "previous bad experience with the healthcare system" (40%) and "Worry about Cost" (17%). SCD co-morbidities had no straightforward trend of association with Unaffiliated status. The 8 sites' results varied.

CONCLUSION

The DCI economic measure of SDOH was not associated with Unaffiliated status of patients recruited in the health care delivery setting. SCDIC Registrants reside in more distressed communities than other Americans. Other SDOH themes of affordability and negative experiences might contribute to Unaffiliated status. Recruiting Unaffiliated SCD patients to care might benefit from systems adopting value-based patient-centered solutions.

Do healthcare providers consider the social determinants of health? Results from a nationwide cross-sectional study in the United States

BACKGROUND

While the social determinants of health (SDOH) have a greater impact on individual health outcomes than the healthcare services a person receives, healthcare providers face barriers to addressing these factors in clinical settings. Previous studies have shown that providers often lack the necessary knowledge and resources to adequately screen for and otherwise assist patients with unmet social needs. This study explores the perceptions and behaviors related to SDOH among healthcare providers in the United States (US).

METHODS

This cross-sectional study analyzed data from a 22-item online survey using Reaction Data's research platform of healthcare professionals in the US. Survey items included demographic questions as well as Likert scale questions about healthcare providers' perceptions and behaviors related to SDOH. Descriptive statistics were calculated, and further analyses were conducted using t-tests and analysis of variance.

RESULTS

A total of 563 respondents completed the survey, with the majority being male (72.6%), White (81%), and located in urban areas (82.2%). In terms of perceptions, most providers agreed or strongly agreed that SDOH affect the health outcomes of all patients (68.5%), while only 24.1% agreed or strongly agreed that their healthcare setting was set up to address SDOH. In terms of behavior, fewer than half currently screened for SDOH (48.6%) or addressed (42.7%) SDOH in other ways. Most providers (55.7%) wanted additional resources to focus on SDOH. Statistical analyses showed significant differences by gender, with females being more likely than males to prioritize SDOH, and by specialty, with psychiatrists, pediatricians, and family/general medicine practitioners being more likely to prioritize SDOH.

CONCLUSION

Most healthcare providers understand the connection between unmet social needs and their patients' health, but they also feel limited in their ability to address these issues. Ongoing efforts to improve medical education and shift the healthcare system to allow for payment and delivery of more holistic care that considers SDOH will likely provide new opportunities for healthcare providers. In addition to what they can do at the institutional and patient levels, providers have the potential to advocate for policy and system changes at the societal level that can better address the root causes of social issues.

High Prevalence of Adverse Social Determinants of Health in Dialysis Access Creation Patients in a Safety-Net Setting

BACKGROUND

Patients receiving dialysis access surgery are often exposed to adverse social determinants of health (SDH) that negatively impact their care. Our goal was to characterize these factors experienced by our arteriovenous dialysis access patients and identify differences in health outcomes based on their SDH.

METHODS

We performed a retrospective cohort study of all patients who underwent dialysis access creation (2017-2021) and were screened for SDH at a clinical visit (using THRIVE survey) implemented at an urban, safety-net hospital institution within 1 year of access creation. Demographics, procedural details, early postoperative outcomes, survey responses, and referral to our hospital's preventive food pantry were recorded. Univariable analysis and multivariable analyses were performed to assess for associations with key health outcomes.

RESULTS

There were 190 patients who responded to the survey within 1 year of their operation. At least 1 adverse SDH was identified in 42 (22%) patients. Normalized to number of respondents for each question, adverse SDH identified were difficulty obtaining transportation to medical appointments (18%), food insecurity (16%), difficulty affording utilities (13%), difficulty affording medication (12%), unemployed and seeking employment (9%), unstable housing (7%), difficulty caring for family/friends (6%), and desiring more education (5%). There were 71 (37%) patients who received food pantry referrals. Mean age was 60 years and 38% of patients were female and 64% were Black. More than half of patients (57%) had a tunneled dialysis catheter (TDC) at the time of access creation. Dialysis accesses created were brachiocephalic (39%), brachiobasilic (25%), radiocephalic fistulas (16%), and arteriovenous grafts (14%). Thirty-day emergency department (ED) visits, 30-day readmissions, and 90-day mortality occurred in 23%, 21%, and 2%, respectively. On univariable and multivariable analyses, any adverse SDH determined on survey and food pantry referral were not associated with preoperative dialysis through TDCs, receiving nonautogenous dialysis access, 30-day ED visits and readmissions, or 90-day mortality.

CONCLUSION

Nearly a quarter of dialysis access surgery patients at a safety-net hospital experienced adverse SDH and more than one-third received a food pantry referral. Most common difficulties experienced include difficulty obtaining transportation to medical appointments, food insecurity, and difficulty paying for utilities and medication. Although there were no differences in postoperative outcomes, the high prevalence of these adverse SDH warrants prioritization of resources in this population to ensure healthy equity and further investigation into their effects on health outcomes.

Addressing adverse social determinants of health in pediatric primary care: Study protocol for a hybrid type 2 effectiveness-implementation randomized controlled trial in two national pediatric practice-based research networks

BACKGROUND

Growing evidence linking social determinants of health (SDOH) to child health outcomes has prompted widespread recommendations for pediatricians to screen and refer for adverse SDOH at primary care visits. Yet there is little evidence to date demonstrating the effectiveness of practice-based SDOH screening and referral interventions on increasing family engagement with resources. This hybrid type 2 effectiveness-implementation trial aims to demonstrate the non-inferiority of a low-touch implementation strategy in order to facilitate dissemination of an existing SDOH screening and referral system (WE CARE) and demonstrate its effectiveness and sustainability in various pediatric practices.

METHODS

We recruited eighteen pediatric practices in fourteen US states through two pediatric practice-based research networks. For this stepped wedge cluster RCT, practices serve as their own controls during the Usual Care phase and implement WE CARE during the intervention phase via one of two randomized implementation strategies: self-directed, pre-recorded webinar vs. study team-facilitated, live webinar. We collect data at practice, clinician/staff, and parent levels to assess outcomes grounded in the Proctor Conceptual Model of Implementation Research. We use generalized mixed effects models and differences in proportions to compare rates of resource referrals by implementation strategy, and intention-to-treat analysis to compare odds of engagement with new resources among families enrolled in the Usual Care vs. WE CARE phases.

DISCUSSION

Findings from this trial may inform decisions about broader dissemination of SDOH screening systems into a diverse spectrum of pediatric practices across the US and potentially minimize the impact of adverse SDOH on children and families.

Factors Associated With Transitions to Adult Care Among Adolescents and Young Adults With Medical Complexity

Introduction: Thanks to advances in healthcare and technology, adolescents with medical complexity (AMC) and life-threatening conditions are living longer lives and may be expected to transition to adult health care. Yet, current systems and policies of transition care may not reflect their needs, those of their family, or the impact of social determinants of health. The goal of this study was to describe the relationship between social determinants of health and high-quality transition care. Methods: Retrospective cohort study of the 2019-2020 National Survey of Children's Health. The main outcome variable was any support for transition to adult health care. Independent variables were based on a social determinants of health framework. Weighted logistic regression was used to evaluate the association between social determinants and any support for transition to adult health care. Results: Final weighted sample included 444,915 AMC. AMC were distributed across income levels, most commonly lived in the South, and in supportive, resilient communities. More than 50% experienced adverse childhood events and less than 50% had adequate insurance. Less than one third received any transition support from providers; those who did reported time alone with the provider or active management. Social determinants related to missed days of school, community support/family context, and poverty were associated with both receipt and absence of transition care. Conclusion: AMC and their families navigate complex environments and associated stressors. Social determinants of health, particularly economic, community/social, and healthcare exert significant and nuanced influence. Such impacts should be incorporated into transition care.

The Impact of Social Determinants of Health on Outcomes and Complications After Total Knee Arthroplasty: An Analysis of Neighborhood Deprivation Indices

BACKGROUND

Social determinants of health (SDOH) are important factors in the delivery of orthopaedic care. The purpose of this study was to investigate the relationship between outcomes following total knee arthroplasty (TKA) and both the Social Vulnerability Index (SVI) and the Area Deprivation Index (ADI).

METHODS

The Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) database was utilized to identify TKA cases for inclusion. Demographic characteristics and medical history were documented. The SVI, its subthemes, and the ADI were analyzed. Outcome data included length of stay, discharge disposition, postoperative change in the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS, JR), 90-day incidences of emergency department (ED) visits, readmission, death, deep venous thrombosis (DVT) and/or pulmonary embolism (PE), periprosthetic fracture, implant failure, periprosthetic joint infection (PJI), and all-cause reoperation. Database cross-referencing was completed to document aseptic and septic revisions beyond 90 days postoperatively. Bivariate quartile-stratified and multivariable analyses were used to associate deprivation metrics with outcomes.

RESULTS

A total of 19,321 TKA cases met inclusion criteria. Baseline patient characteristics varied among the SVI and/or ADI quartiles, with patients of non-White race and with a greater number of comorbidities noted in higher deprivation quartiles. Higher SVI and/or ADI quartiles were correlated with an increased rate of discharge to a skilled nursing facility (p < 0.05). A higher SVI and/or ADI quartile was associated with increased incidences of ED visits and readmissions postoperatively (p < 0.05). DVT and/or PE and long-term aseptic revision were the complications most strongly associated with higher deprivation metrics. Upon multivariable analysis, greater length of stay and greater incidences of ED visits, readmissions, DVT and/or PE, and aseptic revision remained significantly associated with greater deprivation based on multiple metrics.

CONCLUSIONS

Greater deprivation based on multiple SVI subthemes, the composite SVI, and the ADI was significantly associated with increased length of stay, non-home discharge ED visits, and readmissions. The SVI and the ADI may be important considerations in the perioperative assessment of patients who undergo TKA.

LEVEL OF EVIDENCE

Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Routine screening for adverse childhood experiences (ACEs) still doesn't make sense

When a serious health or social problem is identified as both prevalent and in need of attention, a common response is to propose that various systems implement routine identification, such as universal screening. However, these well-intentioned responses often fail to consider the key requirements necessary to determine whether benefits outweigh harms. Unfortunately, this continues to be the case for calls to implement routine screening for Adverse Childhood Experiences (ACEs). Persistent evidence gaps for this type of screening include the lack of any randomized controlled trials demonstrating that ACEs screening programs lead to any benefits. Rather than being informed by established screening principles, the calls to proceed with ACEs screening appear to rely on the assumption that simply identifying risk factors can lead to beneficial outcomes that outweigh any risk of harms. This may reflect a gap in understanding that patterns identified at the population level (e.g., that more ACEs are associated with more health and social problems) cannot be directly translated to practices at the level of the individual. This commentary does not question the importance of ACEs; rather it identifies that directing limited resources to screening approaches for which there is no evidence that benefits outweigh harms is problematic. Instead, we advocate for the investment in high-quality trials of prevention interventions to determine where best to direct limited resources to reduce the occurrence of ACEs, and for the prioritization of evidence-based treatment services for those with existing health and social conditions, whether or not they are attributed to ACEs.

The Utility of the Social Vulnerability Index as a Proxy for Social Disparities Following Total Knee Arthroplasty

BACKGROUND

In 2021, alternative payment models accounted for 40% of traditional Medicare reimbursements. As such, we sought to examine health disparities through a standardized categorization of social disparity using the social vulnerability index (SVI). We examined (1) risk factors for SVI ≥ 0.50, (2) incidences of complications, and (3) risk factors for total complications between patients who have SVI < 0.50 and SVI ≥ 0.50 who had a total knee arthroplasty (TKA).

METHODS

Patients who underwent TKA between January 1, 2022 and December 31, 2022 were identified in the state of Maryland. A total of 4,952 patients who had complete social determinants of health data were included. Patients were divided into 2 cohorts according to SVI: < 0.50 (n = 2,431) and ≥ 0.50 (n = 2,521) based on the national mean SVI of 0.50. The SVI identifies communities that may need support caused by external stresses on human health based on 4 themed scores: socioeconomic status, household composition and disability, minority status and language, and housing and transportation. The SVI theme of household composition and disability encompassed patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies. The higher the SVI, the more social vulnerability or resources are needed to thrive in a geographic area.

RESULTS

When controlling for risk factors and patient comorbidities, the theme of household composition and disability (odds ratio 2.0, 95% confidence interval 1.1 to 5.0, P = .03) was the only independent risk factor for total complications. Patients who had an SVI ≥0.50 were more likely to be women (65.8% versus 61.0%, P < .001), Black (34.4% versus 12.9%, P < .001), and have a median household income < $87,999 (21.3% versus 10.2%, P < .001) in comparison to the patients who had an SVI < 0.50, respectively.

CONCLUSIONS

The SVI theme of household composition and disability, encompassing patients aged 65 years and more, patients aged 17 years and less, civilians who have a disability, single-parent households, and English language deficiencies, were independent risk factors for total complications following TKA. Together, these findings offer opportunities for interventions with selected patients to address social disparities.

National patterns in the use of International Statistical Classification of Diseases and Health Related Problems, tenth revision Z codes in ambulatory surgery from 2016 to 2019

BACKGROUND

In the tenth revision of the International Statistical Classification of Disease and Health Related Problems (ICD-10), Z codes were added to improve documentation and understanding of health-related social needs. We estimated national Z code use in the ambulatory surgery setting from 2016 to 2019.

METHODS

Using the Nationwide Ambulatory Surgery Sample (NASS), we identified encounters for ambulatory surgery with an ICD-10 code between Z55.0 and Z65.9. Data were stratified by Z code domains from the Centers for Medicare and Medicaid Services (CMS).

RESULTS

This analysis of 41,827 ambulatory surgery encounters with documented Z codes found that the most documented determinants of health related to multiparity or unwanted pregnancy, homelessness, and incarceration. There was a 16.1% increase in the use of Z codes from 2016 to 2019.

CONCLUSION

Rates of Z code use in the ambulatory surgery setting are increasing with current documentation serving as a specific but not sensitive measure of socioeconomic need.

The Use of Telemedicine for Screening and Addressing Social Needs in a Primary Care Pediatric Population in Brooklyn, New York

The objective of this study was to analyze temporal changes in social needs (SN), comparing those who received routine annual in-person care to those receiving SN screenings through a combination of tele-social care and in-person care biannually. Our prospective cohort study used a convenience sample of patients from primary care practices. Baseline data were collected from April 2019 to March 2020. The intervention group (n = 336) received SN screening and referral telephone outreach from June 2020 to August 2021. The control group (n = 2890) was screened, in person, during routine visits at baseline and summer 2021. We used a repeated-measures logistic regression with general estimating equations to assess incremental change in individual SN for the intervention group. Food, housing, legal and benefit needs increased and peaked at the beginning of the pandemic and decreased after interventions (P < 0.001). There was a 32% decrease in the odds of food insecurity for those in the intervention group compared to the control group (adjusted OR 0.668, 95% confidence interval 0.444-1.004, P = 0.052), and a 75% decrease in the odds of housing insecurity (adjusted OR 0.247, 95% confidence interval 0.150-0.505, P < 0.001). During COVID-19, there was an increase in SN followed by a decrease after interventions were offered. Those who completed tele-social care showed greater improvements in social needs than those in routine care, with the greatest improvements in food and housing needs.

Improving food insecurity screening across a health system throughout the COVID-19 pandemic

BACKGROUND

Food insecurity has direct and indirect negative outcomes on the physical and mental health of children, with impacts throughout adult life. Rates of food insecurity have increased dramatically since the start of the COVID-19 pandemic. The American Academy of Pediatrics recommends paediatricians screen and intervene to address food insecurity. We aimed to increase the percentage of patient encounters with food insecurity screening completion at the paediatric medical home from 0% to 85% by July 2020 with extension to the paediatric emergency department (ED) and paediatric specialty clinic in the following year.

METHODS

This multicentre project occurred in three sites within our health system: a teaching safety-net, paediatric medical home; a paediatric ED; and five divisions within paediatric specialty medical clinics. A screening tool was created using the validated Hunger Vital Sign Questionnaire. A standard screening, documentation and referral process was developed. The Model for Improvement was used testing changes via Plan-Do-Study-Act cycles.

RESULTS

The percentage of households screened for food insecurity increased from a median of 0% to 30% for all sites combined. There was significant variability in screening with the ED screening a median of 24% and the medical home screening 80% by the end of the study period. A total of 9842 households (20.9%) screened were food insecure. During the study period, 895 families with 3925 household members received 69 791 pounds of food from our primary community resource using our clinic's food prescription. Of these families, 44% (398) also qualified for the US Department of Agriculture programme ensuring ongoing food distribution up to twice a month.

DISCUSSION

Using quality improvement methodology to address a critical community need, we implemented food insecurity screening across a hospital system including multiple sites and specialties and provided critical resources to households in need.

Revising the Logic Model Behind Health Care's Social Care Investments

Policy Points This article summarizes recent evidence on how increased awareness of patients' social conditions in the health care sector may influence health and health care utilization outcomes. Using this evidence, we propose a more expansive logic model to explain the impacts of social care programs and inform future social care program investments and evaluations.

Drivers for low-acuity pediatric emergency department visits in two tertiary hospitals in Switzerland: a cross-sectional, questionnaire-based study

PURPOSE

Low-acuity pediatric emergency department (PED) visits are frequent in high-income countries and have a negative impact on patient care at the individual and health system levels. Knowing what drives low-acuity PED visits is crucial to inform adaptations in health care delivery. We aimed to identify factors associated with low-acuity PED visits in Switzerland, including socioeconomic status, demographic features, and medical resources of families.

METHODS

We conducted a prospective, questionnaire-based study in the PEDs of two Swiss tertiary care hospitals, Bern and Lausanne. We invited all consecutive children and their caregiver attending the PED during data collection times representative of the overall PED consultation structure (e.g. day/night, weekdays/weekends) to complete a questionnaire on demographic features, socioeconomic status, and medical resources. We collected medical and administrative data about the visit and defined low-acuity visits as those meeting all of the following criteria: (1) triage category 4 or 5 on the Australasian Triage Scale, (2) no imaging or laboratory test performed, and (3) discharge home. We used a binary multiple logistic regression model to identify factors associated with low-acuity visits.

RESULTS

We analysed 778 PED visits (September 2019 to July 2020). Most children visiting our PEDs had a designated primary care provider (92%), with only 6% not having seen them during the last year. Fifty-five per cent of caregivers had asked for medical advice before coming to the PED. The proportion of low-acuity visits was 58%. Low-acuity visits were associated with caregiver's difficulties paying bills (aOR 2.6, 95% CI 1.6 - 4.4), having already visited a PED in the last 6 months (aOR 1.7, 95% CI 1.1 - 2.5) but not with parental education status, nor parental country of birth, parental employment status or absence of family network.

CONCLUSION

Economic precariousness is an important driver for low-acuity PED visits in Switzerland, a high-income country with compulsory health coverage where most children have a designated primary care provider and a regular pediatric follow-up. Primary care providers and PEDs should screen families for economic precariousness and offer anticipatory guidance and connect those in financial need to social support.

Racial differences in length of stay and readmission for asthma in the all of us research program

BACKGROUND

This study addresses the limited research on racial disparities in asthma hospitalization outcomes, specifically length of stay (LOS) and readmission, across the U.S.

METHODS

We analyzed in-patient and emergency department visits from the All of Us Research Program, identifying various risk factors (demographic, comorbid, temporal, and place-based) associated with asthma LOS and 30-day readmission using Bayesian mixed-effects models.

RESULTS

Of 17,233 patients (48.0% White, 30.7% Black, 19.7% Hispanic/Latino, 1.3% Asian, and 0.3% Middle Eastern and North African) with 82,188 asthma visits, Black participants had 20% shorter LOS and 12% higher odds of readmission, compared to White participants in multivariate analyses. Public-insured patients had 14% longer LOS and 39% higher readmission odds than commercially insured patients. Weekend admissions resulted in a 12% shorter LOS but 10% higher readmission odds. Asthmatics with chronic diseases had a longer LOS (range: 6-39%) and higher readmission odds (range: 9-32%) except for those with allergic rhinitis, who had a 23% shorter LOS.

CONCLUSIONS

A comprehensive understanding of the factors influencing asthma hospitalization, in conjunction with diverse datasets and clinical-community partnerships, can help physicians and policymakers to systematically address racial disparities, healthcare utilization and equitable outcomes in asthma care.

Association Between Family Income and Positive Developmental Screening Using the Infant Toddler Checklist at the 18-Month Health Supervision Visit

OBJECTIVE

To examine the associations between several potential predictors (child biologic, social, and family factors) and a positive screen for developmental delay using the Infant Toddler Checklist (ITC) at the 18-month health supervision visit in primary care.

METHODS

This was a cross-sectional study of healthy children attending an 18-month health supervision visit in primary care. Parents completed a standardized questionnaire, addressing child, social, and family characteristics, and the ITC. Logistic regression analyses were used to assess the associations between predictors and a positive ITC.

RESULTS

Among 2188 participants (45.5% female; mean age, 18.2 months), 285 (13%) had a positive ITC and 1903 (87%) had a negative ITC. The aOR for a positive ITC for male compared with female sex was 2.15 (95% CI, 1.63-2.83; P < .001). The aOR for birthweight was 0.65 per 1 kg increase (95% CI, 0.53-0.80; P < .001). The aOR for a family income of <$40,000 compared with ≥$150,000 was 3.50 (95% CI, 2.22-5.53; P < .001), and the aOR for family income between $40,000-$79,999 compared with ≥$150,000 was 1.88 (95% CI, 1.26-2.80; P = .002).

CONCLUSIONS

Screening positive on the ITC may identify children at risk for the double jeopardy of developmental delay and social disadvantage and allow clinicians to intervene through monitoring, referral, and resource navigation for both child development and social needs.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT01869530).

Social determinants of health for children with cerebral palsy and their families

Social determinants of health (SDH) influence health and social outcomes in positive and negative ways. Understanding the impact of SDH on children with cerebral palsy (CP) is essential to improve health equity, optimize health outcomes, and support children with CP and their families to thrive in society. In this narrative review, we summarize the landscape of SDH impacting children with CP and their families worldwide. In high-income countries, children from poorer neighbourhoods are more likely to have severe comorbidities, present with spastic bilateral CP, and report lower frequency of participation in community activities. In low- and middle-income countries, socioeconomic disadvantage is associated with increased risk of malnutrition, living in poorer housing conditions, not having access to proper sanitation, and living below the poverty line. Low maternal education is associated with increased likelihood of the child with CP experiencing increased severity of gross motor and bimanual functioning challenges, and poorer academic performance. Lower parental education is also associated with reduced child autonomy. On the other hand, higher parental income is a protective factor, associated with greater diversity of participation in day-to-day activities. A better physical environment and better social support are associated with higher participation in daily activities. Clinicians, researchers, and the community should be aware of these key challenges and opportunities. Then adopt a range of approaches that target adverse SDH/social needs and foster positive SDH in the clinical setting. WHAT THIS PAPER ADDS: Understanding how social determinants of health influence health and social outcomes is a critical step towards improving health equity and outcomes. Approaches are required that target the impact of adverse SDH on access to health care for children with cerebral palsy and that work towards ensuring equity of access for all.

Assessing Strengths, Challenges, and Equity Via Pragmatic Evaluation of a Social Care Program

OBJECTIVE

Models of pragmatic social care program evaluations are needed as many are clinical services programs and are not focused on research, limiting the ability to address key evidence gaps. We describe the use of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to conduct a pragmatic evaluation of a pediatric ambulatory social care program.

METHODS

Our evaluation was based on automated electronic health record data on clinics, community partners, social care program processes, and social needs screen data linked to patient sociodemographic characteristics from February 2020 to September 2021. Two Reach outcomes were assessed: 1) the proportion of eligible patients that completed social needs screening and 2) the proportion of positive screens that receive social care program follow-up. The Effectiveness outcome was meeting families' resource need(s).

RESULTS

Reach among eligible patients who completed screening was 79.2%. Reach for positive screens receiving social care program referrals demonstrated a higher proportion of referrals among patients with a preferred healthcare language (PHL) of Spanish (45.1%) compared to English (31.2%, P < .001). Effectiveness analyses demonstrated that overall, 75.1% of social care program referrals had all social resource needs met, 17.5% had some needs met, and 7.4% had no needs met. The percent of patients with all resource needs met was higher for patients with PHL of Spanish or Non-English, Non-Spanish (79% for each respectively) compared to English (73%, P = .023).

CONCLUSIONS

Maximizing automated data collection is likely the most feasible way for social care programs to complete evaluation activities outside of the research context.

Addressing unmet social needs for improved maternal and child nutrition: Qualitative insights from community-based organisations in urban South Africa

Maternal and child malnutrition persists globally, despite existing healthcare and social protection systems. Socio-economic disadvantages contribute to high malnutrition rates, particularly in poor urban communities where many disadvantaged mothers cannot fully benefit from services. To address these disparities, a novel social needs framework has been proposed, emphasising the importance of addressing individuals' unmet needs to enhance the benefits of nutrition services. This study investigates the perceived impact of community-based organisations (CBOs) in addressing the social needs of mothers in a resource-constrained urban township in South Africa. Interviews were conducted with 18 employees from 10 CBOs working on maternal and child health, food security and social support in Soweto. Thematic analysis revealed 23 services and four pathways through which CBOs believed to address unmet social needs of beneficiaries. Services were small-scale, including food aid, learning support, and social protection assistance, available to a few in dire need. CBO services partially addressed social needs of mothers due to scale, coverage, and sustainability limitations. The South African government should reaffirm its commitment to financially supporting the non-profit sector and integrating it into government sectors to provide tailored services and resources to address diverse social needs and mitigate nutrition inequalities among mothers and children.

Accuracy of a Single Financial Security Question to Screen for Social Needs

OBJECTIVES

Screening for social needs is recommended during clinical encounters but multi-item questionnaires can be burdensome. We evaluate if a single question about financial stress can be used to prescreen for food insecurity, housing instability, or transportation needs.

METHODS

We use retrospective medical record data from children (<11 years) seen at 45 primary pediatric care offices in 2022. Social needs screening was automated at well child visits and could be completed by the parent/guardian via the patient portal, tablet in the waiting room, or verbally with staff. We report the area under the receiver operating curve for the 5 response options of the financial stress question as well as sensitivity and specificity of the financial stress question ("not hard at all" vs any other response) to detect other reported social needs.

RESULTS

Of 137 261 eligible children, 130 414 (95.0%) had social needs data collected. Seventeen percent of respondents reported a housing, food, or transportation need. The sensitivity of the financial stress question was 0.788 for any one or more of the 3 other needs, 0.763 for food insecurity, 0.743 for housing instability, and 0.712 for transportation needs. Using the financial stress question as the first-step of a screening process would miss 9.7% of the families who reported food insecurity, 22.6% who reported housing instability, and 33.0% who reported transportation needs.

CONCLUSIONS

A single question screener about financial stress does not function well as a prescreen because of low sensitivity to reports of food insecurity, housing instability, and transportation needs.

The Role of an Early Childhood Community Health Worker in Addressing Psycho-Social Needs in the Perinatal and Early Childhood Period

OBJECTIVE

Addressing family psychosocial and mental health needs in the perinatal and early childhood period has a significant impact on long-term maternal and child health and is key to achieving health equity. We aimed to (1) describe and evaluate the role of an Early Childhood Community Health Worker (EC-CHW) to address psychosocial needs and improve psychosocial well-being for families in the perinatal period, and (2) examine factors associated with completion of goals.

METHODS

An EC-CHW program was modeled after an existing hospital CHW program for children with special healthcare needs and chronic disease. An evaluation was conducted using repeated measures to assess improvements in psychosocial outcomes such as family stress and protective factors after participating in the EC-CHW program. Linear regression was also used to assess factors associated with completion of goals.

RESULTS

Over a 21-month period (January 2019-September 2020), 161 families were referred to the EC-CHW. The most common reasons for referral included social needs and navigating systems for child developmental and behavioral concerns. There were high rates of family engagement in services (87%). After 6 months, families demonstrated statistically significant improvements in protective factors including positive parenting knowledge and social support. Only 1 key predictor variable, maternal depression, showed significant associations with completion of goals in the multivariable analysis.

CONCLUSIONS

This study demonstrated the need for, and potential impact of an EC-CHW in addressing psychosocial and mental health needs in the perinatal period, and in a primary care setting. Impacts on protective factors are promising.

Addressing Social Determinants of Health in a Free Clinic Setting: A Student-Run Free Clinic and Community Resource Navigator Program

Background

Social determinants of health (SDOH) disproportionately affect medically-underserved populations such as those cared for in student-run free clinics (SRFCs). Community resource programs which address SDOH play an important role in reducing health disparities. The Southside MEDiC Clinic (SMC), a SRFC at the University of Wisconsin School of Medicine and Public Health, partnered with the Community Resource Navigator Program (CRNP), a community resource program focused on addressing SDOH, to remove barriers that prevent positive health outcomes for SMC patients.

Aim

Our objective is to describe the partnership between the SMC and the CRNP. We hope this design may be used as a model for addressing SDOH in other SRFCs.

Discussion

Partnership goals include improved patient perception of health, increased communication between patients and the clinic, and enhanced opportunities for volunteer action learning. Challenges discussed include adaptation to unique clinics. Future directions and potential advancements in this partnership are also addressed.

Recommandations pour des soins préventifs pour promouvoir l’équité en matière de santé

Contexte:

Malgré des investissements importants dans un système de soins de santé public qui comprend des services préventifs, on continue d’observer des disparités évitables en matière de santé au Canada. L’équipe avait pour objectif de formuler des recommandations pour des soins de santé préventifs qui puissent améliorer l’équité en matière de santé par la priorisation des interventions efficaces à l’intention des groupes défavorisés.

Méthodes:

La ligne directrice a été élaborée par un comité composé de spécialistes en soins primaires et de membres de la patientèle, avec la contribution d’un groupe de patientes-et patientspartenaires ayant vécu diverses expériences. Après avoir sélectionné les sujets à prioriser, nous avons recensé les revues systématiques, les essais randomisés et contrôlés récents sur les méthodes de dépistage et d’autres études pertinentes sur l’efficacité du dépistage et de la prise en charge. Nous avons utilisé l’approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation) pour formuler les recommandations et avons suivi le guide AGREE II (Appraisal of Guidelines for Research and Evaluation) pour rédiger le rapport. Il en a été de même avec les principes du Guidelines International Network pour la gestion des intérêts concurrents. Les recommandations ont été passées en revue par un comité externe d’experts en contenu avant d’être distribuées à des intervenants à l’échelle nationale pour approbation.

Recommandations:

Nous avons formulé 15 recommandations concernant le dépistage et d’autres soins préventifs et 1 recommandation de nature politique visant à améliorer l’accès aux soins primaires. Ainsi, nous recommandons de prioriser une stratégie de communication pour le dépistage du cancer colorectal à partir de l’âge de 45 ans et pour l’évaluation du risque de maladie cardiovasculaire pour lutter contre les iniquités en matière de santé et promouvoir la santé. Les interventions particulières qui devraient être déployées pour lutter contre les iniquités comprennent l’autodépistage du virus du papillome humain (VPH) et du VIH, et le test de libération de l’interféron γ pour l’infection tuberculeuse. Le dépistage de la dépression, de la toxicomanie, de la violence conjugale et de la pauvreté devrait également permettre aux personnes touchées d’accéder plus facilement à des interventions éprouvées. Nous recommandons une prise de contact systématique avec des professionnels de la santé en soins primaires pour les personnes défavorisées.

Interprétation:

Les interventions préventives éprouvées peuvent aider à combattre les iniquités en matière de santé si la priorité est accordée aux personnes défavorisées. Les médecins, les organisations de santé et les gouvernements devraient adopter des mesures fondées sur des données probantes et en faire le suivi s’ils veulent promouvoir l’équité en matière de santé partout au Canada.

Effect of the Children and Young People's Health Partnership model of paediatric integrated care on health service use and child health outcomes: a pragmatic two-arm cluster randomised controlled trial

BACKGROUND

Paediatric health systems across high-income countries are facing avoidable adverse outcomes and increasing demands and costs. The aim of this study was to compare the effect of an enhanced usual care model with that of an integrated health-care model that offers local health clinics for general paediatric problems and early intervention and care for children and young people with tracer conditions.

METHODS

In this pragmatic two-arm cluster randomised controlled trial, we compared the Children and Young People's Health Partnership (CYPHP) model of care versus enhanced usual care (EUC) among children registered at general practices in south London, UK. The CYPHP trial intervention was delivered between April 1, 2018, and June 30, 2021, and children younger than 16 years during the intervention period and registered at study practices on June 30, 2021, were included in the analysis. A restricted randomisation (1:1) following a computer-generated sequence was done by a masked independent statistician at the level of general practice cluster, stratified by borough (Lambeth or Southwark). Cluster allocation and data collection were masked, with unmasking of trial statisticians before analysis. The CYPHP model comprised all elements of EUC (electronic decision support, a primary care hotline, health checks, self-management support and health promotion, and resilience building and mental health first aid) plus local child health clinics delivered by paediatricians and general practitioners, and a nurse-led early intervention service for children with tracer conditions (asthma, eczema, and constipation). Primary outcomes were non-elective admissions (NELA; admissions coded as an emergency) among the whole trial population up to June 30, 2021, and paediatric quality of life (Pediatric Quality of Life Inventory [PedsQL]) among participants with tracer conditions at 6 months after recruitment. Secondary outcomes were primary and secondary care use, child mental health, parental wellbeing, standardised symptom scores for asthma, eczema, and constipation, health-care quality, and child absences from school and parent absences from work. The trial was registered on ClinicalTrials.gov, NCT03461848, and is complete.

FINDINGS

The trial was conducted between April 1, 2018, and Dec 31, 2021. In total, 23 general practice clusters, consisting of 70 practices with 97 970 registered children, were randomised to CYPHP (n=11) or EUC (n=12). We found no effect, at the population level, of CYPHP versus EUC on non-elective admissions during the intervention period (adjusted mean incidence rate ratio [IRR] 1·00 [95% CI 0·91 to 1·10], p=0·99). Among children with tracer conditions, we found no difference in paediatric quality of life (PedsQL score) at 6 months (adjusted mean difference -0·033 [95% CI -0·122 to 0·055], p=0·46). As a secondary outcome, among children with tracer conditions and requiring care, NELA rates at 12 months did not differ between the CYPHP and EUC groups (66·1 per 1000 person-years vs 75·3 per 1000 person-years; adjusted mean IRR 0·87 [0·61-1·22], p=0·42). In children requiring care, a statistically significant improvement was observed in eczema symptoms at 6 months from baseline in the CYPHP group versus the EUC group (adjusted mean difference -1·370 [-2·630 to -0·122], p=0·032). Quality of asthma care significantly improved among children in the CYPHP group compared with children in the EUC group. No significant improvement was seen for all other secondary outcomes.

INTERPRETATION

Although the CYPHP trial found a null effect for the primary outcomes, we found clinically important improvements in some secondary outcomes including care quality. Previous research has shown that large-scale system change requires time to observe a potential positive effect.

FUNDING

Guy's and St Thomas Charity, the Lambeth and Southwark Clinical Commissioning Groups, and Evelina London Children's Hospital.

Screening for the social determinants of health: Referring patients to community-based services

BACKGROUND

Screening patients for the social determinants of health (SDOH) allows clinicians to identify those needs and tailor referral efforts. Due to constraints on clinic time and monetary resources, a simple screening tool incorporated into existing clinic workflow increases its usefulness and impact.

LOCAL PROBLEM

Our free, nurse-led, mobile health clinic (MHC) needed an enhanced process or tool for screening patients for SDOH. The purpose of this quality-improvement project was to screen adult patients in the MHC for SDOH needs and to increase volunteer staff perceptions of their knowledge and confidence in referring patients to relevant community-based services.

METHODS

A screening process and tool was developed using guidelines from the Health Leads to identify patients' SDOH needs and related requests for assistance. The tool was introduced to and tested among volunteer staff through pretest/posttest surveys.

INTERVENTIONS

Patients who visited the clinic were screened for the SDOH within the project period, and volunteer staff were surveyed about their perceptions of the screening tool.

RESULTS

Sixty-four patients were screened for SDOH needs. Twenty-three percent reported food insecurity, 27% housing insecurity, 14% difficulty obtaining utilities, and 17% difficulty obtaining transportation; 28% requested assistance with their reported SDOH needs. Seventeen percent of patients reported two or more SDOH needs. At posttest, 100% of volunteer staff ( N = 9) indicated satisfaction with the SDOH screening questions, reported feeling knowledgeable about resources to use for patient referrals, and were confident in referring patients to needed resources.

CONCLUSION

The screening tool aptly guided practice and was evaluated as "easy to use" for clinic patients and volunteer staff.

Integrating social care into gynecologic oncology: Identifying and addressing patient's social needs

OBJECTIVE

We aimed to identify social needs of gynecologic oncology patients using a self-administered social needs assessment tool (SNAT), compare the SNAT to a formal social work assessment performed by cancer care navigators (CCN), and provide SNAT-informed community resources.

METHODS

We analyzed prospectively collected data from a performance improvement initiative in a safety-net gynecologic oncology clinic between October 2021 and July 2022. We screened for eight social needs domains, health literacy, desire for social work, and presence of urgent needs. Clinicodemographic data were abstracted from the electronic medical record. Univariate descriptive statistics were used. Inter-rater reliability for social needs domains was assessed using percent agreement.

RESULTS

1010 unique patients were seen over this study period. 488 (48%) patients completed the SNAT, of which 265 (54%) screened positive for ≥1 social need. 83 (31%) patients were actively receiving cancer treatment, 140 (53%) were in post-treatment surveillance, and 42 (16%) had benign gynecologic diagnoses. Transportation (19% vs 25%), housing insecurity (18% vs 19%), and desire to speak with a social worker (16% vs 27%) were the 3 most common needs in both the entire cohort and among patients actively receiving cancer treatment. 78% patients in active treatment were seen by a CCN and received SNAT informed community resources. The percent agreement between the SNAT and formal CCN assessment ranged from 72%-94%.

CONCLUSIONS

The self-administered SNAT identified many unmet social needs among gynecologic oncology patients, corresponded well with the formal social work CCN assessment, and informed the provision of community resources.

The family burden of paediatric heart disease during the chronic phase of illness

BACKGROUND

CHD is a lifelong condition with a significant burden of disease to patients and families. With increased survival, attention has shifted to longer-term outcomes, with a focus on social determinants of health. Among children with CHD, socioeconomic status is associated with disparities in outcomes. Household material hardship is a concrete measure of poverty and may serve as an intervenable measure of socioeconomic status.

METHODS

A longitudinal survey study was conducted at multiple time points (at acute hospitalisation, then 12-24 months later in the chronic phase) to determine the prevalence of household material hardship among parents of children with advanced heart disease and quality of life during long-term follow-up.

RESULTS

The analytic cohort was 160 children with a median patient age of 1 year (IQR 1,4) with 54% of patients <2 years. During acute hospitalisation, over one-third of families reported household material hardship (37%), with significantly lower household material hardship in the chronic phase at 16% (N = 9 of 52). For parents reporting household material hardship during acute hospitalisation, 50% had resolution of household material hardship by the chronic phase. Household material hardship-exposed children were significantly more likely to be publicly insured (56% versus 20%, p = 0.03) with lower quality of life than those without household material hardship (64% versus 82%, p = 0.013).

CONCLUSION

The burden of heart disease during the chronic phase of illness is high. Household material hardship may serve as a target to ensure equity in the care and outcomes of CHD patients and their families.

Promoting optimal mental health outcomes for children and youth

While paediatric care providers are often the first point of contact for children or youth experiencing mental health challenges, they may lack the resources (e.g., access to a multidisciplinary team) or training to adequately identify or manage such problems. This joint statement describes the key roles and competencies required to assess and address child and youth mental health problems, and the factors that optimize outcomes in this age group. Evidence-informed guidance on screening for and discussing mental health concerns with young people and families is provided. Preventive and therapeutic interventions with demonstrated efficacy in community care settings are discussed. This foundational statement also focuses on the changes to medical education, health systems, and health policy that are needed to improve clinical practice and advocacy efforts in Canada, including appropriate remuneration models, stepped-care approaches, targeted government funding, and professional training and education.

La promotion de l'évolution optimale de la santé mentale chez les enfants et les adolescents

Les dispensateurs de soins pédiatriques sont souvent le premier point de contact des enfants et des adolescents aux prises avec des problèmes de santé mentale, mais ils ne possèdent pas nécessairement les ressources (p. ex., l'accès à une équipe multidisciplinaire) ni la formation nécessaires pour procéder à leur dépistage ou à leur prise en charge. Le présent document de principes conjoint décrit les principaux rôles et les principales compétences à maîtriser pour évaluer et traiter les problèmes de santé mentale chez les enfants et les adolescents, de même que les facteurs qui optimisent le plus possible l'évolution de la santé mentale dans ces groupes d'âge. Il contient des conseils fondés sur des données probantes à propos du dépistage des préoccupations en matière de santé mentale chez les jeunes et leur famille ainsi qu'à propos des échanges sur le sujet. Les interventions préventives et thérapeutiques dont l'efficacité est démontrée en milieu communautaire sont abordées. Le présent document de principes, qui est fondamental, traite également des changements à l'enseignement de la médecine ainsi qu'aux systèmes et aux politiques de santé qui s'imposent pour améliorer la pratique clinique et les efforts de revendications au Canada, y compris les modèles de rémunération appropriés, les approches des soins abordées étape par étape, le financement gouvernemental ciblé, l'enseignement et la formation professionnelle.

Disparities in parental distress in a multicenter clinical trial for pediatric acute lymphoblastic leukemia

BACKGROUND

Parent psychological distress during childhood cancer treatment has short- and long-term implications for parent, child, and family well-being. Identifying targetable predictors of parental distress is essential to inform interventions. We investigated the association between household material hardship (HMH), a modifiable poverty-exposure defined as housing, food, or utility insecurity, and severe psychological distress among parents of children aged 1-17 years with acute lymphoblastic leukemia (ALL) enrolled on the multicenter Dana-Farber ALL Consortium Trial 16-001.

METHODS

This was a secondary analysis of parent-reported data. Parents completed an HMH survey within 32 days of clinical trial enrollment (T0) and again at 6 months into therapy (T1). The primary exposure was HMH at T0 and primary outcome was severe parental distress at T0 and T1, defined as a score greater than or equal to 13 on the Kessler-6 Psychological Distress Scale. Multivariable models were adjusted for ALL risk group and single parent status.

RESULTS

Among 375 evaluable parents, one-third (32%; n = 120/375) reported HMH at T0. In multivariable analyses, T0 HMH was associated with over twice the odds of severe psychological distress at T0 and T1 HMH was associated with over 5 times the odds of severe distress at T1.

CONCLUSIONS

Despite uniform clinical trial treatment of their children at well-resourced pediatric centers, HMH-exposed parents-compared with unexposed parents-experienced statistically significantly increased odds of severe psychological distress at the time of their child's leukemia diagnosis, which worsened 6 months into therapy. These data identify a high-risk parental population who may benefit from early psychosocial and HMH-targeted interventions to mitigate disparities in well-being.