Taking a child to the pediatrician is a rite of passage for parents. Most young children in the United States have up to 11 well-child visits in their first two years. Certain parts of the pediatric check-up are so ubiquitous as to be predictable even to new parents. Fill out medical forms? Check. Talk about vaccines? Check. Inspect the child’s ears? Check.
But there are some nonmedical factors, including where children live, that can influence their health more than any medical intervention does. As a result, pediatricians and their teams are beginning to screen their young patients for social needs such as food insecurity or inadequate housing. The American Academy of Pediatrics recommends that doctors screen families for “social determinants of health” and connect them to community resources as a part of standard care.
Foundations have been playing a role in developing these screening and referral programs. United Hospital Fund teamed up with the Altman Foundation and the New York Community Trust, and later the William J. and Dorothy K. O’Neill Foundation, to create Partnerships for Early Childhood Development (PECD). This initiative provides grants to eight hospital-based pediatric clinics and their community partners to adopt screening and referral programs for social needs. The partnerships are spread throughout the city and focus on a broad range of issues—BronxCare paired with Claremont Neighborhood Center, and Mount Sinai Pediatrics with New York Common Pantry, to name a few.
But what do parents think of these efforts? Through our PECD learning collaborative, grantees shared that while many parents were receptive to social needs screening, they were often caught off guard by sensitive “nonmedical” questions about their family or community life. These are questions such as whether parents are having trouble affording rent or utilities, or are worried about running out of food by the end of the month. Some interactions with parents on these topics were more successful than others. All of us—funders, health care providers, and community organizations—wanted a better understanding of parent perspectives and expectations.
At UHF we realized that, although health care providers are increasingly aware of the value of screening for social needs, their focus is rarely on children. Hospitals may help patients with housing or access to healthy food, but these are usually adult patients, often with high health care utilization. Much less attention has been devoted to how best to meet the social needs of children and their families, including determining whether parents are willing to talk candidly with their children’s doctors about these issues. And yet, there have been numerous studies showing that children exposed to social and economic stressors early in life can suffer lifelong health consequences. The results of those studies make it that much more critical that pediatricians and family physicians figure out how best to address children’s social needs.
Results Of Focus Groups
We reached out to Public Agenda, a nonpartisan, nonprofit organization that conducts qualitative research, to help us learn directly from parents about their viewpoints on screening for social needs. Public Agenda has an extensive history of speaking with parents about how the education system works with them on behalf of their children, making that organization an ideal partner.
Public Agenda conducted eight focus groups, including two in Spanish, with a total of 88 low-income parents in New York City who have children under age five. Among the discussion topics:
- What do parents find challenging when it comes to their children’s health and well-being? Are social needs among their concerns?
- Where can parents go for help in the face of these worries and challenges?
- Do parents view their children’s pediatrician as a good source of help with, or information about, social needs? Why or why not?
- How do parents think that pediatricians can successfully integrate screenings for and conversations about social determinants of health into pediatric primary care?
It became apparent that adopting an approach that prioritized social determinants of health in medical care is not just a change in mindset for health care providers—it’s a transition for parents, too.
The notion of discussing social needs with pediatricians was new to many low-income parents, and they emphasized that pediatricians should approach such discussions carefully and respectfully. A parent from the Queens borough of New York City made this suggestion: “First, more than anything else, the pediatrician should earn your trust.”
Parents drew sharp distinctions among social stressors. They clearly felt more comfortable discussing topics such as nutrition, education, and children’s minor behavioral issues with pediatricians. But talking about domestic violence and parents’ mental health could make them feel uncomfortable or ashamed. They worried that discussing such sensitive topics with pediatricians would expose them to judgment and discrimination.
Of most concern to parents was the fear that such discussions could lead to intervention by a child welfare agency. “We are all as parents afraid of this,” said a parent from the Bronx, New York. “If I went to the doctor and they were like, ‘Oh, we’re going to follow this up with a social work visit,’ then I’m out the door. It’s like when you hear ‘fire,’ you think, ‘run.’”
The parents also expressed concerns about the prospect of sharing sensitive information without getting help from the physician. They were also unsure how pediatricians could address such complex social needs as housing affordability, language barriers, parent education, neighborhood safety, and environmental hazards. As a parent from Brooklyn, New York, said, “If you’re going to ask these questions, at least have some solutions. Don’t just ask, or I’ll think I shouldn’t say any more.”
Despite these reservations, the parents were still enthusiastic about discussing the factors that shape their children’s health and well-being. To have successful discussions, they emphasized that pediatricians should:
- Choose the right moment to ask about social needs. Well-child visits were preferred over visits when a child is sick;
- Not ask about sensitive issues in front of children old enough to understand the conversation;
- Message to parents and clinic staff that patient confidentiality and privacy should be protected, and it should be transparent to all about what would trigger a report to child welfare;
- Not ask just for the sake of asking—be able and willing to offer help;
- Make clear that screening is standard protocol.
The focus groups’ findings reinforce PECD’s approach, particularly the focus on ensuring that families connect to needed services—but they also challenge us to do better. We must consistently check in with parents and understand their views on how health care is changing. We must work with other institutions and government agencies, and particularly our partners in child welfare, to gain back the confidence of communities that have too often been mistreated and discriminated against. And we must insist that screening for social needs is not just another service added on to the clinical visit, but part of a much larger process of building long-term, trusting relationships between parents and pediatricians.
The full report, It’s About Trust: Low-Income Parents’ Perspectives on How Pediatricians Can Screen for Social Determinants of Health, is available online. United Hospital Fund’s Children’s Health Initiative, which commissioned this work, is partially funded by the Ira W. DeCamp Foundation.
“Interest In Early Childhood Health Leads To Three Funders Working Together,” by Suzanne Brundage, Irfan Hasan, and Rachael N. Pine, GrantWatch section of Health Affairs Blog, July 11, 2017.