Pediatric providers are increasingly recognizing the dominant impact of social, environmental, and behavioral factors on children’s health, development, and well-being. An important focus on health equity and the impact of adverse social determinants demand providers’ best efforts to identify and address families’ needs. As a result, many organizations and practices are considering screening for social determinants of health (SDoH) as a strategy to identify and address adverse influences on health outcomes. However, screening processes that focus on SDoH are not without potential problems, which Paul H. Dworkin, MD and Arvin Garg, MD, MPH detail in their latest commentary on the topic.
Their article, “Considering Approaches to Screening for Social Determinants of Health,” is now featured as an invited commentary in the journal Pediatrics. The article responds to a study on the topic in the same issue from Rebeccah Sokol, PhD and colleagues who appropriately raise concerns about the “…deficit in understanding the present state of the science” surrounding SDoH screening efforts. The authors review 17 studies involving 11 SDoH screening tools, look at their reliability and validity, and examine their ability to detect early indicators of risk and inform care. As a result of their review, they encourage providers to pay more attention to the reliability and validity of such tools prior to using them.
As noted by Drs. Dworkin and Garg in their response, the comprehensive review by Dr. Sokol and colleagues highlights the “disappointing, but perhaps not surprising, limitations” in assessing the reliability and validity of such screening tools, as well as the inability to assess whether referrals and interventions that result from SDoH screenings actually improve child well-being. They note that findings from Dr. Sokol and colleagues reinforce the need to continue focusing on the following imperatives that they, along with Renee Boynton-Jarrett, MD, ScD, previously outlined in a Viewpoint published in the Journal of the American Medical Association:
- Ensure patient- and family-centered SDoH screening, which includes shared decision making, a respect for families’ desires for intervention, and considers family circumstances;
- Ensure providers not only screen for SDoH, but also connect families to community-based resources in order to address any identified needs a family wishes to address;
- Perform screening within the context of a comprehensive, integrated systems approach; and
- Use a universal, strength-based approach to support patients and their families.
State affiliates of the Help Me Grow National Center, which was founded by Dr. Dworkin and is part of Connecticut Children’s Office for Community Child Health, remain intrigued by the concept of incorporating screening for SDoH into early childhood systems around the country. In considering whether to do so, Dr. Dworkin notes that discussions acknowledge the need to do so within a comprehensive, family-centered approach, which offsets potential implications that may result from the inherent limitations of screening tools.
Drs. Dworkin and Garg note that several programs reviewed by Dr. Sokol and colleagues utilize the tools as a starting point for a discussion to engage families about their concerns and desires for interventions. As a result, any referrals to community resources happen based on families’ priorities. Screening tools should serve as just one component of the early detection process, Drs. Dworkin and Garg state, as well as be embedded within a comprehensive, integrated approach to developmental promotion, early detection, referral and linkage to services.
Providers may find that using such screening tools without embedding them into a comprehensive approach that addresses needs brought forth from families may have consequences. For example, Drs. Dworkin and Garg detail a scenario in which a family that screens positive for food insecurity may react negatively if they do not want help, or think they need help, addressing such concerns.
Screening for developmental concerns poses similar issues. However, as Drs. Dworkin and Garg note, even with their limitations, such screenings are widely viewed as best practice. Rather than discouraging use of SDoH screening tools due to their limitations, Drs. Dworkin and Garg stress that, similar to screening for developmental concerns, embedding screening for SDoH within a broader system of support for families and considering their priorities and wishes provides the best chance to enhance the health, development and well-being of children.
Read blogs authored by Dr. Dworkin here.
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Categories: Insights for Change