Columbia University Mailman School of Public Health

Risk Factor Screening and Response

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Introduction

Social determinants of health are “conditions in the places where people live, learn, work, and play that affect a wide range of health risks and outcomes.”1 They have an important influence on lifelong health, beginning in early childhood and spanning across developmental domains, including social-emotional and behavioral development.2 The federal government’s Healthy People 2020 initiative identifies five main social determinant areas, each of which contains a number of factors: 1) economic stability (parent employment, food insecurity, housing instability, poverty); 2) education (early childhood education, high school graduation); 3) social and community context (parent incarceration, social support); 4) health and health care (access to health care, parent mental health, substance abuse); 5) neighborhood and built environment (access to foods that support healthy eating patterns, community crime and violence, quality of housing).3

A number of professional organizations and initiatives, including the American Academy of Pediatrics, the Institutes of Medicine, and Healthy People 2020, recognize the importance of social determinants of health and recommend routine screening in clinical settings.4 In spite of this, a study of parents of infants and toddlers found that fewer than half of parents reported discussing six of seven family and community health risks with their child’s pediatrician.5

State Profiles that Include Risk Factor Screening and Response

Research Support for Risk Factor Screening and Response

There are a number of tools to screen for social determinants of health, though many have not been validated or only have some parts validated.6 However, the research described below has shown that the use of a screening tool, typically in conjunction with referrals, can lead to families’ increased use of services that target social adversities associated with worse health and developmental outcomes.

Examples include:

  • Health Leads (HL): In pediatric clinics, Health Leads connects families to services and programs that meet basic needs and address other social risk factors. Parents are invited to complete a screening instrument, providers refer parents to the HL desk within the clinic staffed by trained volunteers, who are undergraduate students, and volunteers connect families to community-based resources. Providers develop their own screening instruments, but the HL screening toolkit suggests questions related to food insecurity, housing instability, utility needs, financial resource strain, transportation, exposure to violence, child care, education, employment, health behaviors, social isolation and supports, and mental health. In a study in an urban health clinic serving approximately 8,500 low-income children, more than 1,000 families used the HL help desk in a two-and-a-half-year period. In that time, more than 2,200 needs were identified, and within six months of using the HL help desk, 50 percent of families had enrolled in at least one community-based resource.7
  • WE CARE (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education): The WE CARE screening instrument has 12 questions covering six basic needs: child care, food security, household heat, housing, parent education, and employment. In a cluster randomized controlled trial, community health centers participating in WE CARE near Boston, Massachusetts, administered the screening instrument and received a family resource book with tear-out sheets listing free community resources for each need. Primary care providers offered referrals to mothers of children under six months old who expressed an interest in assistance with a particular need, and researchers then provided applications to the services to which the mothers had been referred. At the child’s 12-month visit, WE CARE mothers were more likely to have enrolled in a new community resource and were more likely to be employed, have their child in child care, receive fuel assistance, and not be in a homeless shelter.8
  • SWYC (Survey of Well-being of Young Children): The SWYC is a freely available screening instrument for children under five with sections on developmental milestones, behavioral and social-emotional development, and family risk factors. The Family Questions component of the SWYC consists of questions covering parents’ tobacco, alcohol, and drug use, food insecurity, depressive symptoms, intimate partner relations, and literacy activities in the home. While the Family Questions component of SWYC has not been validated, the items it includes have been drawn from previously validated measures (see references here).
  • Safe Environment for Every Kid Parent Questionnaire (SEEK PQ): The SEEK PQ is a validated 16-item tool that screens for parents’ tobacco, alcohol, and drug use, food insecurity, depressive symptoms, intimate partner violence, and harsh punishment practices. It is a component of the SEEK model, an intervention to address the psychosocial problems of parents of children from birth to five and to reduce child maltreatment through: specialized training for primary care providers to address risk factors, screening with the SEEK PQ, and facilitating referrals to community resources. In one randomized control trial of the SEEK model, the incidence of child abuse and neglect was lower among families participating in the SEEK model.9 A second randomized control trial also found that families participating in the SEEK model reported less psychological aggression and fewer minor physical assaults.10

References

  1. Centers for Disease Control and Prevention. (2018). Social determinants of health: Know what affects health. Retrieved from https://www.cdc.gov/socialdeterminants/index.htm
  2. Larson, K., Russ, S. A., Crall, J. J., & Halfon, N. (2008). Influence of multiple social risks on children's health. Pediatrics, 121(2), 337-344.
  3. HealthyPeople.gov. (n.d.). Social determinants of health. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
  4. Morone, J. (2017). An integrative review of social determinants of health assessment and screening tools used in pediatrics. Journal of Pediatric Nursing, 37, 22-28.
  5. Kogan, M. D., Schuster, M. A., Yu, S. M., Park, C. H., Olson, L. M., Inkelas, M., et al. (2004). Routine assessment of family and community health risks: Parent views and what they receive. Pediatrics, 113(6), 1934-1943.
  6. Berman, R. S., Patel, M. R., Belamarich, P. F., & Gross, R. S. (2018). Screening for poverty and poverty-related social determinants of health. Pediatrics in Review, 39(5), 235-346.

    Corvini, M., Cox, K., O’Neil, M., Ryer, R., & Tutko, H. (2018). Addressing childhood adversity and social determinants in pediatric primary care: Recommendations for New Hampshire. Concord, NH: University of New Hampshire, Institute for Health Policy and Practice.

    Fierman, A. H., Beck, A. F., Chung, E. K., Tschudy, M. M., Coker, T. R., Mistry, K. B., et al. (2016). Redesigning health care practices to address childhood poverty. Academic Pediatrics, 16(3S), S136-S146.

    Morone, J. (2017). An integrative review of social determinants of health assessment and screening tools used in pediatrics. Journal of Pediatric Nursing, 37, 22-28.
  7. Garg, A., Marino, M., Vikani, A. R., & Solomon, B. S. (2012). Addressing families’ unmet social needs within pediatric primary care: The Health Leads model. Clinical Pediatrics, 51(12), 1191-1193.

    Health Leads. (2016). Social needs screening toolkit. Boston, MA: Health Leads.
  8. Garg, A., Toy, S., Tripodis, Y., Silverstein, M., & Freeman, E. (2015). Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics, 135(2), e296-e304.
  9. Dubowitz, H., Feigelman, S., Lane, W., & Kim, J. (2009). Pediatric primary care to help prevent child maltreatment: The Safe Environment for Every Kid (SEEK) model. Pediatrics, 123(3), 858-864.
  10. Dubowitz, H., Lane, W. G., Semiatin, J. N., & Magder, L. S. (2012). The SEEK model of pediatric primary care: Can child maltreatment be prevented in a low-risk population? Academic Pediatrics, 12(4), 259-268.