Parent Perspectives on Screening for Social Needs During Pediatric Hospitalizations Free

We used a qualitative design to explore and gain a contextual understanding of parent stakeholder experiences, attitudes, and perspectives.

We recruited participants from the general medical and surgical wards at 1 tertiary and 2 affiliated community hospitals in the Northeastern United States.³⁴  All 3 hospitals serve low-income, racially diverse communities, and none of the hospitals had a formal screening process for social needs during the study timeframe.

We recruited parents during their child’s hospitalization, ensuring parental experience with the pediatric inpatient environment. We excluded parents of children in the custody of the Department of Children and Families. Inclusion criteria included child age $<$18 years, parental age $≥$18 years, and parental ability to speak English or Spanish. Eligible parents were identified through review of daily inpatient census. We used a purposive sampling approach to recruit lower-income families more likely to be affected by adverse social determinants of health: we stratified eligible parents by insurance type and used a random number generator to determine order of approach, first among the publicly-insured, followed by the privately-insured group. A member of the study team called parents on their hospital phone, providing an overview of the study and objectives and inviting parents to participate. If a parent was initially unreachable, the study team continued to attempt contact in approximately ∼1-hour increments, for a total of 3 attempts per day. On any individual day, we ceased recruitment after 2 interviews were performed to facilitate an iterative approach to data collection and analysis.

Informed by the Consolidated Framework for Implementation Research and literature review, we developed a semistructured interview guide probing parental attitudes surrounding and previous experiences with social needs screening, comfort level with discussion of social needs with inpatient providers, and screening process preferences in the hospital setting (Supplemental Information Document 1). We received input on the interview guide from a social service provider and a qualitative methods expert. We pilot-tested and incorporated feedback on the guide with a parent from the tertiary hospital’s patient and family advisory council.

Between July 2020 and February 2021, 2 research assistants, trained to conduct interviews in English and Spanish, performed phone interviews until reaching saturation.³⁵  To describe our study cohort, we also asked participants to complete a questionnaire about their sociodemographics.

All interviews were audio-recorded and professionally transcribed verbatim. Interviews conducted in Spanish were transcribed in Spanish and then translated to English. Transcripts were deidentified and uploaded to Dedoose software for analysis. We analyzed the data iteratively, with a modified-grounded theory approach accounting for preestablished topic domains probed by the interview guide, while allowing for emergent themes to arise from participant responses.³⁶ 

After making a deductive codebook based on the interview guide, 4 research team members, 2 of whom had also conducted the interviews, participated in the iterative development of the codebook, independently coding a preliminary set of 4 interviews (each coder reviewing 2 transcripts, and each transcript reviewed by 2 coders). We used a comparison and consensus approach with the 4 coders to clarify code definitions and identify emergent themes, and we updated the codebook accordingly. With a comparison and consensus approach, trustworthiness of the coding is achieved through rigorous consensus-building deliberation.³⁷  This process was repeated for an additional set of 4 transcripts, after which we determined that no new codes were arising and coding was consistent among team members. Four members of the research team coded remaining transcripts independently, with every third transcript coded by 2 coders to ensure consistency. We then analyzed the data thematically.³⁸  This study received exemption by the 3 hospitals’ institutional review boards.

Among the 72 eligible families approached, the most common reason for nonenrollment was inability to reach the family by hospital phone or parent unavailable (n = 29, 41%). Twenty-six parents declined participation citing lack of interest, resulting in 17 phone interviews performed after which thematic saturation was reached. Interviews were 26 minutes duration on average, and nearly one-half (47%) were performed with parents of children admitted to a community hospital.

Participants ranged in age from 26 to 44 years, with the majority female, English-speaking, and publicly insured, and over one-half reported household incomes < $50 000 (Table 1).

In discussing parent attitudes and preferences surrounding inpatient social needs screening, 5 themes emerged: (1) importance of screening for social needs across multiple health care settings, (2) hospitals viewed as capable systems to respond to social needs, (3) most parents comfortable discussing social needs with inpatient providers, (4) appreciation for providers expressing caring and desire to help during inpatient social needs screening, and (5) importance of a family-centered approach to inpatient screening (Table 2).

Nearly all parents reported that screening for social needs within health care settings is important. Many expanded on this issue, describing their communities in which “there are a lot of people in need, but they are afraid to ask for help.” Parents, therefore, stressed the importance of health care providers screening for social needs as “a conversation starter,” because if a provider directly “asks [families about their needs], it’s more likely for them to give a response, instead of [expecting families] to be asking for help.”

Expanding on this importance of screening, many parents reported that social needs screening should be performed across multiple health care settings, stating they would “expect it from both [inpatient and outpatient],” to identify the greatest number of vulnerable families, including those who may not see an outpatient provider regularly, and to optimize provision of resources. For example, one parent expressed, “If I’m in the hospital, and I need [a resource], they can help me. What if I haven’t gone to my doctor’s in a while, so they’re unable to ask me, but now I’m here at the hospital, and the [hospital providers] do ask? I’d be like, ‘Oh thank God someone brought it up.’

The majority of parents reported that hospitals are well-suited to respond to social needs identified during screening. Some described preexisting connections between hospitals and community resources facilitating response to screening, with 1 parent stating, “[hospitals are] connected with everything…one of the hubs, main hearts of the city. You can…impact a family’s life…connect them to different resources.” Other parents described hospitals as an ideal entity to respond to social needs screening, given the ease of access to a variety of resources on inpatient units, including large multidisciplinary teams and prolonged interaction with families during hospitalizations. Despite the overall positive perceptions regarding hospital systems’ ability to respond to social needs, some parents also acknowledged limitations, such as understaffing of social service programs, describing inpatient screening as “a good start” rather than an ideal.

The majority of parents expressed that they would have no concerns discussing social needs with hospital providers, with some describing inpatient screening performance as a positive indicator of comprehensive care. For example, 1 parent stated, “I feel fine with [inpatient screening], because I feel like it’s important. If I have a need, I would know that at least they care enough to ask me…[and] they know resources to help me.” Others expanded on this issue, expressing particular comfort discussing social needs in the context of advocating for their hospitalized child, recognizing that participation in screening may facilitate getting resources to improve their child’s health. For instance, 1 parent stated, “When it comes to kids’ social development, I think it’s important to ask the questions that need to be asked.”

A minority of parents expressed concerns regarding screening for social needs during hospitalizations, citing fear of harsh judgment and providers “making assumptions” after learning of social needs, and punitive repercussions with the Department of Children and Families. For example, 1 parent expressed, “The only concern that I would have…is there’s a fine line between providing for a kid and not providing…if a parent feels like you're asking this question to see if the kid is being taken care of, and, if not, social services would be involved. If you have mold in your apartment, it's because you have a slumlord and that's all you can afford. That doesn't mean your kids need to be taken away.”

Many parents stated that, to establish trust with inpatient screening providers, it was essential that the screening provider convey the caring purpose behind screening and desire to help. For this reason, the majority of parents expressed a preference for inpatient screening to be performed person-to-person. For example, 1 parent stated, “in-person would be a good idea, because you can see that facial expression. Maybe the person’s ashamed, and you can say, ‘it’s ok…we’re here to help,’ versus a paper can’t do that.”

Expanding on this issue, the majority of parents expressed that they would have no preference for the type of inpatient provider who performed social needs screening, as long as caring and desire to help were adequately conveyed. For instance, 1 parent stated, “I don’t have a preference [of provider]. I think it’s just the way you ask,” whereas another expressed, “anyone [can screen], honestly, as long as they’re heartfelt. And, you know, the body language of somebody. You know if you really want to get into that conversation.”

Many parents reported that for this caring sentiment to come across during screening, hospital providers must learn how to best explain the purpose and the hospital’s potential responses to screening. Parents emphasized “making sure [families] are aware that [inpatient screening] is part of the process, just saying, ‘this is to help ensure that your child is safe and healthy, and this is how we make sure we give you the right treatment.’” Others similarly expressed the importance of providers’ explaining potential responses to a positive screen—attempting to connect families to relevant community resources, to set family members’ minds at ease against punitive repercussions.

Many parents stressed that inpatient screening processes should first and foremost focus on family comfort and a positive hospital experience. Along this reasoning, most parents described a preference to avoid social needs screening during admission intake, and to instead perform screening “after the first wave, as everything is mellowing.” Parents explained that the stress accompanying the admission of an acutely ill child may impede their engagement with screening and cause unnecessary anxiety. For example, 1 parent expressed, “sometimes if you have a medical emergency…you come in [to the hospital] and you’re frustrated…you are not going to answer the same way you would when you’re settled and you feel okay about [your medical care].”

Many parents also reported that their privacy must be prioritized during inpatient screening processes, with location, timing, and information-sharing focused on confidentiality. Some recalled previous admissions, with 1 parent describing screening questions asked “in a hallway,” and stressing the importance of performing inpatient social needs screening “in a more private setting.” Another expanded on this issue, describing the frequency with which multiple family members are present during hospital admission, and expressing the importance of performing inpatient screening at a time respectful of confidentiality, given how difficult it would be to report honestly on social needs in front of extended family. Many parents reported that consideration of privacy must even extend beyond the hospitalization in the context of sharing screening results with nonhospital personnel. Although the majority of parents expressed that screening results should be shared with the child’s primary care provider to facilitate continued support for any social concerns identified, many parents also reported that such information-sharing should be voluntary and not occur “unless the family gives approval.”

Relatively little is known regarding parent perspectives on social needs screening during pediatric hospitalizations and preferences for how inpatient screening should be performed. Our study aimed to fill these knowledge gaps by eliciting the perspectives of parents with children hospitalized in both tertiary and community settings regarding parental attitudes surrounding inpatient social needs screening and screening process preferences in the hospital setting. Our findings illustrate parents’ positive perceptions of inpatient screening importance and hospitals’ ability to respond to social needs and parental comfort in discussing social needs while desiring empathic and confidential inquiry from hospital staff, providing a vital foundation to support broader implementation of inpatient social needs screening with potential to integrate into routine inpatient care.

Most previous research on social needs screening has been performed in ambulatory settings, with studies demonstrating parental acceptance and benefits including increased family connection to community resources and improved parent-reported child health.^{18–24,39,40}  However, research on social needs screening within the pediatric inpatient setting is limited. Three recent studies demonstrated that only a minority of pediatric hospital clinicians perform social screening and that screening tools are rarely used.^28,30,31  When social screening tools are used in an inpatient setting, 3 studies within single children’s hospitals demonstrated their efficacy: Vaz and colleagues and Fortin and colleagues showed that a self-administered caregiver survey identified high proportions of social needs among their inpatient population, with >30% of caregivers reporting at least 1 social need;^29,33  whereas Colvin and colleagues showed that resident use of the IHELP screening tool increased social service consultations and resources provided to families.²⁷  In another study, Colvin et al also demonstrated that caregivers who had previously experienced inpatient social needs screening had more positive opinions surrounding a physician’s role in addressing social needs.²⁶  Although our study is supportive of positive parental opinions surrounding inpatient screening in general, unlike previous studies, we provide parental attitudes and opinions specific to the performance of inpatient social needs screening, demonstrating high parental comfort in discussing social needs with hospital providers, and positive parental perceptions of hospital systems’ ability to address social needs. Beyond the scope of previous works, our study also determines parental process preferences for inpatient social needs screening, including avoidance of the admission intake timeframe used in previous study of inpatient screening.²⁷  We also identified parental preference for person-to-person screening, similar to preferences reported by pediatric inpatient clinicians.³¹  Interestingly, this parental preference for in-person screening contrasts with previous outpatient studies which demonstrated improved parental disclosure of social needs using electronic surveys.^41,42  Additional research is, therefore, needed to further explore parental preferences after implementation of inpatient social needs screening and potential differences between inpatient and outpatient screening experiences.

When considering how to implement pediatric inpatient social needs screening, it is essential to engage parents in the strategic development phase, because parents represent the key stakeholder group who will ultimately experience inpatient social needs screening and be affected by any screening strategy decisions.^34,43  The parent perspectives identified in our study can help clinicians and health systems planning to initiate inpatient social needs screening to overcome barriers and to develop more family-centered screening strategies, which may improve parental acceptance of screening and ultimately increase likelihood of successful implementation. For example, to establish trust and convey the essential caring and desire to help requested by parents, clinicians and administrators may consider developing structured education and introductory scripts for screening providers and piloting and obtaining feedback on person-to-person and survey-based screening.^40,41  These steps may facilitate a clear explanation of screening purpose and potential responses, increasing parental comfort and engagement throughout the screening process, and allowing for process adjustments on the basis of parental feedback to improve the screening experience. Development of follow-up scripts, with a clear statement of the goal to help children in our response to screening, and family-centered approaches to address inpatients’ unmet social needs may also prove helpful for families who screen positively. These tactics may facilitate discussion between parents and screening providers regarding information-sharing with their child’s primary care team to promote longer-term follow-up and continued assistance with identified social concerns after discharge and may assuage parental concerns regarding punitive repercussions.^39,40,44  Other parental preferences identified in this study, including a family-centered approach to screening with optimization of hospital experience and privacy, may encourage hospital informatics teams to develop programs within electronic health systems, allowing providers to delay social needs screening until a comfortable time for the family, while intermittently prompting providers to perform screening when incomplete.

Strengths of our study include the elicitation of perspectives from English- and Spanish-speaking parents at nonchildren’s hospitals, including community hospitals in which the majority of children are hospitalized,⁴⁵  which has not been previously accomplished in the pediatric inpatient social needs literature. We also identified parent preferences for how inpatient social needs screening should be performed, facilitating development of family-centered implementation strategies and translation into clinical practice. Our study findings must be considered within the context of limitations. We collected our data through interviews, and it is possible that parental perspectives may differ between those who agreed to participate and the 26 who declined. Although our sample size falls within the range recommended for maximal response variation in qualitative research and thematic saturation was achieved,³⁵  we conducted 17 interviews with a nonprobabilistic sample of parents that is not meant to be representative of all parent views. It is possible that a sample of parents from another region, with children hospitalized in another setting (eg, ICU), with predominantly private insurance, or with active social needs may have different hospital experiences, attitudes surrounding screening, and/or process preferences for social needs screening. Additionally, 2 of the 17 interviews were performed with Spanish-speaking parents; future research is needed to explore the unique perspectives of parents with limited English proficiency. We also elicited parent perspectives about a hypothetical inpatient screening process. It is reasonable to assume that parents could have different or additional perspectives after experiencing pediatric inpatient social needs screening, highlighting a need for future study of acceptability after real-world implementation.

In conclusion, parents of hospitalized children reported positive perspectives regarding the importance of inpatient social needs screening, comfort in discussing social needs with hospital providers, and hospital systems’ ability to help with social needs, and they identified multiple process preferences for inpatient screening. Building on these results, future proposals will involve the development and evaluation of a family-centered inpatient social needs screening process.