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Social Needs Screening: Is a Non-Response an Answer? :

August 10, 2020

In a recently released study in Pediatrics (10.1542/peds.2020-0174), Dr. Kristin Ray and colleagues examined the pragmatically very important and yet previously unstudied question of what a non-response to social needs screening questions means or tells us.

In a recently released study in Pediatrics(10.1542/peds.2020-0174), Dr. Kristin Ray and colleagues examined the pragmatically very important and yet previously unstudied question of what a non-response to social needs screening questions means or tells us. We are all busy, and it’s easy for the clinician or assistant reviewing the survey to skip an unanswered question, figuring if the patient or parent chose not to answer, it is absolutely within their “right” and realm of choice. This fascinating study, conducted in an academic pediatric emergency room setting, included 142 parent/caregivers who responded to an electronic survey about their health-related social needs, 62 (42%) of whom also participated in a phone follow up in 2 weeks. Information about trust in physicians and perception of primary care as well as last well care and immunization completion were assessed in the initial survey with validated questions.  The authors then examined the frequency of skipped social needs questions, and then compared those who skipped questions to those endorsing or denying social needs, and finally, compared use of a community resource packet provided to all, among those who did and did not endorse needs.

Approximately 1/3 of respondents (29%) did endorse a social need, most frequently food insecurity and transportation difficulties. Ultimately 1 of 8 participants chose not to respond to any one question about social needs, and lack of a response was associated with poorer perceptions of primary care and less use of primary care, as well as lower levels of social support – very intriguing. More detail about those with needs and without needs who did and did not respond is provided in the article. While the setting was an emergency room and not a primary care pediatric practice, the study results are highly informative. The results can guide decisions about so many key subtleties of the survey process: should one use multi-pronged or single item questions, is “forced choice” or permissible skipping in electronic surveys preferable, is giving out a packet of resources to all or some a preferable strategy, and more. This study has terrific “food for thought” about how best to offer social needs screening, and what one might need to know about one’s own setting to make those decisions.

This study made me realize how much is not known about screening for social determinants of health in pediatric settings. The next study I would like to see on the topic relates to the confusing issue of finding the response, “yes” to one or more needs, with a same-questionnaire response of “no” to the query, “Would you like us to call you?” Anecdotally when we have followed up, particularly if a mental health need is identified, the parent/caregiver has resources in place to address the issue, which is reassuring. So should we assume “don’t call” is a mandate, or should we follow our clinical gut and call? Certainly reviewing all screens before the family leaves is critical to addressing such confusing responses, but it can be challenging. And conversely, what about respondents who do not endorse any need, but ask for a call? Another interesting question…screening for health-related social determinants has been a hugely rewarding and successful endeavor in most practices, yet many key operational questions remain unanswered, and this article by Dr. Ray and colleagues is a beautiful beginning that helps us figure this all out.  See the AAP’s resource page for help and more information.

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