Video Abstract
Recognition of the importance of the social determinants of child health has prompted increased interest in clinical pathways that identify and refer for social needs.
The aim of this systematic review was to determine the effectiveness of interventions that identify and refer for social needs for families with children aged 0 to 18 years attending outpatient community and ambulatory healthcare services.
We searched the following databases: Medline, Embase, PsychINFO, CINAHL, Emcare, EBMR.
Studies were included if children and their families underwent a process of identification and referral for social needs in outpatient community and ambulatory healthcare services.
Initial searches identified 5490 titles, from which 18 studies (73 707 families and children) were finally retained.
Intervention pathways were grouped into 3 categories based on whether identification and referral for social needs was conducted with only targeted community resources, a navigator, or with clinician training. The majority of studies reported positive outcomes; with an increase in social needs identification, an increase in referrals following identification, or a reduction in social needs. Child health outcome results were inconsistent.
The search terms used may have provided bias toward countries in which these terms are in use. The heterogeneity of outcome measures between included studies meant a meta-analysis was not possible.
Despite evidence that clinical pathways for children and families help reduce social needs, evidence for improvements in child health is insufficient. Further studies from diverse settings are needed to inform clinical practice to optimize child health outcomes.
Health inequities are defined by the World Health Organization (WHO) as “systematic differences in health status between different socioeconomic groups.”1 Many of these health inequities will start early in a child’s life, with a clear social gradient,2 meaning that children experiencing socioeconomic disadvantage suffer worse well-being, health, and development than their more affluent peers.3 These children grow into adults who are twice as likely to suffer from chronic illnesses and have their lifespan shortened by 3 years.4 Underpinning these health inequities are the social determinants of health (SDH). SDH are the conditions in which people are born, grow, live, work and age, such as poverty, housing affordability, and the availability of high-quality education. The racism and discrimination experienced by First Nations, Black and Hispanic people, and other minority ethnicities across the world has also been clearly linked with poor health outcomes.5,6 Thus, SDH are the wider set of forces and systems influencing the conditions of daily life that impact on health.7,8 To address health inequities, the Health Care Transformation Task Force in the United States recommend that interventions not only address these determinants at a population level, eg, interventions for economic stability or to reduce systemic racism, but also through mitigating the resulting social risk by addressing individual social needs, eg, financial needs.9
The recognition of the importance of addressing unmet social needs has prompted many professional pediatric societies to recommend clinical pathways for identification and referral for social needs for families with children, especially in outpatient community and ambulatory settings where there are multiple opportunities to connect with families.10 The American Academy of Pediatrics and the Royal Australasian College of Physicians recommend that pediatricians and other health professionals be educated with regards to child health equity and the role of SDH at a population level, with materials developed to assist clinicians in addressing social needs at the individual level as a child health equity promoting strategy.3,11 There have been a growing number of tools that have been developed over the last 2 decades to support clinicians in identifying social needs.12 A recent systematic review of the psychometric properties of screening tools that identify social needs in the clinical setting highlighted a critical evidence gap in terms of what should happen once they are identified.10 This review concluded that future research should be directed toward interventions that identify social needs and address their impact on child health and wellbeing.13 Given the recommendations by professional pediatric societies for clinicians to identify and refer for social needs, it is vital that we understand the current evidence base for this practice. The aim of this systematic review was to determine the effectiveness of interventions that identify and refer for social needs for families with children aged 0 to 18 years attending outpatient community and ambulatory healthcare services. Primary outcomes examined were identification and referral uptake for social needs. Secondary outcomes examined were reduction in social needs, improvements in child health and/or wellbeing, acceptability, feasibility, harm, and cost.
EVIDENCE ACQUISITION
This review was registered in PROSPERO, international prospective register of systematic reviews. The registration number in PROSPERO for this systematic review is: CRD42020191072. The study methodology followed PRISMA (Preferred Reporting Items for Systematic Review and Meta-analysis Protocols) guidelines.14
Study Design
Studies of experimental and quasi-experimental designs from selected databases were considered. This included randomized controlled trials (RCT), nonrandomized controlled trials, mixed methods evaluations, before and after studies, and interrupted time-series studies. Also considered for inclusion were analytical observational studies, including prospective and retrospective cohort studies, analytical cross-sectional studies, and case-control studies. Studies were identified using medical subject heading terms or keywords identified from 3 major categories: social determinants of health, healthcare settings, and interventions. Key search terms were used to identify articles in different databases, including Medline, Embase, PsychINFO, CINAHL, Emcare and EBMR. The searches were limited to children aged 0 to 18 years, articles published between January 2000 and June 2022, and English language. Gray literature was searched through Opensigle, topic experts and relevant websites eg, Google Scholar. The reference lists of key reviews and included studies were also scanned. In line with PRISMA (Preferred Reporting Items for Systematic Review and Meta-analysis Protocols) guidelines,15 the search strategy for Medline is shown in Appendix 1 in the Supplemental Information as an example of the way searches were approached in each database.
Inclusion and Exclusion Criteria
Inclusion criteria were: participants who were families and caregivers of children aged 0 to 18 years who were attending outpatient community and ambulatory health care services; interventions that included an identification of and referral pathways for social needs (the identification tool must include financial needs and at least 1 need from the following: food, housing, education, employment, and transportation); reportable outcomes, which included primary outcomes – identification, referral uptake, reduction or resolution of social needs, impact on child health, and secondary outcomes – implementation outcomes including acceptability, feasibility, harm, and cost. Excluded studies were those that focused exclusively on medical care and services (eg, pharmaceutical interventions), were inpatient based, and those where no evaluation for social needs was described and/or no referral pathways or interventions for social needs was included. Additionally, studies were excluded if they described health behavior interventions (ie, for substance use, physical activity, diet) rather than identification and referral pathways.
Data Extraction, Assessment of Methodological Quality and Synthesis
Citations meeting criteria were exported into the reference management system Endnote. Duplicates were removed using Bramer’s method of deduplication within Endnote.16 Each title and abstract was screened by 2 of 3 independent reviewers (H.W., A.C., and K.O.) and inconsistencies were further reviewed by 2 reviewers (S.W. and S.R.). Review of full text articles followed the same independent review process assessed against the inclusion and exclusion criteria to determine eligibility.
Data were extracted from the included papers independently by 3 reviewers (H.W., A.C., and K.O.) using the Cochrane data collection form for intervention reviews for RCTs and non-RCTs.17 The included studies went through a process of critical appraisal by 2 of 3 independent reviewers (H.W., A.C., and K.O.) for methodological quality at the study level using the standardized critical appraisal framework GRADE (Grading of Recommendations, Assessments, Development and Evaluations).18 Inconsistencies that arose during this critical appraisal were resolved through discussion with the fourth and fifth reviewers (S.W. and S.R.). Data from the included studies was analyzed and presented as a narrative synthesis. Given the heterogeneity of the included studies, a meta-analysis was not undertaken.
EVIDENCE SYNTHESIS
Following the database search, 7246 papers were identified, which was reduced to 18 final articles following removal of duplicates and review of titles and full articles (Fig 1). The list of included studies is listed in Appendix 2, reasons for exclusion of the 115 articles following full text review, are listed in Appendix 3 (see Supplemental Information). A randomized controlled trial (RCT) design was used in 5 of the 18 studies,19–23 with 1 of these studies being a cluster RCT.20 The remainder of the studies were analytic studies, which included a nonrandomized prospective intervention study20 and observational studies (Table 1).24–28
Description of Included Publications
| Paper | Study Type | Setting | Participants | Demographics | Intervention | Outcome Measures |
|---|---|---|---|---|---|---|
| Clinical pathway involving identification and referral of social needs | ||||||
| Beck 2014 (United States)24 | Time-series analysis | Pediatric primary care centre – a large, urban primary care clinic. | n = 5071; I = 1042; C = 4029; 0–1 y old | 47.9% female; 71.2% African American; 16.9% white; 9.5% other; 2.4% unknown | Social needs screening and referral. Evaluation of Keeping Infants Nourished and Developing (KIND), a clinical-community intervention for food-insecure families with infants. Families received support in the form of supplementary infant formula, educational materials along with clinic and community resources. | Social needs identification, referral for social needs, contacting of referred resource, child health |
| Beck 2022 (United States)30 | Retrospective cohort study | 3 urban pediatric primary care centers and 3 school based health centers. Across all sites, more than 80% of patients are covered by Medicaid. | n = 33212; I = 2203; C = 31 009; lower limit of age range noted to be 12 mo, higher limit not mentioned. Age range assumed to be 1–18 y as children are attending medical services. | 44.59% female; 77.03% African American; 17.38% white; 5.58% other | Social needs screening and referral. Evaluation of the impact on child health of the Child Health-Law Partnership (Child HeLP), a medical-legal partnership providing support for families with social needs amenable to legal intervention. Families received support ranging from legal advice to legal representation in court. | Child health |
| Fleegler 2007 (United States)27 | Cross sectional descriptive study | 2 urban outpatient pediatric clinics: a community health center and an academic health care practice. | n = 205; 0–6 y old | 52% female; 57% Hispanic, 29% African American; 15% white, mixed, or other | Social needs screening and referral. Characterization of families’ cumulative health-related SDH, experiences and parental acceptability of screening and referral for social needs. | Social needs identification, referral for social needs, acceptability |
| Garg 2015 (United States)20 | Cluster randomized controlled trial | 8 urban community health centers. | n = 336; I = 168; C = 168; 0–6 mo old | 100% female (only mothers recruited into study); child’s sex not mentioned; 23% Hispanic; 24% white; 44% African American; 2% Asian; <1% Native Hawaiian; 4% Non-Hispanic >1 race; 4% unknown or not reported | Social needs screening and referral. Evaluation of the effect the Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) program, a clinic-based screening and referral system, on resolution of social needs and child health. | Social needs identification, referral for social needs, contacting of referred resource, social needs resolution at follow-up, child health |
| Hassan 2015 (United States)29 | Prospective intervention study | An adolescent and youth clinic based in an urban hospital. | n = 401; 15–25 y olda | 69% female; 54% African American; 29% Hispanic; 9% white | Social needs screening and referral. Determination of the effect a web-based intervention in youth for addressing social needs. | Social needs identification, contacting of referred resource, social needs resolution at follow-up |
| Lawton 2020 (United States)31 | Prospective intervention study | Pediatric primary care center. Of study participants, 9% were Medicaid-insured. | n = 1234 referrals; I = 74 received services; age range not mentioned. Mean age of referred children 7.0 y (SD = 4.6). | 37% female; 78% African American | Social needs screening. Evaluation of the Cincinnati Child Health-Law Partnership, a medical-legal partnership (MLP) | Referral for social needs. |
| Clinical pathway involving identification and referral of social needs with navigator | ||||||
| Fiori 2020 (United States)38 | Pilot study | Urban pediatric ambulatory clinic serving a population with a high burden of poverty and adverse health outcomes. | n = 287; age range not mentioned, assumed to be 0–18 y as children are attending medical services | 50% female; 33% Hispanic; 27% Non-Hispanic Black; 8% Non-Hispanic; multicultural; 32% not disclosed | In-person navigator for social needs. Evaluation of the effects of in-person resource navigation following social needs screening on social service uptake. | Social needs identification, contacting of referred resource. |
| Fritz 2020 (United States)49 | Cross sectional descriptive study | 2 primary care clinics; general pediatrics inpatient ward; emergency department (patients with asthma in emergency department) | n = 1952 positive food insecurity screen. I= 371 accepted referrals; C= 1581 declined referral; 0 = 18 y | Child’s sex not reported. Race: 36% white; 27% Black or African American; 37% other. Ethnicity: 54% not Hispanic or Latino; 46% Hispanic or Latino. | Social needs screening and referral. Families who screen positive for food insecurity are offered referral to Hunger Free Colorado (HFC) service. HFC provide families with navigation of food resources. | Referral for social needs, contacting of referred resource. |
| Gottlieb 2020 (United States)21 | Randomized controlled trial | Pediatric urgent care clinic at an urban safety-net hospital which serves primarily low-income, racially, and ethnically diverse populations. | n = 639; I = 321; C = 318; 0–17 y old | 51% female; 79% Hispanic; 8.8% Non-Hispanic Black; 8.8% other or mixed; 3.3% Non-Hispanic white | In-person navigator for social needs. Comparison of the effectiveness of in-person longitudinal social services navigation assistance to a less intensive approach on social needs and child and caregiver health. | Social needs identification, child health, caregiver health |
| Gottlieb 2016 (United States)23 | Randomized controlled trial | Primary or urgent pediatric care clinics located in 2 safety-net hospitals where most patients lack health cover or are enrolled in Medicaid. | n = 1809; I = 872; C = 937; age range not mentioned, assumed to be 0–18 y as children are attending medical services | 50.5% female; 4.1% Non-Hispanic white; 50.9% Hispanic white; 26.1% Non-Hispanic Black; 6.2% Hispanic Black; 4.8% Asian; 7.8% other or mixed race or ethnicity | In-person navigator for social needs. Evaluation of the effects of in-person resource navigation following social needs screening. | Social needs identification, child health |
| Hensley 2021 (United States)33 | Retrospective observational study | An urban hospital-based pediatric clinic at a large academic institution. Approximately 90% of patients are publicly ensured. | n = 14622; I = 236; C = 14386; age range not mentioned, assumed to be 0–18 y as children are attending medical services | 49.1% female; 76.6% African American; 15.2% white; 5.6% other; 2.5% unknown | In-person navigator for social needs. Evaluation of the effects of in-person resource navigation following social needs screening, completion of preventive services and acute service utilization. | Social needs identification, referral for social needs, child health |
| Hill 2022 (United States)34 | Retrospective cohort study | Two academic-based, pediatric primary care practices in Baltimore City. | n = 969; I= 761; C= 208; 1–21 y as children or young people are attending either pediatric primary care practice and referred to the Hopkins Community Connection program. | 52.2% female; 44.7% Non-Hispanic Black; 2.3% Non-Hispanic white; 0.3% white; 0.1% Asian; 3.8% other non-Hispanic; 47.8% Hispanic | In-person navigator for social needs. Evaluation of the effect of in-person navigation following social needs screening on follow-up/connection with resources, emergency department visits, and well-child visits. | Social needs identification, referral for social needs, contacting of referred resource, child health |
| Messmer 2020 (United States)35 | Observational study (part of a cluster randomized controlled trial) | 4 federally qualified health centers (FQHCs) | n = 414; remote = 229; on-site = 185; 0–42 y | 48.1% female; 63.8 African American; 22.7% unreported; 7% white; 5.1% Asian; 1.2% Native Hawaiian or other Pacific Islander; 0.2% American Indian or Alaska Native | Comparison of whether patient navigator located on-site versus remotely is more likely to receive referrals, successfully follow up with patients, and assist families with resource enrollment. | Social needs identification, referral for social needs, contacting of referred resource |
| Pantell 2020 (United States)22 | Randomized controlled trial | 2 primary and urgent pediatric care clinics located in safety net hospitals. | n = 1809; I = 872; C = 937; 0–18 y | 53.2% female; 55.6% Hispanic; 27.5% Hispanic Black; 5.1%; Asian; 4.2% Non-Hispanic white; 7.6% other | In-person navigation for social needs. Comparison of the acute care utilization effects of an intervention with in-person resource navigator versus written resource handout to address social needs. | Social needs identification, child health |
| Clinical pathway involving identification and referral of social needs with clinician training | ||||||
| Garg 2007 (United States)19 | Randomized controlled trial | An urban hospital-based pediatric clinic at a large academic institution. | n = 200; I = 100; C = 100; 2 mo–10 y old; pediatric resident providers: n = 45; I = 24; C=21; (22 completed survey) | 82.7% mothers; child’s sex not mentioned; 90.8% African American; 3.1% white; 1.5% Asian; 4.6% other | Training of clinicians on SDH. Evaluation of the feasibility and impact of an intervention on the screening and referral of social needs in well-child care (WCC) visits at a medical home for low-income children. | Social needs identification, referral for social needs, acceptability |
| Klein 2013 (United States)28 | Case study | 3 clinics in primary care setting (PCS), including an urban academic pediatric clinic, an urban community clinic and a suburban community clinic. All patients are predominantly economically disadvantaged. | n = 1614; Age range not mentioned, assumed to be 0–18 y as children are attending medical services | 46.2% female; 74.5% African American; 18.3% white; 1.6% Hispanic; 5.6% other | Training of clinicians on SDH. Description of the critical steps required in implementing a medical-legal partnership (MLP) colocated in an academic pediatric primary care setting. | Social needs identification, referral for social needs, resolution of social needs (positive medico-legal outcome) |
| Purkey 2019 (Canada)25 | Exploratory study – cross sectional | A range of pediatric care and family medicine settings. | n = 6364; n = 22 clinicians participated; age range not mentioned, assumed to be 0–18 y as children are attending medical services; 18 clinicians completed focus groups; 150 patients completed patient surveys | Not mentioned | Training of clinicians on SDH. Describe and evaluate the implementation of a clinical poverty tool in a range of pediatric care and family medicine settings. | Social needs identification, referral for social needs, acceptability |
| Selvaraj 2019 (United States)26 | Observational study | 4 academic pediatric primary care sites. All sites serve urban, low-income, and racially diverse population. | n = 2569; 2 wk–17 y old; 56% completed ASK tool; 25% of these completed additional demographic survey and family satisfaction survey | 48.31% female; 54.9% African American; 21.4% Hispanic or Latino; 7.6% Caucasian; 4.7% Asian or Pacific Islander; 11.4% other | Training of clinicians on SDH. Determine demographic characteristics, and prevalence associated with social needs factors, evaluate the impact of referrals for social needs. Determine the acceptability of social needs screening by patients. | Social needs identification, referral for social needs, acceptability |
| Paper | Study Type | Setting | Participants | Demographics | Intervention | Outcome Measures |
|---|---|---|---|---|---|---|
| Clinical pathway involving identification and referral of social needs | ||||||
| Beck 2014 (United States)24 | Time-series analysis | Pediatric primary care centre – a large, urban primary care clinic. | n = 5071; I = 1042; C = 4029; 0–1 y old | 47.9% female; 71.2% African American; 16.9% white; 9.5% other; 2.4% unknown | Social needs screening and referral. Evaluation of Keeping Infants Nourished and Developing (KIND), a clinical-community intervention for food-insecure families with infants. Families received support in the form of supplementary infant formula, educational materials along with clinic and community resources. | Social needs identification, referral for social needs, contacting of referred resource, child health |
| Beck 2022 (United States)30 | Retrospective cohort study | 3 urban pediatric primary care centers and 3 school based health centers. Across all sites, more than 80% of patients are covered by Medicaid. | n = 33212; I = 2203; C = 31 009; lower limit of age range noted to be 12 mo, higher limit not mentioned. Age range assumed to be 1–18 y as children are attending medical services. | 44.59% female; 77.03% African American; 17.38% white; 5.58% other | Social needs screening and referral. Evaluation of the impact on child health of the Child Health-Law Partnership (Child HeLP), a medical-legal partnership providing support for families with social needs amenable to legal intervention. Families received support ranging from legal advice to legal representation in court. | Child health |
| Fleegler 2007 (United States)27 | Cross sectional descriptive study | 2 urban outpatient pediatric clinics: a community health center and an academic health care practice. | n = 205; 0–6 y old | 52% female; 57% Hispanic, 29% African American; 15% white, mixed, or other | Social needs screening and referral. Characterization of families’ cumulative health-related SDH, experiences and parental acceptability of screening and referral for social needs. | Social needs identification, referral for social needs, acceptability |
| Garg 2015 (United States)20 | Cluster randomized controlled trial | 8 urban community health centers. | n = 336; I = 168; C = 168; 0–6 mo old | 100% female (only mothers recruited into study); child’s sex not mentioned; 23% Hispanic; 24% white; 44% African American; 2% Asian; <1% Native Hawaiian; 4% Non-Hispanic >1 race; 4% unknown or not reported | Social needs screening and referral. Evaluation of the effect the Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) program, a clinic-based screening and referral system, on resolution of social needs and child health. | Social needs identification, referral for social needs, contacting of referred resource, social needs resolution at follow-up, child health |
| Hassan 2015 (United States)29 | Prospective intervention study | An adolescent and youth clinic based in an urban hospital. | n = 401; 15–25 y olda | 69% female; 54% African American; 29% Hispanic; 9% white | Social needs screening and referral. Determination of the effect a web-based intervention in youth for addressing social needs. | Social needs identification, contacting of referred resource, social needs resolution at follow-up |
| Lawton 2020 (United States)31 | Prospective intervention study | Pediatric primary care center. Of study participants, 9% were Medicaid-insured. | n = 1234 referrals; I = 74 received services; age range not mentioned. Mean age of referred children 7.0 y (SD = 4.6). | 37% female; 78% African American | Social needs screening. Evaluation of the Cincinnati Child Health-Law Partnership, a medical-legal partnership (MLP) | Referral for social needs. |
| Clinical pathway involving identification and referral of social needs with navigator | ||||||
| Fiori 2020 (United States)38 | Pilot study | Urban pediatric ambulatory clinic serving a population with a high burden of poverty and adverse health outcomes. | n = 287; age range not mentioned, assumed to be 0–18 y as children are attending medical services | 50% female; 33% Hispanic; 27% Non-Hispanic Black; 8% Non-Hispanic; multicultural; 32% not disclosed | In-person navigator for social needs. Evaluation of the effects of in-person resource navigation following social needs screening on social service uptake. | Social needs identification, contacting of referred resource. |
| Fritz 2020 (United States)49 | Cross sectional descriptive study | 2 primary care clinics; general pediatrics inpatient ward; emergency department (patients with asthma in emergency department) | n = 1952 positive food insecurity screen. I= 371 accepted referrals; C= 1581 declined referral; 0 = 18 y | Child’s sex not reported. Race: 36% white; 27% Black or African American; 37% other. Ethnicity: 54% not Hispanic or Latino; 46% Hispanic or Latino. | Social needs screening and referral. Families who screen positive for food insecurity are offered referral to Hunger Free Colorado (HFC) service. HFC provide families with navigation of food resources. | Referral for social needs, contacting of referred resource. |
| Gottlieb 2020 (United States)21 | Randomized controlled trial | Pediatric urgent care clinic at an urban safety-net hospital which serves primarily low-income, racially, and ethnically diverse populations. | n = 639; I = 321; C = 318; 0–17 y old | 51% female; 79% Hispanic; 8.8% Non-Hispanic Black; 8.8% other or mixed; 3.3% Non-Hispanic white | In-person navigator for social needs. Comparison of the effectiveness of in-person longitudinal social services navigation assistance to a less intensive approach on social needs and child and caregiver health. | Social needs identification, child health, caregiver health |
| Gottlieb 2016 (United States)23 | Randomized controlled trial | Primary or urgent pediatric care clinics located in 2 safety-net hospitals where most patients lack health cover or are enrolled in Medicaid. | n = 1809; I = 872; C = 937; age range not mentioned, assumed to be 0–18 y as children are attending medical services | 50.5% female; 4.1% Non-Hispanic white; 50.9% Hispanic white; 26.1% Non-Hispanic Black; 6.2% Hispanic Black; 4.8% Asian; 7.8% other or mixed race or ethnicity | In-person navigator for social needs. Evaluation of the effects of in-person resource navigation following social needs screening. | Social needs identification, child health |
| Hensley 2021 (United States)33 | Retrospective observational study | An urban hospital-based pediatric clinic at a large academic institution. Approximately 90% of patients are publicly ensured. | n = 14622; I = 236; C = 14386; age range not mentioned, assumed to be 0–18 y as children are attending medical services | 49.1% female; 76.6% African American; 15.2% white; 5.6% other; 2.5% unknown | In-person navigator for social needs. Evaluation of the effects of in-person resource navigation following social needs screening, completion of preventive services and acute service utilization. | Social needs identification, referral for social needs, child health |
| Hill 2022 (United States)34 | Retrospective cohort study | Two academic-based, pediatric primary care practices in Baltimore City. | n = 969; I= 761; C= 208; 1–21 y as children or young people are attending either pediatric primary care practice and referred to the Hopkins Community Connection program. | 52.2% female; 44.7% Non-Hispanic Black; 2.3% Non-Hispanic white; 0.3% white; 0.1% Asian; 3.8% other non-Hispanic; 47.8% Hispanic | In-person navigator for social needs. Evaluation of the effect of in-person navigation following social needs screening on follow-up/connection with resources, emergency department visits, and well-child visits. | Social needs identification, referral for social needs, contacting of referred resource, child health |
| Messmer 2020 (United States)35 | Observational study (part of a cluster randomized controlled trial) | 4 federally qualified health centers (FQHCs) | n = 414; remote = 229; on-site = 185; 0–42 y | 48.1% female; 63.8 African American; 22.7% unreported; 7% white; 5.1% Asian; 1.2% Native Hawaiian or other Pacific Islander; 0.2% American Indian or Alaska Native | Comparison of whether patient navigator located on-site versus remotely is more likely to receive referrals, successfully follow up with patients, and assist families with resource enrollment. | Social needs identification, referral for social needs, contacting of referred resource |
| Pantell 2020 (United States)22 | Randomized controlled trial | 2 primary and urgent pediatric care clinics located in safety net hospitals. | n = 1809; I = 872; C = 937; 0–18 y | 53.2% female; 55.6% Hispanic; 27.5% Hispanic Black; 5.1%; Asian; 4.2% Non-Hispanic white; 7.6% other | In-person navigation for social needs. Comparison of the acute care utilization effects of an intervention with in-person resource navigator versus written resource handout to address social needs. | Social needs identification, child health |
| Clinical pathway involving identification and referral of social needs with clinician training | ||||||
| Garg 2007 (United States)19 | Randomized controlled trial | An urban hospital-based pediatric clinic at a large academic institution. | n = 200; I = 100; C = 100; 2 mo–10 y old; pediatric resident providers: n = 45; I = 24; C=21; (22 completed survey) | 82.7% mothers; child’s sex not mentioned; 90.8% African American; 3.1% white; 1.5% Asian; 4.6% other | Training of clinicians on SDH. Evaluation of the feasibility and impact of an intervention on the screening and referral of social needs in well-child care (WCC) visits at a medical home for low-income children. | Social needs identification, referral for social needs, acceptability |
| Klein 2013 (United States)28 | Case study | 3 clinics in primary care setting (PCS), including an urban academic pediatric clinic, an urban community clinic and a suburban community clinic. All patients are predominantly economically disadvantaged. | n = 1614; Age range not mentioned, assumed to be 0–18 y as children are attending medical services | 46.2% female; 74.5% African American; 18.3% white; 1.6% Hispanic; 5.6% other | Training of clinicians on SDH. Description of the critical steps required in implementing a medical-legal partnership (MLP) colocated in an academic pediatric primary care setting. | Social needs identification, referral for social needs, resolution of social needs (positive medico-legal outcome) |
| Purkey 2019 (Canada)25 | Exploratory study – cross sectional | A range of pediatric care and family medicine settings. | n = 6364; n = 22 clinicians participated; age range not mentioned, assumed to be 0–18 y as children are attending medical services; 18 clinicians completed focus groups; 150 patients completed patient surveys | Not mentioned | Training of clinicians on SDH. Describe and evaluate the implementation of a clinical poverty tool in a range of pediatric care and family medicine settings. | Social needs identification, referral for social needs, acceptability |
| Selvaraj 2019 (United States)26 | Observational study | 4 academic pediatric primary care sites. All sites serve urban, low-income, and racially diverse population. | n = 2569; 2 wk–17 y old; 56% completed ASK tool; 25% of these completed additional demographic survey and family satisfaction survey | 48.31% female; 54.9% African American; 21.4% Hispanic or Latino; 7.6% Caucasian; 4.7% Asian or Pacific Islander; 11.4% other | Training of clinicians on SDH. Determine demographic characteristics, and prevalence associated with social needs factors, evaluate the impact of referrals for social needs. Determine the acceptability of social needs screening by patients. | Social needs identification, referral for social needs, acceptability |
n, total number included in study; I, number included in intervention group; C, number included in control group.
Age included children from our inclusion criteria of 0 to18.
Of the 18 included studies, 17 were from the United States26–31,33–36,38 and 1 study was from Canada.25 The studies were all based in pediatric primary care, with studies by Pantell22 and the 2 studies by Gottlieb21,23 also based in urgent or acute care in addition to pediatric primary care settings. The interventions could be broadly divided into 3 groups:
Clinical pathway involving identification and referral for social needs with targeted community resource pack only
Clinical pathway involving identification and referral for social needs, with a navigator
Clinical pathway involving identification and referral for social needs, with clinician training
Clinical Pathway Involving Identification and Referral for Social Needs With a Targeted Community Resource Pack Only
In 6 of the included studies, the intervention group received referral for social needs following screening for SDH concerns.20,24,27,29,30,31 In these studies, participants who were identified to have social needs received referrals and were given relevant predetermined local community resources. In addition to resources, the study by Beck24 provided patients in the intervention group with infant formula.
Clinical Pathway Involving Identification and Referral for Social Needs, With Navigator
Of the 18 studies, 8 of the studies used an in-person navigator following identification of social needs.21–23,32–36 In 4 studies, the in-person navigators were volunteers,21–23,34 whereas 2 studies employed an in-person navigator.32,33 Method of employment was not mentioned in 2 studies.35,36 One study compared an in-person and remote patient navigator.35 All in-person navigators received training and provided targeted information and follow-up for families.
Clinical Pathway Involving Identification and Referral for Social Needs, With Clinician Training
In 4 of the 18 included studies, clinicians were provided training as part of the intervention.19,25,28,37 Training sessions ranged from 10 minutes to 3.5 hours and covered a range of topics including pediatric professional guidelines, the intervention material, SDH, medical-legal partnership, poverty and poverty resources, and toxic stress.
Quality Assessment
Table 2 outlines risk of bias of included studies. Thirteen studies were assessed as high risk24–29,30,31,33–36,38 and 5 studies were low risk,19–23 with only 1 to 2 areas of high risk of bias, which included blinding of participants and personnel for all 5 studies and blinding of outcome assessment in 1 study.23
Risk of Bias Summary (Based on GRADE)
| Study | Random Sequence Generation | Allocation Concealment | Blinding of Participants and Personnel | Blinding of Outcome Assessment | Incomplete Outcome Data | Selective Outcome Reporting | Other Reporting Bias |
|---|---|---|---|---|---|---|---|
| Beck 201424 | High | High | High | High | Low | Low | NA |
| Beck 202230 | High | High | High | Low | Low | Low | NA |
| Fiori 202038 | High | High | High | High | Low | Low | High |
| Fleegler 200727 | High | Unclear | High | High | Low | Low | NA |
| Fritz 202036 | High | High | High | High | High | Low | NA |
| Garg 201520 | Low | Low | High | Low | Low | Low | NA |
| Garg 200719 | Low | Low | High | Low | Low | Low | NA |
| Gottlieb 202021 | Low | Low | High | Low | Low | Low | NA |
| Gottlieb 201623 | Low | Low | High | High | Low | Low | NA |
| Hassan 201529 | High | High | High | High | Low | Low | NA |
| Hensley 202133 | High | High | High | High or low | Low | High/Low | Unclear |
| Hill 202234 | High | High | High | High | Low | Low | High |
| Klein 201328 | High | High | High | High | Unclear | Unclear | NA |
| Lawton 202031 | High | High | High | High | High | High | NA |
| Messmer 202035 | High | High | High | High | Low | Low | NA |
| Pantell 202022 | Low | Low | High | Low | Low | Low | Unclear |
| Purkey 201925 | High | High | High | High | Low | High | NA |
| Selvaraj 201926 | High | High | High | High | Low | Low | High |
| Study | Random Sequence Generation | Allocation Concealment | Blinding of Participants and Personnel | Blinding of Outcome Assessment | Incomplete Outcome Data | Selective Outcome Reporting | Other Reporting Bias |
|---|---|---|---|---|---|---|---|
| Beck 201424 | High | High | High | High | Low | Low | NA |
| Beck 202230 | High | High | High | Low | Low | Low | NA |
| Fiori 202038 | High | High | High | High | Low | Low | High |
| Fleegler 200727 | High | Unclear | High | High | Low | Low | NA |
| Fritz 202036 | High | High | High | High | High | Low | NA |
| Garg 201520 | Low | Low | High | Low | Low | Low | NA |
| Garg 200719 | Low | Low | High | Low | Low | Low | NA |
| Gottlieb 202021 | Low | Low | High | Low | Low | Low | NA |
| Gottlieb 201623 | Low | Low | High | High | Low | Low | NA |
| Hassan 201529 | High | High | High | High | Low | Low | NA |
| Hensley 202133 | High | High | High | High or low | Low | High/Low | Unclear |
| Hill 202234 | High | High | High | High | Low | Low | High |
| Klein 201328 | High | High | High | High | Unclear | Unclear | NA |
| Lawton 202031 | High | High | High | High | High | High | NA |
| Messmer 202035 | High | High | High | High | Low | Low | NA |
| Pantell 202022 | Low | Low | High | Low | Low | Low | Unclear |
| Purkey 201925 | High | High | High | High | Low | High | NA |
| Selvaraj 201926 | High | High | High | High | Low | Low | High |
NA, not applicable.
Outcomes
The reportable outcomes in the 18 studies were identification for social needs, referral and uptake for social needs, reduction of social needs, child and caregiver health, acceptability, feasibility, harm, and cost of programs (Tables 3 and 4).
Checklist of Outcomes
| Paper | Social Needs Identification | Referrals Following Identification of Social Needs | Reduction in Social Needs | Child Health | Caregiver Health | Acceptability of Identification of Social Needs by Patients | Acceptability of Identification of Social Needs by Clinicians | Harm identified from identification of social needs | Cost of identification of social needs |
|---|---|---|---|---|---|---|---|---|---|
| Clinical pathway involving identification and referral of social needs with a targeted community resource | |||||||||
| Beck 201424 | x | x | x | ||||||
| Beck 202230 | x | ||||||||
| Fleegler 200727 | x | x | x | ||||||
| Garg 201520 | x | x | x | x | |||||
| Hassan 201529 | x | x | |||||||
| Lawton 202031 | x | ||||||||
| Clinical pathway involving identification and referral of social needs with navigator | |||||||||
| Fiori 202038 | x | x | |||||||
| Fritz 202049 | x | ||||||||
| Gottlieb 202021 | x | x | x | x | x | ||||
| Gottlieb 201623 | x | x | x | x | |||||
| Hensley 202133 | x | x | x | ||||||
| Hill 202234 | x | x | x | ||||||
| Messmer 202035 | x | x | |||||||
| Pantell 202022 | x | ||||||||
| Clinical pathway involving identification and referral of social needs with clinician training | |||||||||
| Garg 200719 | x | x | x | ||||||
| Klein 201328 | x | ||||||||
| Purkey 201925 | x | x | x | x | |||||
| Selvaraj 201926 | x | x | x | ||||||
| Paper | Social Needs Identification | Referrals Following Identification of Social Needs | Reduction in Social Needs | Child Health | Caregiver Health | Acceptability of Identification of Social Needs by Patients | Acceptability of Identification of Social Needs by Clinicians | Harm identified from identification of social needs | Cost of identification of social needs |
|---|---|---|---|---|---|---|---|---|---|
| Clinical pathway involving identification and referral of social needs with a targeted community resource | |||||||||
| Beck 201424 | x | x | x | ||||||
| Beck 202230 | x | ||||||||
| Fleegler 200727 | x | x | x | ||||||
| Garg 201520 | x | x | x | x | |||||
| Hassan 201529 | x | x | |||||||
| Lawton 202031 | x | ||||||||
| Clinical pathway involving identification and referral of social needs with navigator | |||||||||
| Fiori 202038 | x | x | |||||||
| Fritz 202049 | x | ||||||||
| Gottlieb 202021 | x | x | x | x | x | ||||
| Gottlieb 201623 | x | x | x | x | |||||
| Hensley 202133 | x | x | x | ||||||
| Hill 202234 | x | x | x | ||||||
| Messmer 202035 | x | x | |||||||
| Pantell 202022 | x | ||||||||
| Clinical pathway involving identification and referral of social needs with clinician training | |||||||||
| Garg 200719 | x | x | x | ||||||
| Klein 201328 | x | ||||||||
| Purkey 201925 | x | x | x | x | |||||
| Selvaraj 201926 | x | x | x | ||||||
Outcome Measures and Results
| Paper | Outcome Measure | Tool Used | Results | Significance | Summary |
|---|---|---|---|---|---|
| Clinical pathway involving identification and referral of social needs with targeted community resource only | |||||
| Beck 201424 | Identification of social needs | Parent report | Intervention recipients more likely to report social needs concerns relating to housing, public benefits, domestic violence, and parental depression. | all P < .0001 | Increased identification of social needs in intervention group |
| Referral for social needs | Not documented | Social work referral 29.2% (intervention), 17.6% (control); MLP referral 14.8% (intervention), 5.7% (control). | <.0001; <.0001 | Increased referrals in intervention group | |
| Social work referral 29.2% (intervention), 17.6% (control); MLP referral 14.8% (intervention), 5.7% (control). | <.0001; <.0001 | ||||
| Child health | EMR (electronic medical records) | 9 mo wt for length percentile; <5th percentile: 5% (intervention), 3.7% (control); 5–95th percentile: 88.5% (intervention), 87.5% (control); >95th percentile 6.5% (intervention), 8.7% (control); lead level: below level of detection: 62.9% (intervention), 59% (control); 1.4–2.4: 28.1% (intervention), 29% (control); 2.5–4.9: 7.3% (intervention), 9.9% (control); ≥5 1.7% (intervention), 2.1% (control); ED visits in first 14 mo more likely 0: 16% (intervention), 19.5% (control); 1: 24.9% (intervention), 32.1% (control); 2+: 28.9% (intervention), 48.5% (control). | 0.3 NS; 0.2 NS; <.0001 | No significant difference in child health in intervention group; increased visits to ED in intervention group | |
| Completion of preventative care services: 5+ well child visits in first 14 mo: 42% (intervention) vs 28.7% (control); lead test: 81.2% (intervention) vs 75% (control); 9mo ASQ: 26.6% (intervention) vs 20.1% (control). | <.0001; .0006; .0002 | Increased engagement with preventative child health services in intervention group | |||
| Beck 202230 | Child health | EHR (electronic health record) | In the 12 mo before referral, hospitalization rates were 10.1 ± 0.33 per 100 child-years (intervention) vs 9.7 ± 0.33 per 100 child-years (control); In the 12 mo following referral, hospitalization rates were 9.2 ± 0.20 per 100 child-years (intervention) vs 9.6 ± 0.33 per 100 child-years (control); the unadjusted, paired pre and post difference; in hospitalization rates was −0.84 ± 0.03 (intervention cohort) vs −0.09 ± 0.04 (control); unadjusted difference- in-differences analysis suggests that there were 0.73 fewer hospitalizations per 100 child-years as a result of the intervention. Using adjusted generalized estimating equation Poisson models, the intervention was associated with a median postreferral hospitalization rate that was 62.1% (IQR: 60.5–63.4) of what would have been expected had no intervention taken place, across all 100 trials. This equates to 37.9% fewer hospitalizations occurring among those receiving the intervention. Analyses of all 100 trials detected similar, statistically significant effects. | Maximum .0010 | Referral to intervention program decreased likeliness of child hospitalization in the year following referral |
| Fleegler 200727 | Identification of social needs | Parent report | 82% had ≥ 1 health-related social problem (HRSP); 28% had experienced 1 HRSP, 32% experienced 2 HRSP, 22% experienced ≥ 3HRSP. | Increased identification of social needs | |
| Acceptability as rated by patients | Parent report | Parent’s response in regards to computer-based screening and referral program administered within a pediatrician’s office: 92% would “welcome it” or “not mind at all.” | In families who received referrals following identification of social needs, the majority of them made contact with the referral agencies and considered the referral agencies helpful. | ||
| Parental acceptability of a computer-based screening and referral program inquiring about the 5 HRSPs: would “welcome it” or “not mind at all”: 94% for access to health care, 88% for food security, 90% for income security, 93% for housing stability, 81% for intimate partner violence | The majority of patients found screening and referral of social needs in a pediatrician’s office acceptable. | ||||
| Fritz 202048 | Referral for social needs | Parent report | 81% of families with food insecurity declined referral to Hunger Free Colorado (HFC) service; 19% of families with food insecurity accepted referral to HFC service. Of those that accepted referral, 61% were connected to food resource and 39% were not connected to food resource. Of those that were not connected to food resource, 62% were unable to contact and 38% were contacted by declined. | High connection to SDH resources from families who accept referral to service and from families with more people living in home. | |
| Parent report | Compared with those who declined HFC referral, families who accepted HFC referral were more likely to be screened in emergency department and inpatient setting, and less likely to be screened in special care clinic. | <.001 | |||
| Parent report and EMR | Families with more people in the home (≥3 people) were more likely to be connected to resources. | .002 | |||
| Garg 201520 | Referral for social needs | Parent report | WE CARE mothers receiving ≥ 1 referral at index visit: 70% (intervention) vs 8% (control); aOR = 29.6; 95% CI, 14.7 to 59.6). | Increased referrals for social needs in intervention group | |
| Overall, 42% of WE CARE mothers received ≥ 2 referrals at the visit; 21% of WE CARE mothers received ≥3 referrals. | |||||
| WE CARE mothers contact with community resource at 9 mo follow-up; 65% (intervention) vs 49% (control); aOR = 1.5; 95% CI, 1.1 to 2.1. | Increased uptake of SDH resources by intervention group | ||||
| WE CARE mothers enrolled in ≥1 new resource at 12 mo well child care visit: 39% (intervention) vs 24% (control); aOR = 2.1; 95% CI, 1.2 to 3.7. | |||||
| Reduction in social needs | Parent report | Mothers being employed or enrolled in job training program at 12 mo; aOR = 44.4; 95% CI, 9.8 to 201.4. Intervention group had greater odds of being employed or enrolled in job training program. | Reduction in social needs in intervention group | ||
| Receiving fuel assistance; aOR = 11.9; 95% CI, 1.7 to 82.9. Intervention group had greater odds of receiving fuel assistance. | |||||
| Being in a homeless shelter; aOR 0.20; 95% CI, 0.1 to 0.9. Intervention group had lower odds of being in a homeless shelter. | |||||
| Child health | Parent report | Children enrolled in child care at 12 mo; aOR = 6.3; 95% CI, 1.5 to 26. Intervention group had greater odds of being enrolled in childcare. | Increased engagement with child health services | ||
| Hassan 201529 | Reduction in social needs | Adolescent report | 40% of adolescents had contacted a referral agency for their top priority; 50% of these reported their top-priority problem either ‘completely’ or “mostly” resolved; 45% of adolescents who did not contact a referred resource reported their problem resolved; >90% of these reported contacting other resources; overall, 47% of all adolescents reported resolution of their top priority problem. | Improved uptake of resources. Reduction in social needs at follow-up | |
| Social needs related to income security had significantly lower resolution rates (aOR = 0.40 = 2.41, 95% CI, 1.20 to 4.840. | .01 | Decreased resolution of social needs related to income security | |||
| Lawton 202031 | Referral for social needs | EMR | 6% of referred patients received services from medical-legal partnership. | Rates of engagement with service were low. | |
| Clinical pathway involving identification and referral of social needs with navigator | |||||
| Fiori 202038 | Identification of social needs | Parent report | 20% of households reported 1 or more social needs. | Successful referral to resources was associated with a higher number of navigator outreach attempts and a shorter follow up time | |
| Referral for social needs | 43% of households referred to the navigator reported successful referral to resources; households that had 4 or more navigator outreach attempts were more likely to report a successful referral (aOR = 1.92, 95% CI, 1.06 to 3.49). Follow up time ≥30 d was associated with a lower likelihood of successful referral (aOR = 0.43, 95% CI, 0.25 to 0.73). | .03; .002 | |||
| Gottlieb 202021 | Identification of social needs | Parent report | 7.7% did not report any social needs 50.7% reported 4 or more social needs. | Increased identification of social needs in both intervention group and active control group | |
| Reduction in social needs | No significant differences found between intervention and control group in the number of social needs reported at follow-up; number of successful navigator contacts associated with decreases in number of social needs was not significant (r = −0.10); at 6-mo follow-up, both groups experienced a decrease in number of social needs relative to baseline, with mean (SE) difference of −1.28 (0.19) social needs (control) and −1.74 (0.21) (intervention). | NS; NS; .15; <.001 | No significant difference in social needs, child health, or caregiver health found between intervention and active control group. | ||
| Child health | At 6-mo follow up, there was a small improvement from baseline in child health in both groups (mean (SE) change; 0.37(0.07) (control) vs 0.24(0.07) (intervention). No significant differences found between intervention and control group in the improvement in child health mean (SE) adjusted difference 0.12(0.09), 95% CI, −0.04 to 0.27. | both <.001; .13; NS | |||
| Caregiver health | At follow-up, no statistically significant differences in caregiver perceived stress, depression symptoms or general health between intervention versus control groups. | NS | |||
| Gottlieb 201623 | Identification of social needs | Parent report | 17% did not report any social needs 20% reported 4 or more social needs. | Increased identification of social needs | |
| Reduction in social needs | At follow-up, a statistically difference in social needs was found with decrease in social needs in intervention group and slight increase in control group: mean (SE) −0.39 (0.13) intervention vs 0.22 (0.13) (control) for a mean (SE) Statistically significant cumulative between-group difference of 0.61 (0.18) need. | <.001 | In person navigation resulted in reduction of reported social needs, and improvement in child health. | ||
| Child health | At follow-up, caregiver report of Child Global Health improvement in both groups (lower scores representing better health): mean (SD) −0.36(0.05) (intervention) vs (SE) −0.12(0.05) (control). Statistically significant mean (SE) difference of −0.24(0.07) between intervention and control group. | <.001 | Improvement in child health in intervention group | ||
| Hensley 202133 | Identification of social needs | EHR electronic health records | At follow up, 54.7% of patients in the intervention group had a social need identified, compared with 23.8% of patients in the control group. | <.01 | Greater identification of social needs in intervention group |
| Referral for social needs | At follow up: 24.6% of intervention group had been referred to medical-legal partnership (MLP), compared with 4.5% of control group. Those in the control group had a 2.81-times increased odds of referral to the MLP (95% CI, 2.01 to 4.12). 2.1% of intervention group had been referred to social work compared with 0.8% of control group. No significant difference in referral to social workers (OR = 1.26, 95% CI, 0.62 to 5.12); 11.4% of intervention group had been referred to infant formulary program compared with 5.2% of control group | <.01; .03; <.01 | Referral to medical-legal partnership and infant formula program clinic resources was higher among patients in intervention group compared with control. No significant difference in referral to social workers. | ||
| Child health | At 12 mo follow up no significant difference in lead screening (OR =1.29, 95% CI, 0.70 to 1.95), emergency department visits (RR = 1.22, 95% CI, 0.997 to 1.49), hospitalizations RR = 0.94, 95% CI, 0.56 to 2.34) or primary care no-shows (RR = 1.11, 95% CI,0.94 to 1.33). | No significant difference between intervention and control groups in completion of preventive services and acute service utilization. | |||
| Hill 202234 | Identification of social needs | Parent report | Site A: the most common needs were food and health (eg, assistance with scheduling appointments and applying for insurance). Site B: the most common needs were health (eg, insurance) and commodities (eg, baby supplies). | ||
| Referral for social needs | Parent report | Site A: 81% patients completed screening and enrolled into in-person navigation program. Site B: 76% patients completed screening and enrolled into in-person navigation program. | High uptake of screening and enrolled into in-person navigation program. | ||
| Contacting of referred SDH resource | Parent report and EMR | Site A: of the enrolled participants, 54.6% were successfully connected to SDH resources. Site B: of the enrolled participants, 40.4% were successfully connected to SDH resources. | |||
| Child health | EMR | Site A: In the 12 mo before intervention, there were nonsignificant differences in rates of high well-child visits (WCV) attendance (75% to 100%) between enrolled (49.3%) and nonenrolled (60.4%) participants. Site A: in the 12 mo following intervention, there were significant difference in rates of high WCV attendance (75% to 100%) between enrolled (81.6%) and nonenrolled (52.7%) participants (P < .001). Site A: there were no significant differences in emergency department in either 12-before intervention or 12-mo post intervention between enrolled and nonenrolled groups. Site B: in the 12 mo before intervention, there were nonsignificant differences in rates of high WCV attendance (75% to 100%) between enrolled (51.5%) and nonenrolled (49.6%) participants. Site B: in the 12 mo following intervention, there were significant difference in rates of high WCV attendance (75% to 100%) between enrolled (71.4%) and non-enrolled (35.0%) participants (P < .001). Site B: there were nonsignificant differences in emergency department in either 12-mo before intervention or 12-mo post intervention between enrolled and nonenrolled groups. | <.001 | Increased engagement with WCV services in families enrolled into in-person navigation program. | |
| Messmer 202035 | Identification of social needs | EHR Electronic health records, Microsoft Excel patient database | The majority of clinician referrals were made through the EHR (83%) vs in person (16%). This was also true when the patient navigator was on-site (67% via EHR vs 32% in person) When the patient navigator was on-site, significantly more referrals were made than expected (45% vs 29%). | <.0001; <.0001 | A greater number of referrals were made to an on-site navigator rather than a remote navigator |
| Referral for social needs | 72% of families were successfully contacted, with no significant difference in the number of successful contacts between remote (1.0 points) vs on-site (1.1 points) groups nor in the proportion of families enrolled in a resource (10.4% vs 8.1%). | .32; .43 | No significant difference between on-site compared with remote navigator groups in the number of contacts with families or enrolment of families in resources | ||
| Pantell 202022 | Child health | EHR electronic health records | Acute care utilization: At 12 mo, no significant difference in children with 1 ED visit 37.1% (intervention) vs 37.7% (control); risk difference −0.7%, 95% CI, −5.9% to 4.6%, relative risk of 0.98, 95% CI, 0.85 to 1.1. | NS | In person navigation decreased likeliness of child hospitalization |
| At 12 mo, significantly less hospital admissions for children in the intervention 29(4.6%) (intervention) vs 50(7.5%) (control), risk difference −3%; (95% CI, −5.6% to −0.4%), relative risk 0.60 (95% CI, 0.39 to 0.94). Cox proportional hazard regression showed children in intervention group had a decreased risk of being hospitalized (hazard ratio 0.59; 95% CI, 0.38 to 0.94) meaning they were 69% less likely to be hospitalized versus control group. This remained significant when controlling for all sociodemographic variables (hazard ratio, 0.59; 95% CI, 0.35 to 0.99). | Significant; 0.03; .46 | ||||
| Time to ED visit 12 mo post enrolment log-rank P = .66; Kaplan-Meier curves revealed no statistically significant difference between time to ED visit within 12 mo. Cox proportional hazard regression showed no significant change in risk of having an ED visit between intervention and control group (hazard ratio 0.96; 95% CI, 0.80 to 1.14). | NS; NS P = .81 | ||||
| Clinical pathway involving identification and referral of social needs with clinician training | |||||
| Garg 200719 | Identification of social needs | Parent report | 2.9 (intervention) vs 1.8 (control); intervention group had significantly higher mean number of psychosocial topics discussed. In multivariate regression analyses, intervention group had significantly higher odds for discussion of parent’s education status and food security at WCC visits compared with control group. | <.01 | Increased identification of social needs in intervention group |
| Intervention group had significantly fewer desires to discuss family psychosocial topics 0.46 (intervention) vs 1.41 (control). | .0001 | ||||
| Referral for social needs | Intervention group received significantly higher number of referrals with means of 1.15 (intervention) vs 0.24 (control); intervention group had significantly greater odds of receiving referrals for food resources, graduate equivalent degree programs, job training, and smoking cessation classes 51% (intervention) vs 11.6% (control) receiving ≥ 1 referral. | <.001; <0.001 | More patients received referrals in the intervention group. | ||
| At 1 mo post visit, significantly more parents recalled receiving referral at index visit 41.2% (intervention) vs 6.7% (control). At 1 mo post visit, more parents in the intervention group reported contacting a referral resource 20% (intervention) vs 2.2% (control). | <.001 | Patients in the intervention group had greater odds of having contacted a community resource at 1 mo. | |||
| Acceptability as rated by clinicians | Clinician report | None of the clinicians reported feeling uncomfortable with having parents hand them the WE CARE survey. | All clinicians found screening and referral for social needs acceptable | ||
| Klein 201328 | Referral and resolution of legal issues or efficacy of medical-legal partnership | Not documented | Referrals resulted in 1945 legal outcomes, of which 89% were positive (improvement in housing, benefits, education, or provision of legal advice). | Reduced social needs in intervention group | |
| Purkey 201925 | Identification of social needs | Parent report | 38% of parents reported they were asked by health care provider if they were having trouble making ends meet. | Rates of identification of social needs by clinicians were low | |
| Referral for social needs | 67% of parents received resources, 33% did not receive resources. | ||||
| Acceptability as rated by patients | 72% of parents supported, 22% were neutral about the appropriateness of poverty screening and intervention by HCPs. 75% felt comfortable or very comfortable being asked if they were having trouble making ends meet by HCPs. | Majority of patients found identification of and referral for social needs acceptable | |||
| 75% of parents felt comfortable or very comfortable, 14% neutral, 11% uncomfortable when asked “Do you ever have trouble making ends meet?” | |||||
| Acceptability as rated by Clinicians | Clinician report | HCPs reported that they thought poverty was relevant to discuss with patients in clinical care. | Majority of Clinicians supported social needs screening | ||
| Selvaraj 201926 | Referral for social needs | Parent report | At least 1 referral was made at 12% of well-child visits (WCV); 1 of the 4 clinic sites had baseline data on community referrals: there was a significant increase in social needs referrals following implementation of universal screening with 2% referrals before vs 13.3% referrals after implementation of screening. | <.0001 | Increased social needs referrals in intervention group |
| Acceptability as rated by patients | Parent report | Most parents were comfortable and felt supported following identification of social needs with ASK tool, with 77% feeling comfortable and 79% feeling supported speaking with HCP about results. Majority (86%) of parents reported wanting identification of social needs to continue. | Majority of patients found identification of and referral for social needs acceptable | ||
| Paper | Outcome Measure | Tool Used | Results | Significance | Summary |
|---|---|---|---|---|---|
| Clinical pathway involving identification and referral of social needs with targeted community resource only | |||||
| Beck 201424 | Identification of social needs | Parent report | Intervention recipients more likely to report social needs concerns relating to housing, public benefits, domestic violence, and parental depression. | all P < .0001 | Increased identification of social needs in intervention group |
| Referral for social needs | Not documented | Social work referral 29.2% (intervention), 17.6% (control); MLP referral 14.8% (intervention), 5.7% (control). | <.0001; <.0001 | Increased referrals in intervention group | |
| Social work referral 29.2% (intervention), 17.6% (control); MLP referral 14.8% (intervention), 5.7% (control). | <.0001; <.0001 | ||||
| Child health | EMR (electronic medical records) | 9 mo wt for length percentile; <5th percentile: 5% (intervention), 3.7% (control); 5–95th percentile: 88.5% (intervention), 87.5% (control); >95th percentile 6.5% (intervention), 8.7% (control); lead level: below level of detection: 62.9% (intervention), 59% (control); 1.4–2.4: 28.1% (intervention), 29% (control); 2.5–4.9: 7.3% (intervention), 9.9% (control); ≥5 1.7% (intervention), 2.1% (control); ED visits in first 14 mo more likely 0: 16% (intervention), 19.5% (control); 1: 24.9% (intervention), 32.1% (control); 2+: 28.9% (intervention), 48.5% (control). | 0.3 NS; 0.2 NS; <.0001 | No significant difference in child health in intervention group; increased visits to ED in intervention group | |
| Completion of preventative care services: 5+ well child visits in first 14 mo: 42% (intervention) vs 28.7% (control); lead test: 81.2% (intervention) vs 75% (control); 9mo ASQ: 26.6% (intervention) vs 20.1% (control). | <.0001; .0006; .0002 | Increased engagement with preventative child health services in intervention group | |||
| Beck 202230 | Child health | EHR (electronic health record) | In the 12 mo before referral, hospitalization rates were 10.1 ± 0.33 per 100 child-years (intervention) vs 9.7 ± 0.33 per 100 child-years (control); In the 12 mo following referral, hospitalization rates were 9.2 ± 0.20 per 100 child-years (intervention) vs 9.6 ± 0.33 per 100 child-years (control); the unadjusted, paired pre and post difference; in hospitalization rates was −0.84 ± 0.03 (intervention cohort) vs −0.09 ± 0.04 (control); unadjusted difference- in-differences analysis suggests that there were 0.73 fewer hospitalizations per 100 child-years as a result of the intervention. Using adjusted generalized estimating equation Poisson models, the intervention was associated with a median postreferral hospitalization rate that was 62.1% (IQR: 60.5–63.4) of what would have been expected had no intervention taken place, across all 100 trials. This equates to 37.9% fewer hospitalizations occurring among those receiving the intervention. Analyses of all 100 trials detected similar, statistically significant effects. | Maximum .0010 | Referral to intervention program decreased likeliness of child hospitalization in the year following referral |
| Fleegler 200727 | Identification of social needs | Parent report | 82% had ≥ 1 health-related social problem (HRSP); 28% had experienced 1 HRSP, 32% experienced 2 HRSP, 22% experienced ≥ 3HRSP. | Increased identification of social needs | |
| Acceptability as rated by patients | Parent report | Parent’s response in regards to computer-based screening and referral program administered within a pediatrician’s office: 92% would “welcome it” or “not mind at all.” | In families who received referrals following identification of social needs, the majority of them made contact with the referral agencies and considered the referral agencies helpful. | ||
| Parental acceptability of a computer-based screening and referral program inquiring about the 5 HRSPs: would “welcome it” or “not mind at all”: 94% for access to health care, 88% for food security, 90% for income security, 93% for housing stability, 81% for intimate partner violence | The majority of patients found screening and referral of social needs in a pediatrician’s office acceptable. | ||||
| Fritz 202048 | Referral for social needs | Parent report | 81% of families with food insecurity declined referral to Hunger Free Colorado (HFC) service; 19% of families with food insecurity accepted referral to HFC service. Of those that accepted referral, 61% were connected to food resource and 39% were not connected to food resource. Of those that were not connected to food resource, 62% were unable to contact and 38% were contacted by declined. | High connection to SDH resources from families who accept referral to service and from families with more people living in home. | |
| Parent report | Compared with those who declined HFC referral, families who accepted HFC referral were more likely to be screened in emergency department and inpatient setting, and less likely to be screened in special care clinic. | <.001 | |||
| Parent report and EMR | Families with more people in the home (≥3 people) were more likely to be connected to resources. | .002 | |||
| Garg 201520 | Referral for social needs | Parent report | WE CARE mothers receiving ≥ 1 referral at index visit: 70% (intervention) vs 8% (control); aOR = 29.6; 95% CI, 14.7 to 59.6). | Increased referrals for social needs in intervention group | |
| Overall, 42% of WE CARE mothers received ≥ 2 referrals at the visit; 21% of WE CARE mothers received ≥3 referrals. | |||||
| WE CARE mothers contact with community resource at 9 mo follow-up; 65% (intervention) vs 49% (control); aOR = 1.5; 95% CI, 1.1 to 2.1. | Increased uptake of SDH resources by intervention group | ||||
| WE CARE mothers enrolled in ≥1 new resource at 12 mo well child care visit: 39% (intervention) vs 24% (control); aOR = 2.1; 95% CI, 1.2 to 3.7. | |||||
| Reduction in social needs | Parent report | Mothers being employed or enrolled in job training program at 12 mo; aOR = 44.4; 95% CI, 9.8 to 201.4. Intervention group had greater odds of being employed or enrolled in job training program. | Reduction in social needs in intervention group | ||
| Receiving fuel assistance; aOR = 11.9; 95% CI, 1.7 to 82.9. Intervention group had greater odds of receiving fuel assistance. | |||||
| Being in a homeless shelter; aOR 0.20; 95% CI, 0.1 to 0.9. Intervention group had lower odds of being in a homeless shelter. | |||||
| Child health | Parent report | Children enrolled in child care at 12 mo; aOR = 6.3; 95% CI, 1.5 to 26. Intervention group had greater odds of being enrolled in childcare. | Increased engagement with child health services | ||
| Hassan 201529 | Reduction in social needs | Adolescent report | 40% of adolescents had contacted a referral agency for their top priority; 50% of these reported their top-priority problem either ‘completely’ or “mostly” resolved; 45% of adolescents who did not contact a referred resource reported their problem resolved; >90% of these reported contacting other resources; overall, 47% of all adolescents reported resolution of their top priority problem. | Improved uptake of resources. Reduction in social needs at follow-up | |
| Social needs related to income security had significantly lower resolution rates (aOR = 0.40 = 2.41, 95% CI, 1.20 to 4.840. | .01 | Decreased resolution of social needs related to income security | |||
| Lawton 202031 | Referral for social needs | EMR | 6% of referred patients received services from medical-legal partnership. | Rates of engagement with service were low. | |
| Clinical pathway involving identification and referral of social needs with navigator | |||||
| Fiori 202038 | Identification of social needs | Parent report | 20% of households reported 1 or more social needs. | Successful referral to resources was associated with a higher number of navigator outreach attempts and a shorter follow up time | |
| Referral for social needs | 43% of households referred to the navigator reported successful referral to resources; households that had 4 or more navigator outreach attempts were more likely to report a successful referral (aOR = 1.92, 95% CI, 1.06 to 3.49). Follow up time ≥30 d was associated with a lower likelihood of successful referral (aOR = 0.43, 95% CI, 0.25 to 0.73). | .03; .002 | |||
| Gottlieb 202021 | Identification of social needs | Parent report | 7.7% did not report any social needs 50.7% reported 4 or more social needs. | Increased identification of social needs in both intervention group and active control group | |
| Reduction in social needs | No significant differences found between intervention and control group in the number of social needs reported at follow-up; number of successful navigator contacts associated with decreases in number of social needs was not significant (r = −0.10); at 6-mo follow-up, both groups experienced a decrease in number of social needs relative to baseline, with mean (SE) difference of −1.28 (0.19) social needs (control) and −1.74 (0.21) (intervention). | NS; NS; .15; <.001 | No significant difference in social needs, child health, or caregiver health found between intervention and active control group. | ||
| Child health | At 6-mo follow up, there was a small improvement from baseline in child health in both groups (mean (SE) change; 0.37(0.07) (control) vs 0.24(0.07) (intervention). No significant differences found between intervention and control group in the improvement in child health mean (SE) adjusted difference 0.12(0.09), 95% CI, −0.04 to 0.27. | both <.001; .13; NS | |||
| Caregiver health | At follow-up, no statistically significant differences in caregiver perceived stress, depression symptoms or general health between intervention versus control groups. | NS | |||
| Gottlieb 201623 | Identification of social needs | Parent report | 17% did not report any social needs 20% reported 4 or more social needs. | Increased identification of social needs | |
| Reduction in social needs | At follow-up, a statistically difference in social needs was found with decrease in social needs in intervention group and slight increase in control group: mean (SE) −0.39 (0.13) intervention vs 0.22 (0.13) (control) for a mean (SE) Statistically significant cumulative between-group difference of 0.61 (0.18) need. | <.001 | In person navigation resulted in reduction of reported social needs, and improvement in child health. | ||
| Child health | At follow-up, caregiver report of Child Global Health improvement in both groups (lower scores representing better health): mean (SD) −0.36(0.05) (intervention) vs (SE) −0.12(0.05) (control). Statistically significant mean (SE) difference of −0.24(0.07) between intervention and control group. | <.001 | Improvement in child health in intervention group | ||
| Hensley 202133 | Identification of social needs | EHR electronic health records | At follow up, 54.7% of patients in the intervention group had a social need identified, compared with 23.8% of patients in the control group. | <.01 | Greater identification of social needs in intervention group |
| Referral for social needs | At follow up: 24.6% of intervention group had been referred to medical-legal partnership (MLP), compared with 4.5% of control group. Those in the control group had a 2.81-times increased odds of referral to the MLP (95% CI, 2.01 to 4.12). 2.1% of intervention group had been referred to social work compared with 0.8% of control group. No significant difference in referral to social workers (OR = 1.26, 95% CI, 0.62 to 5.12); 11.4% of intervention group had been referred to infant formulary program compared with 5.2% of control group | <.01; .03; <.01 | Referral to medical-legal partnership and infant formula program clinic resources was higher among patients in intervention group compared with control. No significant difference in referral to social workers. | ||
| Child health | At 12 mo follow up no significant difference in lead screening (OR =1.29, 95% CI, 0.70 to 1.95), emergency department visits (RR = 1.22, 95% CI, 0.997 to 1.49), hospitalizations RR = 0.94, 95% CI, 0.56 to 2.34) or primary care no-shows (RR = 1.11, 95% CI,0.94 to 1.33). | No significant difference between intervention and control groups in completion of preventive services and acute service utilization. | |||
| Hill 202234 | Identification of social needs | Parent report | Site A: the most common needs were food and health (eg, assistance with scheduling appointments and applying for insurance). Site B: the most common needs were health (eg, insurance) and commodities (eg, baby supplies). | ||
| Referral for social needs | Parent report | Site A: 81% patients completed screening and enrolled into in-person navigation program. Site B: 76% patients completed screening and enrolled into in-person navigation program. | High uptake of screening and enrolled into in-person navigation program. | ||
| Contacting of referred SDH resource | Parent report and EMR | Site A: of the enrolled participants, 54.6% were successfully connected to SDH resources. Site B: of the enrolled participants, 40.4% were successfully connected to SDH resources. | |||
| Child health | EMR | Site A: In the 12 mo before intervention, there were nonsignificant differences in rates of high well-child visits (WCV) attendance (75% to 100%) between enrolled (49.3%) and nonenrolled (60.4%) participants. Site A: in the 12 mo following intervention, there were significant difference in rates of high WCV attendance (75% to 100%) between enrolled (81.6%) and nonenrolled (52.7%) participants (P < .001). Site A: there were no significant differences in emergency department in either 12-before intervention or 12-mo post intervention between enrolled and nonenrolled groups. Site B: in the 12 mo before intervention, there were nonsignificant differences in rates of high WCV attendance (75% to 100%) between enrolled (51.5%) and nonenrolled (49.6%) participants. Site B: in the 12 mo following intervention, there were significant difference in rates of high WCV attendance (75% to 100%) between enrolled (71.4%) and non-enrolled (35.0%) participants (P < .001). Site B: there were nonsignificant differences in emergency department in either 12-mo before intervention or 12-mo post intervention between enrolled and nonenrolled groups. | <.001 | Increased engagement with WCV services in families enrolled into in-person navigation program. | |
| Messmer 202035 | Identification of social needs | EHR Electronic health records, Microsoft Excel patient database | The majority of clinician referrals were made through the EHR (83%) vs in person (16%). This was also true when the patient navigator was on-site (67% via EHR vs 32% in person) When the patient navigator was on-site, significantly more referrals were made than expected (45% vs 29%). | <.0001; <.0001 | A greater number of referrals were made to an on-site navigator rather than a remote navigator |
| Referral for social needs | 72% of families were successfully contacted, with no significant difference in the number of successful contacts between remote (1.0 points) vs on-site (1.1 points) groups nor in the proportion of families enrolled in a resource (10.4% vs 8.1%). | .32; .43 | No significant difference between on-site compared with remote navigator groups in the number of contacts with families or enrolment of families in resources | ||
| Pantell 202022 | Child health | EHR electronic health records | Acute care utilization: At 12 mo, no significant difference in children with 1 ED visit 37.1% (intervention) vs 37.7% (control); risk difference −0.7%, 95% CI, −5.9% to 4.6%, relative risk of 0.98, 95% CI, 0.85 to 1.1. | NS | In person navigation decreased likeliness of child hospitalization |
| At 12 mo, significantly less hospital admissions for children in the intervention 29(4.6%) (intervention) vs 50(7.5%) (control), risk difference −3%; (95% CI, −5.6% to −0.4%), relative risk 0.60 (95% CI, 0.39 to 0.94). Cox proportional hazard regression showed children in intervention group had a decreased risk of being hospitalized (hazard ratio 0.59; 95% CI, 0.38 to 0.94) meaning they were 69% less likely to be hospitalized versus control group. This remained significant when controlling for all sociodemographic variables (hazard ratio, 0.59; 95% CI, 0.35 to 0.99). | Significant; 0.03; .46 | ||||
| Time to ED visit 12 mo post enrolment log-rank P = .66; Kaplan-Meier curves revealed no statistically significant difference between time to ED visit within 12 mo. Cox proportional hazard regression showed no significant change in risk of having an ED visit between intervention and control group (hazard ratio 0.96; 95% CI, 0.80 to 1.14). | NS; NS P = .81 | ||||
| Clinical pathway involving identification and referral of social needs with clinician training | |||||
| Garg 200719 | Identification of social needs | Parent report | 2.9 (intervention) vs 1.8 (control); intervention group had significantly higher mean number of psychosocial topics discussed. In multivariate regression analyses, intervention group had significantly higher odds for discussion of parent’s education status and food security at WCC visits compared with control group. | <.01 | Increased identification of social needs in intervention group |
| Intervention group had significantly fewer desires to discuss family psychosocial topics 0.46 (intervention) vs 1.41 (control). | .0001 | ||||
| Referral for social needs | Intervention group received significantly higher number of referrals with means of 1.15 (intervention) vs 0.24 (control); intervention group had significantly greater odds of receiving referrals for food resources, graduate equivalent degree programs, job training, and smoking cessation classes 51% (intervention) vs 11.6% (control) receiving ≥ 1 referral. | <.001; <0.001 | More patients received referrals in the intervention group. | ||
| At 1 mo post visit, significantly more parents recalled receiving referral at index visit 41.2% (intervention) vs 6.7% (control). At 1 mo post visit, more parents in the intervention group reported contacting a referral resource 20% (intervention) vs 2.2% (control). | <.001 | Patients in the intervention group had greater odds of having contacted a community resource at 1 mo. | |||
| Acceptability as rated by clinicians | Clinician report | None of the clinicians reported feeling uncomfortable with having parents hand them the WE CARE survey. | All clinicians found screening and referral for social needs acceptable | ||
| Klein 201328 | Referral and resolution of legal issues or efficacy of medical-legal partnership | Not documented | Referrals resulted in 1945 legal outcomes, of which 89% were positive (improvement in housing, benefits, education, or provision of legal advice). | Reduced social needs in intervention group | |
| Purkey 201925 | Identification of social needs | Parent report | 38% of parents reported they were asked by health care provider if they were having trouble making ends meet. | Rates of identification of social needs by clinicians were low | |
| Referral for social needs | 67% of parents received resources, 33% did not receive resources. | ||||
| Acceptability as rated by patients | 72% of parents supported, 22% were neutral about the appropriateness of poverty screening and intervention by HCPs. 75% felt comfortable or very comfortable being asked if they were having trouble making ends meet by HCPs. | Majority of patients found identification of and referral for social needs acceptable | |||
| 75% of parents felt comfortable or very comfortable, 14% neutral, 11% uncomfortable when asked “Do you ever have trouble making ends meet?” | |||||
| Acceptability as rated by Clinicians | Clinician report | HCPs reported that they thought poverty was relevant to discuss with patients in clinical care. | Majority of Clinicians supported social needs screening | ||
| Selvaraj 201926 | Referral for social needs | Parent report | At least 1 referral was made at 12% of well-child visits (WCV); 1 of the 4 clinic sites had baseline data on community referrals: there was a significant increase in social needs referrals following implementation of universal screening with 2% referrals before vs 13.3% referrals after implementation of screening. | <.0001 | Increased social needs referrals in intervention group |
| Acceptability as rated by patients | Parent report | Most parents were comfortable and felt supported following identification of social needs with ASK tool, with 77% feeling comfortable and 79% feeling supported speaking with HCP about results. Majority (86%) of parents reported wanting identification of social needs to continue. | Majority of patients found identification of and referral for social needs acceptable | ||
aOR, adjusted odds ratio; ED, emergency department; EMR, electronic medical record; HFC, Hunger Free Colorado; HCP, healthcare professional; HRSP, health related social problems; IQR, interquartile range; MLP, medical-legal partnership; ASQ, Ages & Stages Questionnaires NS, not significant; OR, odds ratio; WCC, well child care; WCV, well child visit.
Identification of Social Needs
The rate of social needs identification was reported in 15 studies.19–21,23–27,29,31–36 These varied between studies and included needs related to food insecurity, income security, health care access, household heat, legal concerns, housing, childcare, domestic violence, other public benefit enrolments, parental education, smoking, drug and alcohol abuse, and transportation needs. All of these studies reported identification of social needs above baseline, or significantly increased in the intervention group in comparison with the control group. One study which compared an in-person navigator and remote navigator found a greater number of referrals for social needs were made to the in-person navigator.35
Referral and Uptake Following Identification of Social Needs
The rates of referral following social needs identification were assessed in 12 studies.19,20,24–26,31–36 These studies all found a significantly increased rate of referral in the intervention group compared with the control group or compared with baseline.
Four studies also assessed rates of uptake of targeted community resources by patients.19,20,29,38 These studies found that uptake of targeted community resources was significantly higher in the intervention group compared with the control group or with the baseline. One study found that successful uptake of resources following referral was associated with a higher number of navigator outreach attempts and a shorter follow up period.38
Reduction in Social Needs
The outcome measures that were assessed for reduction in social needs were varied, and in addition to patient self-report of social needs at follow-up, also included medical-legal outcomes, employment, receipt of fuel assistance and homelessness. Reduction in social needs was assessed in 5 of the 18 studies.17,20 25,21,24,29,39 Of these, 3 studies compared social needs reduction in the control and intervention groups,20,21,23 and 2 of the studies compared social needs reduction in the intervention group with baseline.25,26 Overall, the studies found a reduction in social needs compared with baseline. In the studies that compared social needs reduction between the control and intervention group, 2 studies found a reduction in the intervention group compared with the control group20,23 . One study found no significant difference in reduction between the intervention and control group and both groups had reduced social needs compared with baseline.21 This study compared 2 clinical pathways, a clinical pathway with an in-person navigator, and a clinical pathway involving targeted community resources only.
Child Health and Caregiver Health
Child health outcomes were explored in 8 studies; outcome measures included growth parameters, lead level, emergency department visits, hospital admission, primary care visit, emotional functional scores, and parental reports of child global health and child quality of life.20–22,24,30,33,34,39 One study found no significant differences in measurements of growth parameters, or lead levels between the intervention and control group.24 Two studies examined child global health, and although 1 of the studies found an improvement in child global health in the intervention group compared with the control group,23 the other study found no significant difference between intervention and control group in child global health, with a small improvement from baseline for child global health found in both groups.21 The latter study compared 2 clinical pathways, a clinical pathway involving an in-person navigator, and a clinical pathway involving targeted community resources only, and also found that there were no statistically significant differences in reported caregiver’s perceived stress, general health, or depression symptoms between control and intervention group.21
One study found no significant differences between intervention and control groups in the completion of preventive services and acute service utilization.33 Two studies found that the intervention group was less likely to be hospitalized within 12 months compared with the control group.19,30 One study found increased engagement with primary health services in the intervention group compared with the control group.34
Acceptability, Feasibility, Harm, and Cost
Acceptability was assessed in 4 studies.19,25–27 All studies found that the majority of respondents (patients or clinicians) found social needs screening was acceptable. Cost was mentioned in 2 studies21,23 ; actual monetary sums were not provided. These studies, both by Gottlieb et al,21,23 used their interventions to demonstrate that relatively low-cost interventions, such as using volunteers to function as in-person navigators, and the use of high-quality customizable written information at a single encounter, could be effective in reducing social needs.
Discussion
To the best of our knowledge, this is the first systematic review to examine the effectiveness of interventions that identify and refer for unmet social needs in families with children aged 0 to 18 years attending outpatient community and ambulatory healthcare services. We found mixed evidence for the effectiveness of referral pathways following identification of social needs in children. The studies varied widely in outcome measures and intervention types, thus precluding meta-analysis. Based on our narrative review there was evidence to suggest that pathways designed to identify and refer for social needs may result in greater identification and a reduction in social needs. At present, there is insufficient evidence to suggest that these clinical pathways do anything to improve child health outcomes.
Based on findings from this review, 3 possible ways are suggested for clinical pathways for identification of and referral for social needs. These were: a clinical pathway involving only targeted community resources; a clinical pathway with a navigator; and a clinical pathway that involved training of clinicians. There was no clearly superior pathway type; however, outcome measures were heterogeneous and not readily comparable to each other. For example, in the 2020 study by Gottlieb21 that is included in the review there was a similar benefit in reduction in social needs between a pathway involving only targeted community resources, compared with one with a navigator.
Where it was reported, these pathways were acceptable to both parents and clinicians. In studies that measured clinician acceptability of the clinical pathway process, the majority of the clinicians supported it. Despite this, other studies have found there are a number of barriers to the feasibility of implementing these clinical pathways.12 These include lack of clinician time, training and knowledge of community resources and a lack of support and role models.12,20,40,41 Clinicians also question whether it is part of their role and report feelings of helplessness and powerlessness when faced with daunting social challenges.12 Navigators can be beneficial, alleviating many of these barriers, including lack of time, training, resources, and competing clinical priorities. However, whereas included studies described a patient navigator as part of the intervention description, there was a lack of clarification regarding how much difference there was in existing clinic resources or services, such as social workers, with respect to levels of support offered with the inclusion of a patient navigator, whether that be in-person or remote. Additional supports including the integration of a resource list into the electronic medical record (EMR) can also be helpful, along with an internal champion for the process.41
There was no information on harm in the included studies in this review. There are potential harms to identification of and referral for social needs, including a lack of resources to address identified needs.42 Identifying social needs, while not having the capacity to support families is arguably ineffective and unethical.42 In addition, there is potential danger of reinforcing stereotypes, perpetuating deficit discourses and stigmatizing families, particularly those families who already experience racism and discrimination.6 There is also the potential of damage to the patient and clinician relationship that could ensue if expectations following identification of and referral for social needs are not satisfied.42
This review highlighted the scant data available on the cost-effectiveness of such programs, which can influence a health services decision on whether to implement identification and referral for social needs programs and which program to choose.
Our review found a number of issues with study quality that limit the strength of the current evidence base, with 13 of the included studies having a high risk of bias. although there has been a rapid development of screening tools for social needs, our review highlights the lack of evidence for interventions to date. This is in keeping with the findings of a previous systematic review by Gottlieb43 that examined the interventions addressing a patient’s social and economic needs. This systematic review, which addressed only studies from the United States, was not specific to children, and searched a single database Pubmed, found that evaluations of programs addressing social needs focused mainly on social outcomes and process, and were often limited by poor study quality. There is also an evidence gap with regards to the psychometric properties of screening tools that can be used in these clinical pathways. A number of scoping and systematic reviews have highlighted that the screening tools currently used are largely unevaluated in terms of their validity and reliability.9,10 However, the limited evidence for efficacy of screening and referral for social needs reflects the difficulties of designing and implementing an effective tool, and not on the importance of social needs on child health.
Limitations of the Review
The search strategy consisted of searching for the key terms “Social Determinants of Health,” “poverty,” and text word searches for social need, social determinant, social economic factors. These search terms may have provided bias toward countries where these terms are in use and may miss articles where other terms to describe social needs are used, such as “social and income protection” or “social inclusion and nondiscrimination” and “unequal access to healthcare.” Similarly, the search did not include adverse childhood experiences (ACE) terms because these are retrospective and conceptually different to SDH.44 A recent systematic review by Loveday et al45 that looked at screening for ACEs in children included studies which screened for both ACEs and social needs. This review found 4 articles matching their inclusion criteria, 1 of which is also included in our review. The 3 other studies included in the review did not screen for poverty and thus did not meet the inclusion criteria for our systematic review. In addition, although there has been a considerable increase in literature about social needs, our study’s inclusion criteria and requirement of reportable primary outcomes that included identification, referral uptake, reduction in social needs; and/or improvements in child health and/or wellbeing meant that many potential studies were not included. Another limitation of the review is the heterogeneity of outcome measures between included studies. This meant it was not possible to complete a meta-analysis, which would have added a synthesized quantitative analysis to our review.
Recommendations
With only a small number (18) of studies found, the main recommendation from our systematic review is that further high-quality studies are needed that evaluate the effectiveness of clinical pathways to identify and refer for social needs. It is important for future studies to indicate which clinical pathways are most appropriate in different settings and health systems to guide implementation practices. Future studies that assess harm and cost of program interventions along with patient and clinician acceptability would also be important to help practices improve uptake and adoption of social needs identification and referral practices. Evidence for improvements in child health is insufficient and thus, further research is needed to understand potential impacts. Furthermore, key to the design of any new clinical pathway would be the involvement of end-users, including parents, clinicians, and support services in its design. This includes centering on the lived experiences of people affected by racism and discrimination.46 The burden of social disadvantage is far greater in low resource settings47 and there is certainly interest in exploring social needs in clinical settings in low and middle income countries48 ; research is therefore, urgently required from health systems outside of North America to understand how such an approach may work in different sociocultural contexts.
Based on the findings that these interventions increase the identification and reduction of social needs, we recommend that outpatient community and ambulatory health services involving families and children consider systematizing the identification and response to social needs using identification and referral pathways. The clinical pathway should be one that would be easy to implement, suitable to the health system within which it is situated and have clearly defined roles using a formalized workflow.41 Clinical pathways should avoid stigma by being universal and not limited to screening only of families from an apparent social status or race.42
Conclusions
With the increasing recognition of the importance of SDH on child health, identification, and appropriate support for families of children who experience social needs is required. This systematic review demonstrates that although there is evidence that clinical pathways that identify and refer for social needs help to identify and reduce these social needs, there is insufficient evidence for improvements in child health outcomes. Further high-quality studies in diverse geographies and health systems evaluating the impact, implementation and cost-effectiveness of these clinical pathways is required.
Acknowledgments
We thank Dr Karen Zwi and Dr Paul Hotton for their initial contributions in conceptualizing this study.
Dr Wong-See designed the study and systematically searched the literature, screened all the articles for inclusion and exclusion criteria, extracted data, assessed quality of papers, conducted the initial analysis, drafted the initial manuscript and reviewed and revised the manuscript; Dr Calik designed the inclusion and exclusion form, screened all the articles for inclusion and exclusion criteria, extracted data, assessed quality of papers, and reviewed and revised the manuscript; Dr Ostojic screened all the articles for inclusion and exclusion criteria-updated search strategy, extracted data, assessed quality of papers, and reviewed and revised the manuscript; Drs Woolfenden and Raman conceptualized the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
The template for Cochrane data collection form for interventions review for RCTs and non-RCTs17 can be found on their website: https://dplp.cochrane.org/data-extraction-forms. The PRISMA 2020 checklist for systematic reviews can be found on their website: http://www.prisma-statement.org/.
FUNDING: No external funding. Susan Woolfenden was funded by the National Health and Medical Research Council of Australia.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.
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