Health inequities are often driven by population-level social determinants of health, including public policies related to education, housing, and economic security, and by household-level social risks, such as food insecurity and housing instability.1 Many pediatric health systems are therefore implementing interventions aimed at assessing and addressing families’ social risks (adverse social conditions associated with poor health) or social needs (adverse social conditions with which families would like assistance).2,3 The 2019 National Academy of Science, Engineering, and Medicine report on integrating social care into healthcare provides a valuable framework for these interventions, but this report fails to acknowledge racism as a key driver of social risks and resulting health inequities.4 To ensure that social care interventions are equitable and ultimately beneficial for all patients and families, we believe they must be grounded in an antiracist approach.
Antiracism accepts that racial and ethnic groups are equal; observed inequities arise from the social construct of racism.5 An antiracist approach requires recognizing that actions and policies can either promote or subvert racism and then deliberately designing and implementing policies that produce and sustain racial equity. Because of the effects of historical and contemporary structural racism, minoritized children, such as Black, Hispanic or Latinx, American Indian, and Alaska Native children, disproportionately live in poverty and are more likely to have social risks.6 In this perspective, we aim to build on the National Academy of Science, Engineering, and Medicine framework for social care integration,4 the American Academy of Pediatrics policy statement on racism and child health,7 and a recent call to incorporate abolitionism into social care8 by presenting a framework for how pediatric health systems can address structural, institutional, interpersonal, and internalized racism in their social care programs and policies (Fig 1).
A framework for addressing structural, institutional, interpersonal, and internalized racism in social care programs and policies.
A framework for addressing structural, institutional, interpersonal, and internalized racism in social care programs and policies.
Structural Racism
Structural racism comprises the cumulative array of societal factors that systematically disadvantage individuals from minoritized groups. Many of these factors can impact health systems’ ability to address social needs.9 For example, health systems frequently refer parents and caregivers to government benefit programs, like the Supplemental Nutrition Assistance Program and Low-Income Heat and Energy Assistance Program. These programs are often difficult to navigate, particularly for minoritized individuals and other vulnerable families, perpetuating inequities in access to benefits even when referrals are made equitably.10 In one recent survey, Black and Hispanic or Latinx adults were more likely than white adults to report unfair treatment when accessing public assistance programs and more than 40% of those who experienced unfair treatment reported not getting services they needed as a result.11 Pediatric health systems should therefore assist minoritized families in connecting to safety net programs by augmenting referrals with enrollment support, for example, through clinic and community-based medical-financial partnerships.12
Pediatric health systems should also use their anchor status to invest meaningfully in minoritized communities, for example, by supporting community-based food resources, affordable housing, and job training programs.13 Nonprofit health systems should use their community benefit spending to invest in needs identified by patients and local community-based organizations (CBOs); recent evidence suggests that for most nonprofit hospitals, community benefit spending does not reflect local needs.14 For example, pediatric health systems could use community benefit funds to partner with local CBOs and provide free or subsidized home remediation services to patients with asthma.15
Institutional Racism
Institutional racism occurs within systems of authority, manifesting as differential access to power and resources.9 Within pediatric health systems, this can occur when patient-facing policies perpetuate disparities in healthcare access or quality. For example, some primary care clinics have no-show policies that prevent patients from being seen if they arrive late. This may unduly penalize low-income and minoritized families, who disproportionately face transportation-related barriers to care.16 These and other similar policies can lead to inequitable access to healthcare and to health system-based social care programs.
Pediatric health systems therefore should evaluate all patient-facing policies through an antiracist lens. Minoritized patients, caregivers, and CBOs serving these families should be respectfully engaged to provide feedback on policies impacting patient care, including those related to social care integration. To facilitate equitable participation, community members providing this feedback should be compensated and supported with resources like transportation vouchers and on-site childcare.
In addition, acknowledging that many members of the healthcare workforce are also members of the surrounding community, health systems should prioritize equitable recruitment practices that promote workforce diversity, provide adequate and equitable wages and benefits to staff members, and ensure that social care resources created for families (eg, food pantries, medical-financial partnerships) are also readily available to staff members in need.
Interpersonal Racism
Interpersonal or personally mediated racism occurs between individuals, often stemming from their implicit and explicit biases.9 Pediatric clinicians and staff members have conscious and unconscious biases that impact all aspects of the care they provide to families, including whom they screen for social needs, how they conduct screening (and therefore, how patients respond), and whom they refer to resources.17 These biases may lead a provider to blame a minoritized family’s structurally mediated needs on personal failings and may even translate into a failure to effectively communicate referral information. In addition, documenting information about a caregiver’s social needs in their child’s electronic health record problem list could risk perpetuating racial bias and discrimination by changing how they are perceived and treated by future providers.
To address these potential prejudices, health systems should implement longitudinal structural competency training for staff involved with social care programs18 and track and report screening and referral rates stratified by race, ethnicity, language, and insurance type. To reduce the impact of clinician bias on referrals, health systems could consider providing resource directories to all families universally, as is done in the evidence-based CommunityRx intervention,19–21 or implementing standardized tablet- or paper-based screening with automated referrals. Providers and staff should also be trained in appropriate documentation and interpretation of social needs in the electronic health record, and clinical informaticians should design documentation workflows to minimize stigma.
Internalized Racism
Internalized or intrapersonal racism stems from an individual’s acceptance of racist narratives about their worth and abilities.9,22 Social needs screening, unlike traditional disease screening, focuses on highlighting needs that are often already well-known to patients so that health systems can intervene. Minoritized patients may perceive this screening as a way in which their healthcare providers are focusing on their internalized deficits, rather than their strengths.23 To ensure social care interventions are perceived favorably, particularly by patients from minoritized backgrounds, social care interventions should ideally be implemented with a strengths-based focus on normalizing risks and prioritizing families’ needs. For example, the validated WE CARE assessment tool asks caregivers whether they would like assistance with resources across several domains, allowing them the agency to decide whether and when they would like to receive support.24
Conclusions
Health system leaders may resist adopting an antiracist approach to social care integration because of concerns about negative publicity, politicization, or compliance with laws and regulations requiring race “neutrality.” However, social care interventions will fall short if they fail to address racism at its multiple intersecting levels, as both a root cause of social risks and a key factor in determining the services and supports that families need. It is only by recognizing and targeting the racist structures and policies that drive health inequities that we can generate enduring improvements in health outcomes for minoritized children, families, and communities.
Dr Vasan conceptualized this piece and drafted the initial manuscript; Drs Dalembert and Garg conceptualized this piece and critically reviewed and revised the manuscript; and all authors have approved the manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: Dr Vasan’s work on this project was supported by the Agency for Healthcare Research and Quality (grant F32HS02855).
CONFLICT OF INTEREST DISCLOSURES: Dr Vasan reported grants from the Agency for Healthcare Research and Quality and the Academic Pediatric Association and Dr Garg reported grants from the National Institutes of Health (National Institute for Nursing Research; National Heart, Lung, and Blood Institute; and National Institute of Child Health and Development). No other disclosures were reported.
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