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Abstract

Background: Addressing health-related social needs is essential for improving health and reducing longstanding disparities. However, barriers to screening – including clinician and patient time burden of screening for multiple social needs – limit identification. To address this concern and promote the uptake of screening by clinicians, it is important that screening tools effectively and efficiently identify social needs’ presence and absence among patients.

Objective: This study evaluated whether a validated and widely implemented 2-question food insecurity screening tool, the Hunger Vital Sign™ (HVS™), has adequate negative predictive value to serve as a pre-screen for other social needs.

Methods: In 2007-2015, Children's HealthWatch interviewed 28,611 publicly insured caregivers from households with low incomes with children age 0-48 months at 5 pediatric clinic/emergency departments (AR, MA, MD, MN, PA). Caregivers self-reported information about their households. Descriptive data were used to describe the sample and negative predictive value was calculated between the Hunger Vital Sign™ and other household hardships.

Results: A negative Hunger Vital Sign™ identified 18,259 households (63.8%) as food secure. The negative predictive value in these households was 77.4% (95% CI 76.7, 78.2) for housing instability, 82.4% (95% CI 81.9, 83.0) for energy insecurity, 87.2% (95% CI 86.7, 87.7) for foregone health care at the household level, and 97.5% (95% CI 97.3, 97.7) at the child level. Results demonstrate, at varying levels, high NPV of the HVS™ to correctly identify other hardships’ absence, indicating that families who do not endorse the HVS™ may not be the highest priority for screening for other hardships. However, clinicians should be aware that roughly 20% of families who do not endorse the HVS™ do, in fact, experience other hardships and would not be identified as warranting further hardship-specific screening by this method.

Conclusions: This is the first paper to our knowledge that examines the NPV of a screening tool for other social needs. While acknowledging the limited amount of time during a clinical visit, we recommend clinicians choose a multi-domain screener to obtain a nuanced understanding of their patients’ unique challenges. To best inform screening tool selection, providers seeking to screen for and address health-related social needs should first and foremost achieve clarity of purpose - by identifying the social needs of concern, the institution's ability to suitably identify those needs, and what targeted actions will be taken. Further research to replicate and expand these findings in diverse samples of children of varying ages and more economically diverse circumstances as well as in other geographic regions is needed to develop a maximally efficient approach for clinical screening for social determinants of health. Beyond adopting a SDOH framework, providers and the health care sector can advocate for strong evidence-based policies that enable them to better address health inequities and improve health outcomes.

Key Take Away Points

  • This manuscript builds on the growing commitment of the healthcare community to address social determinants of health (SDOH) in clinical settings, and adds to the knowledge base of the utility of a social needs screening tool, the Hunger Vital Sign™.
  • This paper is the first of our knowledge assessment of whether screening for a single hardship (food insecurity) during the clinical encounter may be sufficient to identify those requiring no additional SDOH screening.
  • Results demonstrate, at varying levels, high NPV of the HVS™ to correctly identify other hardships’ absence, indicating that families who do not endorse the HVS™ may not be the highest priority for screening for other hardships. However, clinicians should be aware that roughly 20% of families who do not endorse the HVS™ do, in fact, experience other hardships and would not be identified as warranting further hardship-specific screening by this method.
  • While acknowledging the limited amount of time during a clinical visit, we recommend clinicians choose a multi-domain screener to obtain a nuanced of their patients' unique challenges and attain greater confidence in the role multiple SDOH play in the patient’s case.
  • To best inform screening tool selection, providers seeking to screen for and address health-related social needs should first and foremost achieve clarity of purpose - by identifying the social needs of concern, the institution's ability to suitably identify those needs, and what targeted actions will be taken.
  • Beyond adopting a SDOH framework, providers and the health care sector can advocate for strong evidence-based policies that enable them to better address health inequities and improve health outcomes.

Author Biography

Richard Sheward, MPP, is the Director of Innovative Partnerships at Children's HealthWatch Charlotte Bruce, MPH, is the Research & Policy Analyst at Children's HealthWatch. Deborah A. Frank, MD, FAAP, is a pediatrician, founder of Children's HealthWatch, and founder and former Director of the Grow Clinic for Children at Boston Medical Center. Sharon Coleman, MS, MPH, is a Research Manager and Statistical Analyst at the Biostatistics and Epidemiology Data Analytics Center. Among other projects, she is the Research Manager and Statistical Analyst for Children's HealthWatch. Stephanie Ettinger de Cuba, MPH, is the Executive Director of Children's HealthWatch. Blair Robinson, MD, MPH, is a practicing physician at Massachusetts General Hospital. She previously served as a policy intern for Children's HealthWatch. Dianna B. Cutts, MD, is the Chief of Pediatrics at Hennepin County Medical Center and co-lead Principal Investigator of Children's HealthWatch.

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