It’s About Trust: Low-Income Parents’ Perspectives on How Pediatricians Can Screen for Social Determinants of Health

June 24, 2019

Unmet social needs in early childhood can have long-lasting and wide-ranging consequences, including increased risk for chronic health conditions, behavioral problems and poor academic performance. The American Academy of Pediatrics in 2016 called on its members to begin universally screening for social needs and facilitating connections to community resources as a part of routine care.

Yet little research has asked parents, particularly low-income parents, for their perspectives about social determinants of health and how screenings can be implemented successfully. To help fill this gap, Public Agenda, with support from United Hospital Fund, conducted focus group research with low-income parents in New York City to understand parents’ perspectives on social needs screenings. 

Findings include:

  • Parents in these focus groups cited a broad range of social stressors that affected their children’s health and well-being, including some that screening tools for social determinants of health may not currently include. 
  • These parents did not immediately identify pediatricians as sources of help with social stressors. Their reactions to the idea of pediatricians discussing these stressors were mixed. They saw some topics, such as nutrition, education and minor behavioral issues, as appropriate to discuss with pediatricians, but others, such as domestic violence, parents’ mental health and legal issues, as more sensitive. 
  • Parents’ concerns about discussing sensitive social needs with pediatricians included worries about being judged and discriminated against, fear of intervention by a child welfare agency, lack of time during appointments and frustration at the prospect of disclosing sensitive information without getting help.
  • Parents’ recommendations for pediatricians about discussing social determinants of health included building trust, choosing the right moment and making clear that screening is standard protocol.

Finding 1: What social stressors concerned these parents? 

Parents in the focus groups cited a broad range of social stressors that affected their children’s health and well-being, including some that screening tools for social determinants of health may not currently include. 

Finding 2: What roles did these parents think pediatricians could play in addressing social needs? 

The parents did not immediately identify pediatricians as sources of help with social stressors. Their reactions to the idea of pediatricians discussing these stressors were mixed. They saw some topics, such as nutrition, education and minor behavioral issues, as appropriate to discuss with pediatricians, but others, such as domestic violence, parents’ mental health and legal issues, as more sensitive. 

Finding 3: Why did parents think discussing the more sensitive social needs with pediatricians would be difficult? 

Parents’ concerns about discussing sensitive social needs with pediatricians included worries about being judged and discriminated against, fear of intervention by a child welfare agency, lack of time during appointments and frustration at the prospect of disclosing sensitive information without getting help. 

Finding 4: How did these parents think pediatricians should discuss social determinants of health with them? 

Parents’ recommendations for pediatricians about discussing social determinants of health included building trust, choosing the right moment and making clear that screening is standard protocol.

Despite the concerns they cited about discussing social needs with pediatricians, particularly their more sensitive needs, most parents in these groups responded enthusiastically when the moderators asked for their ideas about how pediatricians should approach discussing social determinants of health. Parents’ recommendations for pediatricians included:

Build trust. Parents in the groups emphasized that talking openly about social determinants of health with pediatricians is a matter of building trusting relationships. While some parents said they would prefer discussing social determinants of health with pediatricians face to face and others said they would prefer a questionnaire, their overriding message was that they could only share information about sensitive topics in the context of a trusting relationship with their children’s pediatricians. 

Choose the right moment for parents. With long waits for short appointments, parents felt pediatricians should choose the right moment to start conversations about social needs. They emphasized that if they come to an office visit with a child who has a cold or other immediate concern, the pediatrician should address that concern and wait for another visit, when they might have the time and energy for the conversation, to bring up more sensitive, complex topics. 

Not in front of the children. Parents said that if they were to discuss social determinants of health with their children’s pediatricians, they would prefer to do so in private, not in front of their children. They said pediatric offices should create dedicated spaces where children can play, giving adults time and space to discuss sensitive, complex topics, as well as easing the burden of long waits for appointments with sick children or siblings. 

Let parents choose to learn about helpful resources at their own initiation. Parents often said they wanted posters on waiting room or exam room walls and pamphlets they could take themselves. They said posters and pamphlets would let them choose to learn about social needs—particularly more sensitive ones—and about helpful resources on their own time, discreetly and at their initiation. 

Signal confidentiality and be transparent about what triggers reporting to child welfare. Parents in these groups understood that when a child is truly in danger, a pediatrician must share that information with the appropriate authorities. But they also wanted pediatricians to be transparent about what triggers reporting and what does not, so they would know which issues they could talk about openly. They also felt strongly that when they share sensitive information, it must be kept confidential. 

Do not ask just for the sake of asking. These parents were very firm in their conviction that if pediatricians ask about sensitive issues, they should be willing and able to provide or suggest helpful resources. Parents wanted to avoid the double loss of disclosing sensitive information without receiving help. They said referrals to other organizations should come with an offer of guidance and a warm handoff. 

Make clear that screening is standard protocol. It was very important to parents in these groups to be assured that everyone gets screened—whether face to face or with questionnaires—not just those who appear to be struggling, are enrolled in Medicaid or are low-income. Otherwise, parents said, they would feel judged or profiled. 

Consider “letters of support” and other ways to be parents’ allies. Parents in these groups indicated that the doctors have a unique authority and can be their allies in difficult situations. Parents specifically said it could be helpful for pediatricians to provide what they called “letters of support,” for instance, when they face problems with the public housing authority or private landlords regarding peeling paint, pests or other environmental hazards. Some parents said pediatricians could vouch for them when they face legal difficulties or child welfare investigations.

Parents Talk About Social Needs Screening—Identify Trust as a Major Issue (Georgetown Health Policy Institute Center for Children and Families, July 24, 2019)

Screening for Unmet Social Needs: Patient Engagement or Alienation? (NEJM Catalyst, July 20, 2020)

How Do Social Determinants of Health Affect Patient Wellness? (PatientEngagementHIT, October 9, 2020)

How Do Patients Feel About Social Risk Screening? (Healthcare Innovation, February 22, 2021)

This research summarizes findings from eight focus groups with low-income parents of children ages five years and younger in New York City, conducted in English and Spanish by Public Agenda in July and August 2018.

For four of the focus groups, participants were recruited by a professional market research facility in Manhattan. In total, 40 parents participated in the focus groups at the market research facility. All participants were low-income parents of children ages five years and younger who had experience taking their children to pediatricians.They included residents of all five boroughs of New York City and reflected a diversity of low-income parents in terms of race and ethnicity, age, educational attainment, employment status and frequency with which they took their children to pediatricians.

For the other four focus groups, participants were recruited by community organizations associated with United Hospital Fund’s Partnerships for Early Childhood Development initiative: Children’s Aid in the Bronx, the Northern Manhattan Perinatal Partnership in Harlem, and Public Health Solutions in Queens. In total, 48 parents participated in the focus groups at the community organizations. All participants in these groups were parents of children ages five years and younger and clients of one or another of the community organizations and had experience taking their children to pediatricians. Two of these groups were conducted in Spanish.