“First, more than anything else, the pediatrician should earn your trust.”
— Parent from Queens, New York

Unmet basic needs, such as food insecurity, in childhood can have long-lasting and wide-ranging consequences for kids, including increased risk for chronic health conditions, behavioral problems and poor academic performance. For these reasons the American Academy of Pediatrics recommends child health care providers try to address those unmet needs, also known as the social determinants of health, through screenings and community referrals, in addition to encouraging broader public policy reforms focused on reducing child poverty.

But what do parents themselves think about social determinants of health?  How receptive are they to screening for social needs during pediatric care appointments? How much will they share?

A new report by Public Agenda, It’s About Trust: Low-Income Parents’ Perspectives on How Pediatricians Can Screen for Social Determinants of Health, details parents’ own ideas about how to make social determinants of health screenings meaningful in pediatric primary care.

The United Hospital Fund commissioned this research as part of its efforts to support clinical-community partnerships that address the health and social needs of families. Public Agenda conducted eight focus groups with low-income New York City parents of children ages five and younger, including two groups in Spanish.

Parents in the focus groups recognized that social stressors impact their children’s health and well-being. As one parent from Brooklyn explained:

“Mentally, if you’re not right, it can really affect your children because it affects the way that you deal with your children.”

A few parents indicated that their children’s pediatricians had discussed social needs with them. While they framed those conversations positively, they emphasized that they had taken place in the context of trusting, long-term relationships with the pediatricians. Most parents in the groups, however, did not immediately identify pediatricians as sources of help with social needs.

Parents in the groups drew distinctions among different types of social stressors. They could envision themselves being comfortable talking about certain issues like food and nutrition, child care, or reading to a child. But parents identified some issues, including domestic violence, immigration status, major child behavioral issues, parent mental health, and drug and alcohol use, as particularly sensitive. The parents expressed some concerns about discussing these needs:

• Parents worried about being judged and discriminated against.
• Parents feared that sharing information could trigger intervention by a child welfare agency.
• Short appointments and long waits could make it difficult for parents to discuss complex problems.
• Disclosing sensitive information without getting help might frustrate parents.

As a parent from Queens explained in a focus group:

“Not to say that [pediatricians] shouldn’t be concerned about some of these things, because a lot of these things are very detrimental to a child’s health and mental stability. It’s just that if there is no assistance coming after the question, I really don’t think that should be your objective with this visit that I scheduled about my child.”

Despite the concerns they cited about discussing social needs with pediatricians, particularly their more sensitive needs, 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.
• Choose the right moment for parents.
• Don’t ask about sensitive needs in front of the children.
• Let parents choose to learn about helpful resources at their own initiation.
• Signal confidentiality and be transparent about what triggers reporting to child welfare.
• Do not ask just for the sake of asking.
• Make clear that screening is standard protocol.
• Consider “letters of support” and other ways to be parents’ allies

From forming policy to implementing programs, listening to parents is essential. Our work suggests that parents are open to discussing the non-medical factors that shape their families’ health — but those conversations must be respectful, thoughtful, and lead to concrete help. In the context of a trusting relationship, a pediatrician thinking holistically about a family’s needs may make all the difference for that parent and child. As a parent from the Bronx shared:

“Sometimes it’s easier when somebody else opens the door than for you to open yourself up—if they ask in a sensitive way.” 

Listening to parents is the first step towards successfully implementing social determinants of health screenings.

The full report can be downloaded from the Public Agenda website here.

Support for the report was provided by a grant to Public Agenda from United Hospital Fund. UHF’s Children’s Health Initiative, which commissioned and collaborated on this work, is funded in part by the William J. & Dorothy K. O’Neill Foundation and the Ira W. DeCamp Foundation.