Assessing for Violence Exposure and Other Health-Related Social Needs in Children By Pediatric Health Care Providers

Background: Childhood exposure to violence (CEV) is a significant and preventable public health problem in the United States. Pediatric healthcare settings are meaningfully positioned to identify and intervene upon early CEV. Yet, challenges abound given time constraints, underdeveloped assessment tools and documentation, and the lack of adequate personnel and/or referral resources to address endorsed risks or adverse experiences. The 2023 Joint Commission mandate to assess for health-related social needs (HRSN; e.g., CEV, food insecurity) across healthcare settings provides a unique opportunity to investigate how to integrate CEV items into routine pediatric HRSN assessments for young children and their families to decrease CEV, prevent associated negative sequelae, and reduce health disparities. Specifically, this project examined: (1) existing HRSN assessment processes and tools; (2) current facilitators and barriers to assessing for HRSN, particularly CEV; (3) follow-up care processes and resources for identified HRSNs; and (4) innovative strategies for effective, consistent HRSN assessment and follow-up care.

Methods: A convenience sampling approach was used to recruit pediatric healthcare providers across the state of Washington. Interviewees were selected with the goal of equal representation of providers/staff from varying health care settings (e.g., rural vs. urban; large vs small practices, hospital vs. community-based). A total of 35 semi-structured, individual interviews were conducted with pediatric healthcare providers (e.g., pediatricians) and ancillary support staff (e.g., family navigators). All interviews were conducted over Zoom, transcribed verbatim, and uploaded into ATLAS.ti for analysis. Using a grounded theory informed approach to codebook thematic analysis, themes were identified for each aim. Rigor was maintained through confirmability, reflexive journaling, and member-checking.

Results: The majority of participants were pediatricians (n=15, 42.9%) followed by community health workers (n=11, 31.4%), social workers (n=5, 14.3%), and other type of provider (n=4, 11.4%). Participants were drawn from 19 clinics, reflecting different practice settings and locations. Participants reported varied current practices for conducting HRSN assessments, including differences in the assessment tools used, cadence of assessments, and assessment processes (Aim 1). Participants reported common facilitators and barriers to conducting HRSN assessments, primarily time and personnel constraints, the complexity of family needs, the need for improved measures, and the lack of adequate potential referral resources if a need was identified by families (Aim 2). Across clinics, participants shared differing processes for addressing identified HRSN, including the personnel designated to connect families to HRSN services and resources, communication processes between providers, and processes to follow-up on any identified HRSN or suggested referrals (Aim 3). Participants consistently noted the value of HRSN assessments in pediatric primary care settings and suggested innovative solutions (e.g., embedded community health workers) to support the implementation of HRSN assessments in pediatric primary care settings (Aim 4).

Conclusions/Implications: Integrating CEV into HRSN assessments in pediatric primary care settings is essential to providing high-quality, holistic care to children and families. Further work with researcher-practitioner partnerships are needed to develop and test strategies to consistently, effectively implement these assessments across practice settings and patient populations.