In pediatric practices across the country, parents and caregivers fill out questionnaires about their family’s everyday needs like food or transportation.

The answers can help pediatricians and other clinicians gain a more complete picture of challenges children face that could impede their health and allow for referrals to needed resources.

However, caregivers may opt not to fill out the forms or leave some questions blank.

In one recent study of pediatric clinics that administered screeners on social needs, nearly 10% of caregivers to more than 177,000 children did not respond to one or more questions. Nonresponse was higher among caregivers with public insurance like Medicaid and those who were Black, Hispanic, or another non-White race or ethnicity. Caregivers most frequently did not answer if they had trouble accessing food, housing, or transportation.

“There can sometimes be lack of trust….Sometimes there’s lack of clarity about where this information is stored, and who has access to it,” said Maya Ragavan, MD, MPH, MS, associate professor of pediatrics at the School of Medicine, University of Pittsburgh, Pittsburgh, and lead author of the study. “They may not necessarily have built rapport with their provider or the health system yet,” she added.

But clinicians can use a few strategies to broach the topics of unanswered questions, Ragavan said.

The reasons for not answering a question can vary. Some parents may be afraid that indicating they need help getting food or clothes for their children could later be used against them in custody battles or by the Child Protective Services, Ragavan said. In other cases, they may feel like their medical provider cannot help them.

But the impact of social needs “can be just as important as blood work or blood pressure readings to someone’s overall health,” said Wilfredo Giordano-Perez, MD, MBA, family medicine physician and CMO of Fenway Health in Boston, a nonprofit community health center. “We don’t just ask the questions to ask the questions — we ask the questions because we recognize that connecting individuals to care to address some of their needs can absolutely impact their overall health.”

Handling Nonresponses

Clinicians can handle nonresponses in several ways, said Jean Raphael, MD, MPH, primary care pediatrician and chief of the Division of Academic General Pediatrics at Baylor College of Medicine in Houston.

He said he usually asks the caregiver during the visit if omitting an answer was deliberate or by accident. If the latter, he explains the purpose of the questionnaire. If a caregiver continues to say they are not interested, Raphael tells them that the screening results will not affect the care he provides but potentially help meet their nonmedical needs.

But an uncompleted questionnaire can also be a signal, Giordano-Perez said.

“It’s telling us that we have more work to do building trust or clarifying why it is we’re asking in the first place, but also to ensure that we actually have followed through when there is a need that’s identified,” he said.

Some practices are shifting toward offering resource connections to all patients, regardless of screening answers. This might include telling patients and families a social worker is available through the practice, Ragavan said.

“Then it doesn’t matter if they disclose,” Ragavan said. “It’s best to take cues from the patient. Just because somebody does or doesn’t fill out a screener doesn’t necessarily mean that they do or don’t want resources.”

While many physicians find the screening tools helpful overall, some may feel overwhelmed trying to fit patient responses into a regular checkup or medical visit.

“What I tell our clinicians and staff is, we’re not being nosy when you ask these questions,” Giordano-Perez said. “It’s just as clinical asking about someone’s transportation access as it is asking about their pain level.”
 

Tips for engaging patients and caregivers who do not answer:

• Be patient. “Sometimes you have to engage people over time, and then they get more comfortable and understand where you’re coming from,” Raphael said.
• Become comfortable discussing patient needs. If not, the patient will notice, Raphael said. “If I walk into a room and I’m awkward with how I present the screening and questions, and I’m asking them not in the most respectful manner — those are all things that decrease trust as opposed to building it,” Raphael said.
• For pediatric or family practices, discuss answers with parents and caregivers away from children.
• Coordinate screenings within electronic medical record systems so the screener is conducted only occasionally. For example, if a patient or family member is screened in the emergency department and is then screened during a follow-up outpatient visit, “they start to wonder, ‘Why am I being screened so frequently?’ Raphael said. “It becomes stigmatizing and degrades trust within the system.”
• Give patients more than a resource sheet with names and phone numbers. Pair screening with handoffs to social workers, family health navigators, or contacts within social service agencies. “Studies have shown that people want tangible resources other than just a list,” Ragavan said. Use online databases like findhelp.org to locate services in the patient’s ZIP code that match their needs, Raphael suggested.

The interviewees reported no relevant financial disclosures.

Karen Blum is a freelance medical/science writer in the Baltimore area.