During the past two decades, the public health community's attention has been drawn increasingly to the social determinants of health (SDH)-the factors apart from medical care that can be influenced by social policies and shape health in powerful ways . We use "medical care" rather than "health care" to refer to clinical services, to avoid potential confusion between "health" and "health care ." The World Health Organization's Commission on the Social Determinants of Health has defined SDH as "the conditions in which people are born, grow, live, work and age" and "the fundamental drivers of these conditions ." The term "social determinants" often evokes factors such as health-related features of neighborhoods (e .g ., walkability, recreational areas, and accessibility of healthful foods), which can influence health-related behaviors . Evidence has accumulated, however, pointing to socioeconomic factors such as income, wealth, and education as the fundamental causes of a wide range of health outcomes . This article broadly reviews some of the knowledge accumulated to date that highlights the importance of social-and particularly socioeconomicfactors in shaping health, and plausible pathways and biological mechanisms that may explain their effects . We also discuss challenges to advancing this knowledge and how they might be overcome .

IMPORTANCE Social determinants of health shape both children's immediate health and their lifetime risk for disease. Increasingly, pediatric health care organizations are intervening to address family social adversity. However, little evidence is available on the effectiveness of related interventions. OBJECTIVE To evaluate the effects of social needs screening and in-person resource navigation services on social needs and child health. DESIGN, SETTING, AND PARTICIPANTS Patients were randomized to intervention or active control conditions by the day of the week. Primary outcomes observed at 4 months after enrollment included caregivers' reports of social needs and child health status. Recruitment occurred between October 13, 2013, and August 27, 2015, in pediatric primary and urgent care clinics in 2 safety-net hospitals. Participants were English-speaking or Spanish-speaking caregivers accompanying minor children to nonacute medical visits. INTERVENTIONS After standardized screening, caregivers either received written information on relevant community services (active control) or received in-person help to access services with follow-up telephone calls for further assistance if needed (navigation intervention). MAIN OUTCOMES AND MEASURES Change in reported social needs and in caregiver assessment of child's overall health reported 4 months later. RESULTS Among 1809 patients enrolled in the study, evenly split between the 2 sites, 31.6% (n = 572) were enrolled in a primary care clinic and 68.4% (n = 1237) were enrolled in an urgent care setting. The children were primarily Hispanic white individuals (50.9% [n = 921]) and non-Hispanic black individuals (26.2% [n = 473]) and had a mean (SD) age of 5.1 (4.8) years; 50.5% (n = 913) were female. The reported number of social needs at baseline ranged from 0 to 11 of 14 total possible items, with a mean (SD) of 2.7 (2.2). At 4 months after enrollment, the number of social needs reported by the intervention arm decreased more than that reported by the control arm, with a mean (SE) change of −0.39 (0.13) vs 0.22 (0.13) (P < .001). In addition, caregivers in the intervention arm reported significantly greater improvement in their child's health, with a mean (SE) change of −0.36 (0.05) vs −0.12 (0.05) (P < .001). CONCLUSIONS AND RELEVANCE To our knowledge, this investigation is the first randomized clinical trial to evaluate health outcomes of a pediatric social needs navigation program. Compared with an active control at 4 months after enrollment, the intervention significantly decreased families' reports of social needs and significantly improved children's overall health status as reported by caregivers. These findings support the feasibility and potential effect of addressing social needs in pediatric health care settings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01939704

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Health care systems and policymakers in the United States increasingly use language related to social determinants of health in their strategies to improve health and control costs, but the terms used are often misunderstood, conflated, and confused. Greater clarity on key terms and the concepts underlying them could advance policies and practices related to social determinants of health—including by defining appropriate roles and limits of the health care sector in this multisector field.

BACKGROUND: There is growing interest in clinical screening for pediatric social determinants of health, but little evidence on formats that maximize disclosure rates on a wide range of potentially sensitive topics. We designed a study to examine disclosure rates and hypothesized that there would be no difference in disclosure rates on face-to-face versus electronic screening formats for items other than highly sensitive items. METHODS: We conducted a randomized trial of electronic versus face-to-face social screening formats in a pediatric emergency department. Consenting English-speaking and Spanish-speaking adult caregivers familiar with the presenting child’s household were randomized to social screening via tablet computer (with option for audio assist) versus a face-to-face interview conducted by a fully bilingual/bicultural researcher. RESULTS: Almost all caregivers (96.8%) reported at least 1 social need, but rates of reporting on the more sensitive issues (household violence and substance abuse) were significantly higher in electronic format, and disclosure was marginally higher in electronic format for financial insecurity and neighborhood and school safety. There was a significant difference in the proportion of social needs items with higher endorsement in the computer-based group (70%) than the face-to-face group (30%). CONCLUSIONS: Pediatric clinical sites interested in incorporating caregiver-reported socioeconomic, environmental, and behavioral needs screening should consider electronic screening when feasible, particularly when assessing sensitive topics such as child safety and household member substance use.

Our results indicate that adoption of systematic EHR-based SDH documentation may be feasible, but substantial barriers to adoption exist. Lessons from this study may inform primary care providers seeking to implement SDH-related efforts, and related health policies. Far more research is needed to address implementation barriers related to SDH documentation in EHRs.

This study demonstrates a significant association between neighborhood walkability and depressive symptoms in older men. Further research on the effects of neighborhood walkability may inform community-level mental health treatment and focus depression screening in less-walkable areas.

Introduction: This study aimed to better understand patient and caregiver perspectives on social risk screening across different healthcare settings. Methods: As part of a mixed-methods multisite study, the authors conducted semistructured interviews with a subset of adult patients and adult caregivers of pediatric patients who had completed the Center for Medicare and Medicaid Innovation Accountable Health Communities social risk screening tool between July 2018 and February 2019. Interviews, conducted in English or Spanish, asked about reactions to screening, screening acceptability, preferences for administration, prior screening experiences that informed perspectives, and expectations for social assistance. Basic thematic analysis and constant comparative methods were used to code and develop themes. Results: Fifty interviews were conducted across 10 study sites in 9 states, including 6 primary care clinics and 4 emergency departments. There was broad consensus among interviewees across all sites that social risk screening was acceptable. The following 4 main themes emerged: (1) participants believed screening for social risks is important; (2) participants expressed insight into the connections between social risks and overall health; (3) participants emphasized the importance of patient-centered implementation of social risk screening; and (4) participants recognized limits to the healthcare sector's capacity to address or resolve social risks.