Adolescence is a unique stage in the life course that is marked by both tremendous opportunity and potential vulnerability. Globally, attention is turning to the importance of meaningfully engaging adolescents in their health care to effectively and holistically support them in achieving healthy growth and development.1 In this effort, attention must be turned to the key factors that influence adolescents’ ability to realize their optimal trajectory. It is broadly recognized that the predominant determinants of the health of populations are not those traditionally conceptualized as “medical” but rather those forces that have come to be termed the social determinants of health. In the literature, an emphasis is emerging on screening for the social determinants of health, poverty in particular, during health care visits, owing to the mounting evidence of these determinants’ importance to patients’ well-being and ultimate health.2,3 Canada has been a global leader in advocating for such screening through the dissemination of the Centre for Effective Practice’s “Poverty: A Clinical Tool for Primary Care Providers” resource.4 Adolescents are equally, and often more, susceptible to these social determinants than the general population is5-7; however, the usefulness of universal screening for social determinants of health in the adolescent population has been largely unstudied.
Best practices for the implementation of screening tools emphasize that questions should be appropriate for the developmental stage of the patient being screened, and that screening should only be conducted if there are resources readily available to support a patient’s needs.3 These principles are founded in ethical standards that have been developed in response to broader dialogues and concerns around the practice of screening; in particular, the potential negative effects of screening such as stigma, or the problem of identifying patients when there is no evidence-based intervention available. Validated, innovative tools that are appropriate for adolescents and their developmental stage are thus critical in both promoting ethical practice and ensuring providers are positioned to manage the unique needs that are identified through this process. This commentary aims to build on previous research by first outlining the gaps in current approaches and then discussing strategies that clinicians can incorporate into their practice when working with adolescent patients.
The focus of this commentary is on the opportunity to identify social determinants of health for which instrumental interventions (eg, income subsidies, housing) are available and can be implemented. Additional determinants of health that have considerable and pervasive potential relevance and require a deeper understanding, such as gender, race, exposure to adverse childhood experiences, and others, must also be recognized and addressed. An in-depth assessment of the most appropriate approach to taking action on these issues is imperative, but beyond the scope of the current article.
Gaps in current knowledge and approaches
When physicians are asked about barriers to screening for patients’ social needs, they frequently voice concerns about a lack of time, available resources, or expertise.8 In a health care setting where social workers or other allied health professionals are unavailable, screening tools to detect socioeconomic adversity might play a role to bridge this resource gap, because of their potential to facilitate rapid, consistent, and standardized information collection. The HEEADSSS assessment, which focuses on elements of the home environment, education and employment, eating, peer-related activities, drugs, sexuality, suicide or depression, and safety from injury and violence,9,10 is a framework commonly used to structure the psychosocial component of the adolescent interview and requires approximately 20 minutes to complete. Information on its sensitivity and specificity is not available; however, it has been found that these assessments are often incomplete and sensitive questions are asked less frequently.11
There are a few promising studies pertaining to a developmentally appropriate tool designed to detect socioeconomic need and connect adolescents to community resources. The potential benefit of mobilizing technology to screen patients for socioeconomic need and generate referrals automatically has become prevalent in the literature.12 One such example of this type of practice is the Online Advocate system. This technology allows youth to complete an electronic questionnaire that asks about health-related social problems, then invites them to complete a self-directed social service referral based on their preferred location and prioritized needs. In 1 study, 96% of participants said they would recommend the system to a friend or peer.13 Other strengths of this tool included privacy, ease of use, and personalization. The main shortcoming of the tool was the time burden, as the questionnaire took on average 25 minutes to complete. Sensitivity and specificity of this screening and referral system are not currently available.13
A recently conducted study assessed the usefulness of currently available rapid screening tools in an adolescent parenting population.14 The study examined the Centre for Effective Practice’s tool, “Poverty: A Clinical Tool for Primary Care”4 and the WE CARE (well-child care, evaluation, community resources, advocacy, referral, education) screening tool.15 The Centre for Effective Practice’s core question, “Do you ever have difficulties making ends meet at the end of the month,” has been found to have a sensitivity of 98% and a specificity of 60% in detecting patients living below the poverty line among adult respondents.16 The WE CARE tool was validated in adolescent parents and found to facilitate the discussion of more psychosocial problems, lead to more referrals to community resources, and add only a few minutes to the health care visit.17 Despite the promise of both screening tools, this study found relatively low sensitivity when the tools were piloted in an adolescent parent population. Despite the low sensitivity, adolescents were highly receptive to health care providers asking them questions about socioeconomic adversity, and 92% of participants stated that similar questions should be incorporated into their health care visits.14
These studies highlight the receptivity of adolescents to screening in a health care visit context for need related to the social determinants of health. They also highlight that further research is needed to generate rapid, efficient, and effective tools that centre on the adolescent experience.
Given the tools that are currently available, we have outlined 5 take-home principles that we recommend clinicians incorporate into practice to guide their screening for social determinants of health when working with adolescent patients.
Take-home recommendations
Adolescents should be screened. If you are planning to implement universal screening for socioeconomic adversity, do not overlook the importance of screening adolescents. Developmentally, adolescents might be hesitant to bring up concerns or seek support for sensitive issues at health care visits.1,2 These issues might involve the social determinants of health, underscoring the potential value of universal screening for socioeconomic adversity as part of adolescents’ routine care. This recommendation is supported by organizations such as the Centre for Effective Practice and the American Academy of Pediatrics.2,4,18
Adolescents want you to ask. Adolescents want to be asked about their needs related to the social determinants of health and believe that health care providers should initiate this conversation. As outlined above, research has demonstrated that adolescents endorse the applicability of this screening to their health, and want to be asked these questions as part of a health care visit.12,14 Research suggests that, despite some concerns about stigma, adolescents are highly receptive to pertinent psychosocial screening.
Adolescents have unique screening needs. Standard screening tools might not adequately identify the unique needs of adolescents or be appropriate for their developmental stage. Very few of the available rapid socioeconomic adversity screening tools have been validated in an adolescent population, and most tools that have been endorsed for use in pediatric populations ask questions directed at parents and caregivers.3 Challenges arise when these tools are used with adolescents, as some of the questions might be developmentally inappropriate or fail to capture the needs of those living independently or under adverse circumstances. Health care providers should be critical of available tools’ appropriateness when working with youth.
Ethics must underpin screening efforts. Being aware of available resources to address socioeconomic adversity can help prepare health care providers to engage in screening in an ethical way. This recommendation is reflective of ethical standards that guide universal screening principles.3 Some of the rapid screening tools that are typically used in adult populations might offer resources that are inappropriate for adolescents. For example, the Centre for Effective Practice’s tool has had widespread use in Canadian primary care. The tool is designed to connect patients to tax benefits; however, not all adolescents are eligible for these benefits.4 Adolescents should be connected to resources that they can access and that are tailored to their unique developmental needs.
Screening tools are a starting point, not an end point. Screening tools are a useful way to start a conversation about need related to the social determinants of health. Given the lack of developmentally appropriate rapid screening tools designed for the adolescent population, we encourage clinicians to frame their preferred screening method as a starting point for further dialogue. Adolescents are neurodevelopmentally primed to respond to social engagement and might be able to offer meaningful feedback about the chosen screening method if the opportunity for such dialogue is introduced.
Conclusion
As the discourse surrounding the role of health care providers in addressing the social determinants of health continues to evolve and new strategies for addressing such determinants are explored, it is critical that the unique needs and circumstances of the adolescent population are considered. Research is needed to validate existing screening tools, to generate new developmentally appropriate tools that are tailored to the variety of needs encompassed by the age range of adolescence, and to determine the preferences of adolescents when discussing socioeconomic adversity. The meaningful engagement of adolescents at all stages of the screening process, from tool conceptualization to intervention design, will be fundamental to the success of these endeavours and central to achieving the ultimate goal of screening: optimizing the potential for healthy development of all adolescents by minimizing the effect of social inequities and adversity.
Footnotes
Competing interests
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de janvier 2020 à la page e3.
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