Effects of In-Person Assistance vs Personalized Written Resources About Social Services - NowPow

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March 2nd, 2020 | PubMed


Importance: Social and economic contexts shape children’s short- and long-term health. Efforts to address contextual risk factors are increasingly incorporated into pediatric health care.

Objective: To compare the effectiveness of 2 social risk-related interventions.

Design, setting, and participants: This randomized clinical trial included English- and/or Spanish-speaking caregiver-child dyads recruited from a pediatric urgent care clinic nested in a large, urban, safety-net hospital. Study recruitment, enrollment, and follow-up were conducted from July 18, 2016, to March 8, 2019. Data analysis was conducted from January 1, 2019, to January 20, 2020.

Interventions: Following standardized social risk assessment, caregivers were randomly assigned to receive either written information regarding relevant government and community social services resources or comparable written information plus in-person assistance and follow-up focused on service access.

Main outcomes and measures: Caregiver-reported number of social risk factors and child health 6 months after enrollment.

Results: Among 611 caregiver-child dyads enrolled in the study, 302 dyads were randomized to the written resources group and 309 dyads were randomized to the written resources plus in-person assistance group. The mean (SD) age of children was 6.1 (5.0) years; 483 children (79.1%) were Hispanic; and 315 children (51.6%) were girls. There were no significant differences between groups in the effects of the interventions. In post hoc secondary analyses, the number of reported social risks decreased from baseline to 6-month follow-up in both groups: caregivers who received written resources alone reported a mean (SE) of 1.28 (0.19) fewer risks at follow-up, while those receiving written resources plus in-person assistance reported 1.74 (0.21) fewer risks at follow-up (both P < .001). In both groups, there were small but statistically significant improvements from baseline to follow-up in child health (mean [SE] change: written resources, 0.37 [0.07]; written resources plus in-person assistance, 0.24 [0.07]; both P < .001).

Conclusions and relevance: This randomized clinical trial compared 2 approaches to addressing social risks in a pediatric urgent care setting and found no statistically significant differences in the social risk and child and caregiver health effects of providing written resources at the point of care with vs without in-person longitudinal navigation services. Caregivers in both groups reported fewer social risks and improved child and caregiver health 6 months after the intervention. These findings deepen understanding of effective doses of social risk-related interventions.

Trial registration: ClinicalTrials.gov Identifier: NCT02746393.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Gottlieb reported receiving grants from the Agency for Healthcare Research and Quality, Episcopal Health Foundation, Robert Wood Johnson Foundation, Commonwealth Fund, and Kaiser Permanente outside the submitted work. No other disclosures were reported.


    1. National Forum on Early Childhood Policy and Programs, National Scientific Council on the Developing Child The foundations of lifelong health are built in early childhood. https://developingchild.harvard.edu/resources/the-foundations-of-lifelong-health-are-built-in-early-childhood/. Accessed July 19, 2019.
    1. Shonkoff JP, Garner AS; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics . The lifelong effects of early childhood adversity and toxic stress. Pediatrics. 2012;129(1):-. doi:10.1542/peds.2011-2663 – DOI – PubMed
    1. Meyers A, Cutts D, Frank DA, et al. Subsidized housing and children’s nutritional status: data from a multisite surveillance study. Arch Pediatr Adolesc Med. 2005;159(6):551-556. doi:10.1001/archpedi.159.6.551 – DOI – PubMed
    1. Black MM, Cutts DB, Frank DA, et al. ; Children’s Sentinel Nutritional Assessment Program Study Group . Special Supplemental Nutrition Program for Women, Infants, and Children participation and infants’ growth and health: a multisite surveillance study. Pediatrics. 2004;114(1):169-176. doi:10.1542/peds.114.1.169 – DOI – PubMed
    1. Wood PR, Smith LA, Romero D, Bradshaw P, Wise PH, Chavkin W. Relationships between welfare status, health insurance status, and health and medical care among children with asthma. Am J Public Health. 2002;92(9):1446-1452. doi:10.2105/AJPH.92.9.1446 – DOI – PMC – PubMed
    1. Cook JT, Frank DA, Berkowitz C, et al. Welfare reform and the health of young children: a sentinel survey in 6 US cities. Arch Pediatr Adolesc Med. 2002;156(7):678-684. doi:10.1001/archpedi.156.7.678 – DOI – PubMed
    1. Fieldston ES, Zaniletti I, Hall M, et al. Community household income and resource utilization for common inpatient pediatric conditions. Pediatrics. 2013;132(6):e1592-e1601. doi:10.1542/peds.2013-0619 – DOI – PubMed
    1. Bauman LJ, Silver EJ, Stein RE. Cumulative social disadvantage and child health. Pediatrics. 2006;117(4):1321-1328. doi:10.1542/peds.2005-1647 – DOI – PubMed
    1. Secrest AM, Costacou T, Gutelius B, Miller RG, Songer TJ, Orchard TJ. Associations between socioeconomic status and major complications in type 1 diabetes: the Pittsburgh Epidemiology of Diabetes Complication (EDC) Study. Ann Epidemiol. 2011;21(5):374-381. doi:10.1016/j.annepidem.2011.02.007 – DOI – PMC – PubMed
    1. Colvin JD, Zaniletti I, Fieldston ES, et al. Socioeconomic status and in-hospital pediatric mortality. Pediatrics. 2013;131(1):e182-e190. doi:10.1542/peds.2012-1215 – DOI – PubMed
    1. Wood DL, Valdez RB, Hayashi T, Shen A. Health of homeless children and housed, poor children. Pediatrics. 1990;86(6):858-866. – PubMed
    1. Alaimo K, Olson CM, Frongillo EA Jr. Food insufficiency and American school-aged children’s cognitive, academic, and psychosocial development. Pediatrics. 2001;108(1):44-53. – PubMed
    1. Advisory Committee on Childhood Lead Poisoning Prevention (ACCLPP) Recommendations for blood lead screening of young children enrolled in Medicaid: targeting a group at high risk. MMWR Recomm Rep. 2000;49(RR-14):1-13. – PubMed
    1. Beebe-Dimmer J, Lynch JW, Turrell G, Lustgarten S, Raghunathan T, Kaplan GA. Childhood and adult socioeconomic conditions and 31-year mortality risk in women. Am J Epidemiol. 2004;159(5):481-490. doi:10.1093/aje/kwh057 – DOI – PubMed
    1. Wise PH. Child poverty and the promise of human capacity: childhood as a foundation for healthy aging. Acad Pediatr. 2016;16(3)(suppl):S37-S45. doi:10.1016/j.acap.2016.01.014 – DOI – PubMed
    1. Larson K, Russ SA, Crall JJ, Halfon N. Influence of multiple social risks on children’s health. Pediatrics. 2008;121(2):337-344. doi:10.1542/peds.2007-0447 – DOI – PubMed
    1. COUNCIL ON COMMUNITY PEDIATRICS Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339. doi:10.1542/peds.2016-0339 – DOI – PubMed
    1. American Academy of Family Physicians The EveryONE Project toolkit. 2018; https://www.aafp.org/patient-care/social-determinants-of-health/everyone-project/eop-tools.html. Accessed July 19, 2019.
    1. Daniel H, Bornstein SS, Kane GC; Health and Public Policy Committee of the American College of Physicians . Addressing social determinants to improve patient care and promote health equity: an American College of Physicians position paper. Ann Intern Med. 2018;168(8):577-578. doi:10.7326/M17-2441 – DOI – PubMed
    1. Ligon-Borden BL. Abraham Jacobi, MD: father of American pediatrics and advocate for children’s health. Semin Pediatr Infect Dis. 2003;14(3):245-249. doi:10.1016/S1045-1870(03)00055-4 – DOI – PubMed
    1. Beck AF, Cohen AJ, Colvin JD, et al. Perspectives from the Society for Pediatric Research: interventions targeting social needs in pediatric clinical care. Pediatr Res. 2018;84(1):10-21. doi:10.1038/s41390-018-0012-1 – DOI – PubMed
    1. Sege R, Preer G, Morton SJ, et al. Medical-legal strategies to improve infant health care: a randomized trial. Pediatrics. 2015;136(1):97-106. doi:10.1542/peds.2014-2955 – DOI – PubMed
    1. Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296-e304. doi:10.1542/peds.2014-2888 – DOI – PMC – PubMed
    1. Garg A, Butz AM, Dworkin PH, Lewis RA, Thompson RE, Serwint JR. Improving the management of family psychosocial problems at low-income children’s well-child care visits: the WE CARE Project. Pediatrics. 2007;120(3):547-558. doi:10.1542/peds.2007-0398 – DOI – PubMed
    1. Gottlieb LM, Hessler D, Long D, et al. Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial. JAMA Pediatr. 2016;170(11):e162521. doi:10.1001/jamapediatrics.2016.2521 – DOI – PubMed
    1. Gottlieb L, Hessler D, Long D, Amaya A, Adler N. A randomized trial on screening for social determinants of health: the iScreen study. Pediatrics. 2014;134(6):e1611-e1618. doi:10.1542/peds.2014-1439 – DOI – PubMed
    1. Beck AF, Henize AW, Kahn RS, Reiber KL, Young JJ, Klein MD. Forging a pediatric primary care-community partnership to support food-insecure families. Pediatrics. 2014;134(2):e564-e571. doi:10.1542/peds.2013-3845 – DOI – PubMed
    1. Klein MD, Beck AF, Henize AW, Parrish DS, Fink EE, Kahn RS. Doctors and lawyers collaborating to HeLP children—outcomes from a successful partnership between professions. J Health Care Poor Underserved. 2013;24(3):1063-1073. doi:10.1353/hpu.2013.0147 – DOI – PubMed
    1. Garg A, Sarkar S, Marino M, Onie R, Solomon BS. Linking urban families to community resources in the context of pediatric primary care. Patient Educ Couns. 2010;79(2):251-254. doi:10.1016/j.pec.2009.10.011 – DOI – PMC – PubMed
    1. Garg A, Marino M, Vikani AR, Solomon BS. Addressing families’ unmet social needs within pediatric primary care: the health leads model. Clin Pediatr (Phila). 2012;51(12):1191-1193. doi:10.1177/0009922812437930 – DOI – PubMed
    1. Dubowitz H, Feigelman S, Lane W, Kim J. Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid (SEEK) model. Pediatrics. 2009;123(3):858-864. doi:10.1542/peds.2008-1376 – DOI – PubMed
    1. Feigelman S, Dubowitz H, Lane W, Grube L, Kim J. Training pediatric residents in a primary care clinic to help address psychosocial problems and prevent child maltreatment. Acad Pediatr. 2011;11(6):474-480. doi:10.1016/j.acap.2011.07.005 – DOI – PMC – PubMed
    1. Dubowitz H, Lane WG, Semiatin JN, Magder LS, Venepally M, Jans M. The safe environment for every kid model: impact on pediatric primary care professionals. Pediatrics. 2011;127(4):e962-e970. doi:10.1542/peds.2010-1845 – DOI – PMC – PubMed
    1. Dubowitz H, Lane WG, Semiatin JN, Magder LS. The SEEK model of pediatric primary care: can child maltreatment be prevented in a low-risk population? Acad Pediatr. 2012;12(4):259-268. doi:10.1016/j.acap.2012.03.005 – DOI – PMC – PubMed
    1. Fox CK, Cairns N, Sunni M, Turnberg GL, Gross AC. Addressing food insecurity in a pediatric weight management clinic: a pilot intervention. J Pediatr Health Care. 2016;30(5):e11-e15. doi:10.1016/j.pedhc.2016.05.003 – DOI – PubMed
    1. Fleegler EW, Lieu TA, Wise PH, Muret-Wagstaff S. Families’ health-related social problems and missed referral opportunities. Pediatrics. 2007;119(6):e1332-e1341. doi:10.1542/peds.2006-1505 – DOI – PubMed
    1. Cullen D, Woodford A, Fein J. Food for thought: a randomized trial of food insecurity screening in the emergency department. Acad Pediatr. 2019;19(6):646-651. doi:10.1016/j.acap.2018.11.014 – DOI – PMC – PubMed
    1. Knowles M, Khan S, Palakshappa D, et al. Successes, challenges, and considerations for integrating referral into food insecurity screening in pediatric settings. J Health Care Poor Underserved. 2018;29(1):181-191. doi:10.1353/hpu.2018.0012 – DOI – PubMed
    1. Palakshappa D, Doupnik S, Vasan A, et al. Suburban families’ experience with food insecurity screening in primary care practices. Pediatrics. 2017;140(1):e20170320. doi:10.1542/peds.2017-0320 – DOI – PubMed
    1. Palakshappa D, Strane D, Griffis H, Fiks AG. Determining food-insecure families’ resource access with health system and public data. J Health Care Poor Underserved. 2019;30(1):265-279. doi:10.1353/hpu.2019.0020 – DOI – PubMed
    1. Sanders LM, Gershon TD, Huffman LC, Mendoza FS. Prescribing books for immigrant children: a pilot study to promote emergent literacy among the children of Hispanic immigrants. Arch Pediatr Adolesc Med. 2000;154(8):771-777. doi:10.1001/archpedi.154.8.771 – DOI – PubMed
    1. Silverstein M, Mack C, Reavis N, Koepsell TD, Gross GS, Grossman DC. Effect of a clinic-based referral system to head start: a randomized controlled trial. JAMA. 2004;292(8):968-971. doi:10.1001/jama.292.8.968 – DOI – PubMed
    1. Silverstein M, Iverson L, Lozano P. An English-language clinic-based literacy program is effective for a multilingual population. Pediatrics. 2002;109(5):E76-E6. doi:10.1542/peds.109.5.e76 – DOI – PubMed
    1. Sandel M, Sheward R, Ettinger de Cuba S, et al. Unstable housing and caregiver and child health in renter families. Pediatrics. 2018;141(2):e20172199. doi:10.1542/peds.2017-2199 – DOI – PubMed
    1. Weintraub D, Rodgers MA, Botcheva L, et al. Pilot study of medical-legal partnership to address social and legal needs of patients. J Health Care Poor Underserved. 2010;21(2)(suppl):157-168. doi:10.1353/hpu.0.0311 – DOI – PubMed
    1. Saxe-Custack A, LaChance J, Hanna-Attisha M, Ceja T. Fruit and vegetable prescriptions for pediatric patients living in Flint, Michigan: a cross-sectional study of food security and dietary patterns at baseline. Nutrients. 2019;11(6):E1423. doi:10.3390/nu11061423 – DOI – PMC – PubMed
    1. Gottlieb LM, Wing H, Adler NE. A systematic review of interventions on patients’ social and economic needs. Am J Prev Med. 2017;53(5):719-729. doi:10.1016/j.amepre.2017.05.011 – DOI – PubMed
    1. Lindau ST, Makelarski JA, Abramsohn EM, et al. CommunityRx: A real-world controlled clinical trial of a scalable, low-intensity community resource referral intervention. Am J Public Health. 2019;109(4):600-606. doi:10.2105/AJPH.2018.304905 – DOI – PMC – PubMed
    1. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010 – DOI – PMC – PubMed
    1. University of California, San Francisco ZSFG Health Advocates Program. https://healthadvocates.ucsf.edu/. Accessed July 19, 2019.
    1. Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med Care. 2001;39(8):800-812. doi:10.1097/00005650-200108000-00006 – DOI – PubMed
    1. Chan KS, Mangione-Smith R, Burwinkle TM, Rosen M, Varni JW. The PedsQL: reliability and validity of the short-form generic core scales and Asthma Module. Med Care. 2005;43(3):256-265. doi:10.1097/00005650-200503000-00008 – DOI – PubMed
    1. Varni JW, Limbers CA, Neighbors K, et al. The PedsQL Infant Scales: feasibility, internal consistency reliability, and validity in healthy and ill infants. Qual Life Res. 2011;20(1):45-55. doi:10.1007/s11136-010-9730-5 – DOI – PubMed
    1. Varni JW, Limbers CA, Burwinkle TM. Parent proxy-report of their children’s health-related quality of life: an analysis of 13,878 parents’ reliability and validity across age subgroups using the PedsQL 4.0 Generic Core Scales. Health Qual Life Outcomes. 2007;5:2. doi:10.1186/1477-7525-5-2 – DOI – PMC – PubMed
    1. Varni JW, Limbers CA, Burwinkle TM. How young can children reliably and validly self-report their health-related quality of life: an analysis of 8,591 children across age subgroups with the PedsQL 4.0 Generic Core Scales. Health Qual Life Outcomes. 2007;5:1. doi:10.1186/1477-7525-5-1 – DOI – PMC – PubMed
    1. Data Resource Center for Child and Adolescent Health National Survey of Children’s Health, 2011/12. https://www.childhealthdata.org/browse/survey/archive. Published 2012. Accessed July 19, 2019.
    1. Minkovitz CS, O’Campo PJ, Chen YH, Grason HA. Associations between maternal and child health status and patterns of medical care use. Ambul Pediatr. 2002;2(2):85-92. doi:10.1367/1539-4409(2002)002<0085:ABMACH>2.0.CO;2 – DOI – PubMed
    1. Monette S, Séguin L, Gauvin L, Nikiéma B. Validation of a measure of maternal perception of the child’s health status. Child Care Health Dev. 2007;33(4):472-481. doi:10.1111/j.1365-2214.2006.00713.x – DOI – PubMed
    1. Fowler MG, Johnson MP, Atkinson SS. School achievement and absence in children with chronic health conditions. J Pediatr. 1985;106(4):683-687. doi:10.1016/S0022-3476(85)80103-7 – DOI – PubMed
    1. Schalet BD, Hays RD, Jensen SE, Beaumont JL, Fries JF, Cella D. Validity of PROMIS physical function measured in diverse clinical samples. J Clin Epidemiol. 2016;73:112-118. doi:10.1016/j.jclinepi.2015.08.039 – DOI – PMC – PubMed
    1. Cohen S, Janicki-Deverts D. Who’s stressed? Distributions of psychological stress in the United States in probability samples from 1983, 2006, and 2009. J Appl Soc Psychol. 2012;42(6):1320-1334. doi:10.1111/j.1559-1816.2012.00900.x – DOI
    1. Warttig SL, Forshaw MJ, South J, White AK. New, normative, English-sample data for the Short Form Perceived Stress Scale (PSS-4). J Health Psychol. 2013;18(12):1617-1628. doi:10.1177/1359105313508346 – DOI – PubMed
    1. Kroenke K, Spitzer RL, Williams JB, Löwe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32(4):345-359. doi:10.1016/j.genhosppsych.2010.03.006 – DOI – PubMed
    1. Katz KS, El-Mohandes PA, Johnson DM, Jarrett PM, Rose A, Cober M. Retention of low income mothers in a parenting intervention study. J Community Health. 2001;26(3):203-218. doi:10.1023/A:1010373113060 – DOI – PubMed
    1. Krieger JW, Takaro TK, Song L, Weaver M. The Seattle-King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. Am J Public Health. 2005;95(4):652-659. doi:10.2105/AJPH.2004.042994 – DOI – PMC – PubMed
    1. Alley DE, Asomugha CN, Conway PH, Sanghavi DM. Accountable Health Communities—addressing social needs through Medicare and Medicaid. N Engl J Med. 2016;374(1):8-11. doi:10.1056/NEJMp1512532 – DOI – PubMed
    1. National Association of Community Health Centers, Association of Asian Pacific Community Health Organizations, Oregon Primary Care Association, Institute for Alternative Futures Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE). http://www.nachc.org/research-and-data/prapare/. Accessed July 18, 2019.
    1. Campbell DT, Stanley JC. Experimental and Quasi-experimental Designs for Research. Chicago, IL: R. McNally; 1963.
    1. Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit, 2nd edition. https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool12.html. Accessed July 19, 2019.
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