EquiCare Toolkit

Overview: Guidance is provided for discussing a patient’s sexual health, offering opportunities to: screen for and treat sexually transmitted infections (STIs), address other sexual health concerns, counsel on behaviors that may increase STI risk, and gain a comprehensive understanding of the patient’s overall health.

Centers for Disease Control and Prevention. (2024, April 24). Discussing sexual health with your patients. Centers for Disease Control and Prevention. https://www.cdc.gov/hiv/clinicians/screening/sexual-health.html

Abstract – OBJECTIVE: To review the literature on the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach to alcohol and drug use with racial and ethnic subgroups in the United States and to develop recommendations for culturally competent SBIRT practice. METHODS: Articles reporting on the use of SBIRT components (Screening, Brief Intervention, Referral to Treatment) for alcohol and drug use were identified through a comprehensive literature search of PubMed from 1995–2015. RESULTS: A synthesis of the published literature on racial and ethnic considerations regarding SBIRT components (including motivational interviewing techniques) was created using evidence-based findings. Recommendations on culturally competent use of SBIRT with specific ethnic groups also are described. CONCLUSIONS: Based on the literature reviewed, SBIRT offers a useful set of tools to help reduce risky or problematic substance use. Special attention to validated screeners, appropriate use of language/literacy, trust building, and incorporation of patient and community health care preferences may enhance SBIRT acceptability and effectiveness. PRACTICE IMPLICATIONS: Providers should consider the implications of previous research when adapting SBIRT for diverse populations and use validated screening and brief intervention methods. The accompanying case illustration provides additional information relevant to clinical practice.

Manuel, J. K., Satre, D. D., Tsoh, J., Moreno-John, G., Ramos, J. S., McCance-Katz, E. F., & Satterfield, J. M. (2015). Adapting Screening, Brief Intervention, and Referral to Treatment for alcohol and drugs to culturally diverse clinical populations. Journal of Addiction Medicine, 9(5), 343–351. https://doi.org/10.1097/ADM.0000000000000150

Abstract – Introduction: The Montreal Cognitive Assessment (MoCA), scored from 0 to 30, is used as a screening tool for mild cognitive impairment (MCI). The current cutoff (26) may not be optimal among minorities. Methods: Data from the National Alzheimer’s Coordinating Center Uniform Data Set March 2018 data freeze was used to calculate optimal cutoffs for detection of MCI and dementia by race/ethnic group and education. Results: Of the 3895 individuals included, 80.7% were non-Hispanic White, 15.0% were non-Hispanic Black, and 4.2% were Hispanic. Optimal cutoffs for detection of MCI were 25 among non-Hispanic Whites, 24 among Hispanics, and 23 among non-Hispanic Blacks. Optimal cutoffs for detection of dementia were 19 among non-Hispanic Whites and 16 for both non-Hispanic Blacks and Hispanics. Lower educational attainment produced lower optimal cutoffs. Discussion: Our findings suggest cutoffs may need to be stratified by race/ethnicity and education to ensure detecting MCI from normal and MCI from dementia.

Milani, S. A., Marsiske, M., Cottler, L. B., Chen, X., & Striley, C. W. (2018). Optimal cutoffs for the Montreal Cognitive Assessment vary by race and ethnicity. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 10, 773–781.  https://doi.org/10.1016/j.dadm.2018.09.003

Abstract – Objective: to examine the validity of the Children’s Eating Behavior Questionnaire (CEBQ) through the associations of its 3 subscale scores (food responsiveness, slowness in eating, and satiety responsiveness) with body mass index (BMI). Design: cross-sectional study of baseline data from a clinic-based obesity prevention and control randomized controlled trial. Population: Latino pediatric patients (n = 295) aged 5-11 years from a federally qualified health center in San Diego County, CA, with BMI percentiles ranging from 75.5 to 99.0. Main outcome measure was child BMI-for-age percentile computed using the standardized program for the 2000 Centers for Disease Control and Prevention growth charts. Analysis: consisted of principal components analysis and multivariate linear regressions. Results: Principal components analysis showed a factor structure relatively similar to that of the original 3 CEBQ subscales, with acceptable internal consistency and between-subscale correlations. Analyses demonstrated the validity of the 3 subscales: child BMI was positively associated with food responsiveness (β = .336; P ≤ .001) and negatively associated with slowness in eating (β = -.209; P ≤ .001) and satiety responsiveness (β = -.211; P ≤ .001). Conclusions and Implications: The 14-item CEBQ scale may be useful for assessing obesogenic eating behaviors of Latino children. Further study is needed to replicate these findings. 

Behar, A. I., Crespo, N. C., Garcia, M. L., Ayala, G. X., Campbell, N., Shadron, L. M., & Elder, J. P. (2018). Validation of a shortened version of the Children’s Eating Behavior Questionnaire and associations with BMI in a clinical sample of Latino children. Journal of Nutrition Education and Behavior, 50(4), 372–378.e1. https://doi.org/10.1016/j.jneb.2017.08.013

Abstract: Research has shown that children’s dietary and activity-related behaviors are shaped by the family environment and parenting behaviors. The present study describes the development and validation of a bilingual (Spanish and English) scale assessing parenting strategies associated with children’s dietary and activity-related behaviors in the home. Items were generated from focus groups with Latina mothers and a review of the literature, and two different samples were used to assess the scale’s psychometric properties, including an examination of predictive validity using measured child body mass index. Factor analysis of the first sample (N=91) yielded a 5-factor solution (limit setting, monitoring, discipline, control and concern) and accounted for 65% of the variance. Confirmatory factor analyses on a second sample of Latina mothers recruited into a childhood obesity prevention study (N=714) showed that a 26-item 5-factor solution (limit setting, monitoring, discipline, control and reinforcement) provided the best fit for the data. Parenting strategies characterized as controlling were associated with a lower BMI among children. After using multiple samples and establishing its validity, the parenting strategies for eating and activity scale (PEAS) was found to be valid and reliable in measuring Latino parenting strategies related to children’s dietary and activity-related behaviors.

Larios, S. E., Ayala, G. X., Arredondo, E. M., Baquero, B., & Elder, J. P. (2009). Development and validation of a scale to measure Latino parenting strategies related to children’s obesigenic behaviors: The Parenting Strategies for Eating and Activity Scale (PEAS). Appetite, 52(1), 166–172. https://doi.org/10.1016/j.appet.2008.09.011

Abstract: Research shows that Latino parenting practices influence children’s dietary and weight outcomes. Most studies use parent-reported data, however data from children may provide additional insight into how parents influence their children’s diet and weight outcomes. The Parenting Strategies for Eating and Activity Scale (PEAS) has been validated in Latino adults, but not in children. This study evaluated the factor structure and concurrent and predictive validity of a modified version of the PEAS (PEAS-Diet) among Latino children. Data were collected from 361 children ages 7-13 from Imperial County, California, enrolled in a randomized controlled trial to promote healthy eating. The PEAS-Diet included 25 candidate items targeting six parenting practices pertaining to children’s eating behaviors: (a) monitoring; (b) disciplining; (c) control; (d) permissiveness; (e) reinforcing; and (f) limit-setting. Children were on average ten years old (±2), 50% boys, 93% self-identified as Latino, 81% were US-born, and 55% completed English versus Spanish-language interviews. Using varimax rotation on baseline data with the total sample, six items were removed due to factor loadings <.40 and/or cross-loading (>.32 on more than one component). Parallel analysis and interpretability suggested a 5-factor solution explaining 59.46% of the variance. The subscale “limit-setting” was removed from the scale. The final scale consisted of 19 items and 5 subscales. Internal consistency of the subscales ranged from α = .63-.82. Confirmatory factor analyses provided additional evidence for the 5-factor scale using data collected 4- and 6-months post-baseline among the control group (n = 164, n = 161, respectively). Concurrent validity with dietary intake was established for monitoring, control, permissiveness, and reinforcing subscales in the expected directions. Predictive validity was not established. Results indicated that with the reported changes, the interview-administered PEAS-Diet is valid among Latino children aged 7-13 years.

Soto, S. C., Arredondo, E. M., Horton, L. A., & Ayala, G. X. (2016). Validation of the modified Parenting Strategies for Eating and Physical Activity Scale-Diet (PEAS-Diet) in Latino children. Appetite, 98, 55–62. https://doi.org/10.1016/j.appet.2015.12.003

Abstract – Objective: This study is a preliminary assessment of the psychometric properties of the Trauma Symptoms of Discrimination Scale (TSDS), a new measure of discriminatory distress measuring anxiety-related trauma symptoms. Method: African American monoracial and biracial undergraduate students (n=123) completed questionnaires, including the TSDS, the Multigroup Ethnic Identity Measure, assessments of racial discrimination, and a range of psychopathology measures. The TSDS factor structure was determined with a principal component analysis and internal consistency was assessed. Pearson’s correlations were conducted between the TSDS and measure of discrimination and psychopathology. Linear regression was used to predict the TSDS from frequency of discrimination. Results: Item loadings suggested 4 components: (a) uncontrollable hyperarousal, (b) feelings of alienation, (c) worries about future negative events, and (d) perceiving others as dangerous. All measures of discrimination significantly predicted symptoms of trauma, even when accounting for prior traumatic experiences. Conclusions: Preliminary evidence supports the validity of the TSDS for the measurement of anxiety-related trauma symptoms due to racial discrimination. All forms of discrimination may contribute to traumatization in African Americans.

Williams, M. T., Printz, D. M. B., & DeLapp, R. C. T. (2018, October 1). Assessing racial trauma with the Trauma Symptoms of Discrimination Scale. Psychology of Violence. Advance online publication. https://doi.org/10.1037/vio0000212

Overview: This website provides multiple tools to family physicians and their practice teams to screen for social determinants of health, connect patients with community-based resources, and collaborate on action plans that address social needs, reduce health risks, and improve outcomes.

American Academy of Family Physicians. (n.d.). Assessment and action: Address your patients’ social determinants of health.  https://www.aafp.org › family-physician › patient-care › the-everyone-project › toolkit › assessment.html 

Abstract – Background: Screening for the social determinants of health in clinical practice is still widely debated. Methods: A scoping review was used to (1) explore the various screening tools that are available to identify social risk, (2) examine the impact that screening for social determinants has on health and social outcomes, and (3) identify factors that promote the uptake of screening in routine clinical care. Results: Over the last two decades, a growing number of screening tools have been developed to help frontline health workers ask about the social determinants of health in clinical care. In addition to clinical practice guidelines that recommend screening for specific areas of social risk (e.g., violence in pregnancy), there is also a growing body of evidence exploring the use of screening or case finding for identifying multiple domains of social risk (e.g., poverty, food insecurity, violence, unemployment, and housing problems).

Conclusion: There is increasing traction within the medical field for improving social history taking and integrating more formal screening for social determinants of health within clinical practice. There is also a growing number of high-quality evidence-based reviews that identify interventions that are effective in promoting health equity at the individual patient level, and at broader community and structural levels. 

Andermann, A. (2018). Screening for social determinants of health in clinical care: Moving from the margins to the mainstream. Public Health Reviews, 39, 19. https://doi.org/10.1186/s40985-018-0094-7

Summary: This article explores how cultural competence can enhance healthcare quality and reduce disparities, with a focus on nursing practice. It also introduces the ESFT model – a brief  assessment and discussion tool designed to help healthcare providers improve patient-provider communication by addressing explanatory, social, fears/concerns, and therapeutic contracting aspects.  

Beard, K. V., Gwanmesia, E., & Miranda-Diaz, G. (2015). Culturally competent care: Using the ESFT model in nursing. American Journal of Nursing, 115(6), 58–62. https://doi.org/10.1097/01.NAJ.0000466326.99804.c4

Summary: The article presents a framework for leveraging community vital signs and patient- reported data, integrating this information into primary care workflows, and addressing it through referrals, patient engagement, and care coordination.

DeVoe, J. E., Bazemore, A. W., Cottrell, E. K., Likumahuwa-Ackman, S., Grandmont, J., Spach, N., & Gold, R. (2016). Perspectives in primary care: A conceptual framework and path for integrating social determinants of health into primary care practice. Annals of Family Medicine, 14(2), 104–108. https://doi.org/10.1370/afm.1903

Abstract – Purpose: Social determinants of health (SDoH) have been linked to a variety of health conditions, but there are no multivariate measures of these determinants to estimate the risk of morbidity or mortality in a community. We developed a score derived from multivariate measures of SDoH that predicts county-level cardiovascular disease (CVD) mortality. Methods: Using county-level data from 3,026 US counties, we developed a score considering variables of neighborhood socioeconomic status, food/lifestyle environment, and health care resource availability and accessibility to predict the 3-year average (2015-2017) age-adjusted county-level mortality rate for all CVD. We used one 50% random sample to develop the score and the other to validate the score. A Poisson regression model was developed to estimate parameters of variables while accounting for intrastate correlation. Results: The index score was based on 7 SDoH factors: percentage of the population of minority (nonwhite) race, poverty rate, percentage of the population without a high school diploma, grocery store ratio, fast-food restaurant ratio, after-tax soda price, and primary care physician supply. The area under the curve for the development and validation groups was similar, 0.851 (95% CI, 0.829-0.872) and 0.840 (95% CI, 0.817-0.863), respectively, indicating excellent discriminative ability. The index had better predictive performance for CVD burden than other area-level indexes: poverty only (area under the curve= 0.808, P <.001); the Centers for Disease Control and Prevention’s Social Vulnerability Index (CDC-SVI) (area under the curve =0.786, P <.001); and the Agency for Healthcare Research and Quality’s Socioeconomic Status (AHRQ-SES) index (area under the curve =0.835, P = .03). Conclusions: Our validated multivariate SDoH index score accurately classifies counties with high CVD burden and therefore has the potential to improve CVD risk prediction for vulnerable populations and interventions for CVD at the county level.

Hong, Y.-R., & Mainous, A. G. (2020). Development and validation of a county-level social determinants of health risk assessment tool for cardiovascular disease. Annals of Family Medicine, 18, 318–325. https://doi.org/10.1370/afm.2534

Abstract: Increasingly, health care institutions are called on to address social determinants of health (SDH) given the connection to morbidity and mortality across populations. However, widespread implementation of screening for health-related social conditions (HRSC) is lagging. It is estimated that half of patients who have such needs may be missed by failure to screen routinely. Health care institutions face gaps in information related to screening tools. A review of tools that screen for HRSC at the individual level is needed to share readily available and applicable tools for integration in various settings, to communicate how tools are typically administered, and to assess whether tools capture domains corresponding with Institute of Medicine (IOM) core measures. To address these gaps, an unsystematic rapid review of the literature was conducted. In addition to peer-reviewed literature, Google, PubMed, and CINAHL databases and grey literature were searched with a focus on lead agencies or scholars in the field. English language publications from 2008-2018 with content related to SDH or health-related social condition screening tools were included. Nine commonly applied tools were selected and reviewed for content, setting, and method of administration. Fifteen common domains were identified and assessed for alignment with IOM recommendations and correspondence with the construct of social stability. This review consolidates essential information about HRSC screening tools in 1 place and provides practice, policy, and research recommendations to improve HRSC screening. This review is a practice brief that can help health care institutions and clinicians implement screening and interventions related to HRSC.

Moen, M., Storr, C., German, D., Friedmann, E., & Johantgen, M. (2020). A review of tools to screen for social determinants of health in the United States: A practice brief. Population Health Management, 23(6), 422–429. https://doi.org/10.1089/pop.2019.0158

Abstract – Problem: Social and physical contexts which make up social determinants of health (SDOH) have tremendous impacts on youth development, health and well-being. Despite knowledge and evidence of these impacts, few pediatric SDOH screening tools are known. The purpose of this review was to identify and evaluate available pediatric SDOH screening tools.

Eligibility criteria: Articles were limited to studies in the English language, with pediatric populations, conducted in the United States, and were peer-reviewed, primary studies. Sample: Search of 3 databases (PsychInfo, CINAHL and PubMed) yielded 499 articles, 486 were excluded. Total of 13 articles were appraised and synthesized using the SDOH framework outlined by Healthy People 2020. Results: Thirteen articles relevant to the assessment of SDOH domains were evaluated. Majority of studies were limited in both the number of SDOH domains screened and the depth of screening. Tools were heterogeneous in methods used to assess SDOH risks and few were validated. Limited number of studies included youth or families in the initial development of tools. Conclusions: Despite growing recognition across healthcare that SDOH greatly influence pediatric health risks, management and outcomes, there is a dearth of available high quality, multidimensional, comprehensive screening tools for pediatric care professionals.

Implications: This review emphasizes the need for the continued development of effective, comprehensive and practical tools for assessing pediatric SDOH risk factors. Pediatric nursing care includes the assessment of the youth and family context to effectively evaluate resource needs. Pediatric nurses are well poised to address this knowledge and resource gap.

Morone, J. (2017). An integrative review of social determinants of health assessment and screening tools used in pediatrics. Journal of Pediatric Nursing, 37, 22–28. https://doi.org/10.1016/j.pedn.2017.08.022

Abstract: Community health fair has been used informally as a way of offering health promotion, education, and screening services onsite to underserved and hard to reach populations such as the newcomers. To utilize an annual health fair for the assessment of the overall perception of health status of newcomers in relation to the determinants of health; and to evaluate its effectiveness as an intervention to engage attendees in their community. The 3rd Annual refugees and immigrant’s health and wellness resources fair in Allegheny County. A cross-sectional study was designed using questionnaires focused on the health and social determinants of health, with few open-ended questions related to engagement and networking. A total of 107 individuals participated in the study. The age ranged between 18-75 years, 46.9% males and 53% females. The largest representations from Bhutan, Arab Middle Eastern countries, and Ghana. Perception of health was examined in relation to other determinants such as language, regular checkups, employment, income, education, access to health, and psychosocial needs. Results revealed that health perception varied by ethnicity, was influenced by English proficiency, access to health, employment, and regular checkups, while education, and income did not show an impact. A qualitative analysis to the narrative responses revealed that the health fair was very effective in breaking the structural barriers with providers as well as for community engagement. The annual health fair was a successful strategy in the assessment of the health determinants and for community engagement of the newcomers.

Salman, K., Turek, J. M., & Donovan, C. (2021). Community health and wellness fair: A strategy for assessment of social determinants of health, inclusion, and engagement of newcomers. Journal of Community Health, 46(3), 527–537. https://doi.org/10.1007/s10900-020-00901-0 

Abstract – Context: Screening children for social determinants of health (SDOHs) has gained attention in recent years, but there is a deficit in understanding the present state of the science. Objective: To systematically review SDOH screening tools used with children, examine their psychometric properties, and evaluate how they detect early indicators of risk and inform care. Data sources: Comprehensive electronic search of PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection. Study selection: Studies in which a tool that screened children for multiple SDOHs (defined according to Healthy People 2020) was developed, tested, and/or employed. Data extraction: Extraction domains included study characteristics, screening tool characteristics, SDOHs screened, and follow-up procedures. Results: The search returned 6274 studies. We retained 17 studies encompassing 11 screeners. Study samples were diverse with respect to biological sex and race and/or ethnicity. Screening was primarily conducted in clinical settings with a parent or caregiver being the primary informant for all screeners. Psychometric properties were assessed for only 3 screeners. The most common SDOH domains screened included the family context and economic stability. Authors of the majority of studies described referrals and/or interventions that followed screening to address identified SDOHs. Limitations: Following the Healthy People 2020 SDOH definition may have excluded articles that other definitions would have captured. Conclusions: The extent to which SDOH screening accurately assessed a child’s SDOHs was largely unevaluated. Authors of future research should also evaluate if referrals and interventions after the screening effectively address SDOHs and improve child well-being.

Sokol, R., Austin, A., Chandler, C., Byrum, E., Bousquette, J., Lancaster, C., Doss, G., Dotson, A., Urbaeva, V., Singichetti, B., Brevard, K., Wright, S. T., Lanier, P., & Shanahan, M. (2019). Screening children for social determinants of health: A systematic review. Pediatrics, 144(4), e20191622. https://doi.org/10.1542/peds.2019-1622