Development of a Brief Questionnaire to Identify Families in Need of Legal Advocacy to Improve Child Health

doi:10.1016/j.ambp.2008.04.004

Ambulatory Pediatrics

Volume 8, Issue 4, July–August 2008, Pages 266-269

https://doi.org/10.1016/j.ambp.2008.04.004 Get rights and content

Objective

To determine whether the medical-legal advocacy screening questionnaire (MASQ), a simple 10-item questionnaire, is able to screen families in a primary care setting for possible referral to legal services more effectively than the clinical interview alone.

Methods

Family Advocates of Central Massachusetts (FACM) is a medical-legal collaboration that assists low-income families with legal issues that affect child health. A convenience sample of parents seen at each of 5 medical practices associated with FACM was recruited to complete the MASQ prior to a routine child health care visit. Physicians blinded to the result assessed family need for referral to FACM after their usual clinical encounter. The sensitivity and specificity of both the MASQ and provider assessment were calculated.

Results

Two hundred fifty-five parents from 5 practices participated in the study. The MASQ identified 85 patients in need of legal services. Prior to reviewing the MASQ, the primary care providers identified 35 families in need of referral to the FACM. After completion of both the MASQ and the medical encounter, 37 families agreed to referral. The MASQ had sensitivity of 0.81 and specificity of 0.75 in predicting program referral. Provider assessment had sensitivity of 0.65 and specificity of 0.95 of predicting program referral.

Conclusions

Routine use of the MASQ would likely identify more patients in pediatric practices who would accept referral to legal assistance than reliance on provider impression alone after a routine clinical encounter.

Section snippets

Questionnaire Development

The survey used questions taken verbatim from a series of clinical practice guideline queries developed for legal advocacy at Boston Medical Center (a copy of the questionnaire is available from the authors).⁷ The 10 questions covered 4 topic areas: housing (1 question), financial stability (4 questions), dignity and safety (2 questions), and access to services (3 questions). The questionnaire was pretested by 15 parents in waiting rooms of the participating clinical sites and modified, upon

Results

Two hundred fifty-five (95.5%) of 267 parents who were invited to participate in the study completed the MASQ. Seven were excluded due to language concerns or lack of a parent or guardian, and 5 declined to participate. The mean age of the parent completing the survey was 33.7 years. The mean age of the child being seen was 5.7 years. The mean family size was 4.1. Nearly one half (48%) of families reported a total annual family income of less than $30,000 per year. Just over one half (58%) of

Discussion

The MASQ, a 10-item parent-completed survey, identified more families that accepted referral to the medical-legal partnership than were identified by the clinician's judgment, suggesting that formal screening may be helpful in assuring access for legal services. The MASQ was more sensitive and much less specific than the clinician's judgment, resulting in a lower PPV for the MASQ in the population screened. Identifying a legal need may not result in a program referral. Families may not be

Acknowledgments

This work was support by grant HRSA 1 H17MC02515-01-00 (DK) from the Healthy Tomorrows Partnership for Children, Bureau of Maternal and Child Health, Health Resources and Services Administration. We thank the partners of FACM (Legal Assistance Corporation of Central Massachusetts, Pediatric Primary Care Associates, Family Health Center of Worcester, CHC Family Health Center/Fitchburg, Community Pediatrics of Milford, and South County Pediatrics), without whose enthusiastic cooperation this

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Medical-legal needs are health-harming adverse social conditions with a legal remedy. Medical-legal partnerships in primary care settings have been proposed to address these needs for at-risk patients already seeking medical care. Our hypothesis is that trauma patients represent a unique population that may be more likely to have baseline medical-legal needs.
A trauma-specific medical-legal needs survey was developed. Adult trauma patients who were able to give consent and were admitted to our urban Level I hospital were surveyed. Medical-legal needs were tabulated from the surveys. Those patients in the top decile of medical-legal needs were categorized as having a High Burden of medical-legal needs. Multivariate logistic regression was used to identify those independent risk factors for having a High Burden of medical-legal needs.
A total of 566 participants completed the survey (78.2% response rate). The mean number of medical-legal needs for our population was 2.5 (SD = 3.1). 73% of our respondents had at least one medical-legal need. The most common needs were Housing (n = 229, 40%) and Education/Employment (n = 223, 39%). Older age (aOR = 3.01, 95% CI 1.2-8.1, P = 0.02), being separated or divorced (aOR = 4.25, 95% CI 1.2-14.0, P = 0.02), self perceived poor health (aOR = 8.4, 95% CI 2.61-26.86, P < 0.001), penetrating mechanism of injury (aOR = 2.52, 95% CI 1.22-5.2, P = 0.01), and having been admitted to the hospital for a longer period of time (aOR = 5.48, 95% CI 1.55-19.4, P = 0.008) were all independently associated with a High Burden of medical-legal needs.
Trauma patients have a high baseline burden of medical-legal needs. Medical-legal partnerships embedded in trauma teams may offer an innovative strategy to help address long-term health outcomes in a highly vulnerable population that would not otherwise have contact with the healthcare system.
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No additional unique assessments were identified in the PubMed, CINAHL, PsychInfo, and SocINDEX database searches. Overall, 18 assessments meeting the specified criteria were identified: Accountable Health Communities Health-Related Social Needs (AHC HSRN) (Centers for Medicare and Medicaid Services, 2017), American Academy of Family Physicians (AAFP) Social Needs Screening Tool (Academy of Family Physicians, A, 2018), Bright Futures (American Academy of Pediatrics, n.d.), Health Steps (Fleegler, 2016), Health Leads Social Needs Screening Toolkit (Health Leads, 2016), IHELLP (Kenyon, 2007), IHELP (Colvin, 2016), IOM Social and Behavioral Domains for Electronic Health Records (Institute of Medicine, 2014), iScreen (Laura Gottlieb, 2014), Medical-Legal Advocacy Screening Questionnaire (MASQ) (Keller, 2008), Medical-Legal Partnership (Medical-Legal Partnership Legal Needs Screener, 2016), Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) (PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences, 2016), Pediatric Social Risk Instrument (PSRI) (Cohen-Silver, 2018), SEEK (Dubowitz, 2014), Survey of Wellbeing of Young Children (SWYC) (Tufts, 2019), Your Current Life Situation (Permanente, 2016), WE CARE (Garg, 2015), and WEllRx (Page-Reeves, 2016). Each of the identified assessments was reviewed to determine whether the risk registry was missing any risk factors that should be added to the risk factor listing (based on the inclusion and exclusion criteria described under Expert Elaboration above).
Despite relatively high medical expenditures, the United States performs poorly on population health indicators relative to many other countries. A key step in addressing this situation involves determining impactful and cost-effective interventions for at-risk populations. This requires an understanding of medical, social, behavioral health and safety domains of risk. Of immediate interest are those risks that are modifiable at the individual and family levels and could be reduced through intervention and broader care coordination efforts. Unfortunately, a comprehensive list of such risks does not exist in the published literature.
Using multiple interrelated methods, including clinical, social, and care coordination experience, expert elaboration and validation, and reviews of existing assessments and literature, we present what we believe to be the most comprehensive listing of individually modifiable risk factors (IMRFs), relevant to care coordination, available for individuals aged 0–12 months. The list addresses IMRFs within four broad domains of risk (medical, social, behavioral health, and safety). Comprehensive risk registries such as the one presented here can enhance our collective efforts to identify and mitigate risks for specific populations. Such registries can also support research to build understandings of the impact of risks, individually and in interconnected signature combinations. The risk registry presented here and the enhanced understandings flowing from it may yield useful insights for clinicians, social service providers and researchers seeking a whole person approach to care, as well as for payers and policymakers seeking to enable health policy and payment reforms to improve population health.
Unmet legal and social advocacy needs of children with sickle cell disease: Implications for health care payer costs
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The independent variables of interest were the presence of one or more legal advocacy needs and the presence of one or more social advocacy needs. These advocacy needs were identified through a screening tool that built off an existing questionnaire developed to detect legal advocacy needs with greater sensitivity than medical providers alone were able to identify (Keller, Jones, Savageau, et al., 2008). The original instrument was modified in several ways for study purposes.
Previous studies of advocacy needs faced by children and families have not differentiated needs that require attorney involvement (“legal advocacy needs”) from needs best addressed by social workers or lay advocates (“social advocacy needs”). Studies have also not examined the relationship between either type of need and health care costs. We developed a novel, replicable process to differentiate between legal advocacy needs and social advocacy needs. We then collected cross-sectional data from a sample of 52 children with sickle cell disease who were at least 1 year of age, a population with high advocacy needs and high health care costs. Mean annual health care costs to payers for children whose families had a least one legal advocacy need were $16,314, compared to $5552 for children in families with no legal advocacy needs (P = 0.007). After adjusting for covariates, the presence of a legal advocacy need was associated with $12,040 more in health care costs to payers (P = 0.02). Whether interventions to prevent and resolve legal advocacy needs can reduce health care costs by addressing the social determinants of health warrants future study.
An Integrative Review of Social Determinants of Health Assessment and Screening Tools Used in Pediatrics
2017, Journal of Pediatric Nursing
Citation Excerpt :
Similar to validity and reliability, screening tools are often assessed in terms of their sensitivity and specificity to accurately discern families in need of resources from those who are not in need. Therefore, in lieu of validation, Keller, Jones, Savageau, and Cashman (2008) evaluated the quality of their tool's sensitivity and specificity in accurately capturing those in need of services. Methods used to develop an initial tool can include a number of strategies such as literature reviews, sampling of previously created tools, expert consultation and consumer participation.
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.
Articles were limited to studies in the English language, with pediatric populations, conducted in the United States, and were peer-reviewed, primary studies.
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.
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.
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.
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.
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2017, Academic Pediatrics
To describe a clinical approach for food insecurity screening incorporating a menu offering food-assistance referrals, and to examine relationships between food insecurity and referral selection.
Caregivers of 3- to 10-year-old children presenting for well-child care completed a self-administered questionnaire on a laptop computer. Items included the US Household Food Security Survey Module: 6-Item Short Form (food insecurity screen) and a referral menu offering assistance with: 1) finding a food pantry, 2) getting hot meals, 3) applying for Supplemental Nutrition Assistance Program (SNAP), and 4) applying for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Referrals were offered independent of food insecurity status or eligibility. We examined associations between food insecurity and referral selection using multiple logistic regression while adjusting for covariates.
A total of 340 caregivers participated; 106 (31.2%) reported food insecurity, and 107 (31.5%) selected one or more referrals. Forty-nine caregivers (14.4%) reported food insecurity but selected no referrals; 50 caregivers (14.7%) selected one or more referrals but did not report food insecurity; and 57 caregivers (16.8%) both reported food insecurity and selected one or more referrals. After adjustment, caregivers who selected one or more referrals had greater odds of food insecurity compared to caregivers who selected no referrals (adjusted odds ratio 4.0; 95% confidence interval 2.4–7.0).
In this sample, there was incomplete overlap between food insecurity and referral selection. Offering referrals may be a helpful adjunct to standard screening for eliciting family preferences and identifying unmet social needs.
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2016, Academic Pediatrics
Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

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Brief ReportDevelopment of a Brief Questionnaire to Identify Families in Need of Legal Advocacy to Improve Child Health

Objective

Methods

Results

Conclusions

Section snippets

Questionnaire Development

Results

Discussion

Acknowledgments

J Pediatr

Patient Educ Couns

The effects of poverty on child health and development

Annu Rev Public Health

Welfare reform and the health of young children: a sentinel survey in 6 US cities

Arch Pediatr Adolesc Med

Childhood asthma and poverty: differential impacts and utilization of health services

Pediatrics

Implications of welfare reform for child health: emerging challenges for clinical practice and policy

Pediatrics

Brief Report
Development of a Brief Questionnaire to Identify Families in Need of Legal Advocacy to Improve Child Health