Screening and Intervention for Psychosocial Needs by U.S. Obstetrician-Gynecologists

Abstract

Objectives:

To determine the psychosocial needs screening and intervention practices of obstetrician-gynecologists (OBGYNs) and elucidate characteristics associated with screening and resource availability.

Methods:

We administered a cross-sectional paper and online survey to 6288 U.S. office-based OBGYNs from March 18 to September 1, 2020, inquiring about screening and intervention practices for intimate partner violence, depression, housing, and transportation. We analyzed associations between demographic/practice characteristics and screening/having resources for all four needs.

Results:

1210 OBGYNs completed the survey. One hundred ninety-five OBGYNs (16%) reported their practices screened all patients for all four needs. Having resources to address all four needs (prevalence ratio [PR] = 4.39, 95% confidence interval [CI] = 3.04–6.34), working in health centers/clinics (PR = 2.22, 95% CI = 1.43–3.45), and seeing ≥50% Medicaid patients (PR = 1.62, 95% CI = 1.02–2.58) were associated with screening for all four needs. One hundred sixty-eight OBGYNs (14%) reported their practices had resources onsite to address all four needs. Working in health centers/clinics (PR = 3.99, 95% CI = 2.56–6.22), large practices (PR = 3.37, 95% CI = 1.63–6.95), Medicaid expansion states (PR = 2.60, 95% CI = 1.45–4.65), and practices with >11% uninsured patients (PR 2.30, 95% CI = 1.31–4.04) were associated with having resources onsite for all four needs.

Conclusion:

Most OBGYN practices appeared underresourced to address psychosocial needs within clinical care. Innovative financial models or collaborative care models may help incentivize this work.

Introduction

Health outcomes are heavily influenced by factors outside of clinical care; upward of 80% of health outcomes is a result of socioeconomic and behavioral factors,¹ and the coronavirus disease 2019 (COVID-19) pandemic has made clear that many health disparities stem from socioeconomic inequities.² In recent years, some policymakers have turned their attention toward addressing social needs within the U.S. health care system, particularly for patients covered by Medicaid.

Many state Medicaid programs have experimented with funding and integrating social need services into health care through Section 1115 waivers and Medicaid-managed care contracts. In fact, a 2017 survey found nearly all Medicaid-managed care plans reported engaging in activities to address the social determinants of health.³ In addition, since 2016, the Accountable Health Communities Model, funded by the Centers for Medicare and Medicaid Services (CMS), has provided support to clinicians in identifying and intervening on health-related social needs.⁴

Concurrently, there has been mounting momentum by health professionals to address unmet psychosocial needs.^5,6 Public health initiatives, like the Healthy People campaign, and medical societies, like the American College of Obstetricians and Gynecologists (ACOG), have been active in encouraging physicians to screen for such needs.⁷ As early as 1999, ACOG recognized the importance of social needs, urging obstetrician-gynecologists (OBGYNs) to evaluate patients for barriers to care, housing instability, safety, nutrition, substance use, and mental health, and to refer for these needs.^8,9

The United States Preventive Services Task Force (USPSTF) recommends all reproductive age women be screened for intimate partner violence (IPV),¹⁰ and all adults be screened for depression.¹¹ There are no formal screening recommendations for housing and transportation; however, CMS includes them in their Accountable Health Communities social needs screening tool,¹² and the USPSTF is currently developing screening recommendations for the social determinants of health.¹³

OBGYN practices are potentially well positioned to identify unmet health and social needs. OBGYNs often practice in small or large group private practices and serve as a frequent and sometimes the only touchpoint within the health care system for many people of reproductive age.¹⁴ Many women consider their OBGYNs to be their primary care physicians,¹⁵ and according to a 2017 nationwide survey of women, the majority of those who had a well-woman visit or general checkup in the past 2 years had seen an OBGYN.¹⁶ However, no national data exist on how often OBGYNs screen for psychosocial needs, and what they do in the event of a positive screen.

To our knowledge, our study is the first to ask a nationally representative sample of OBGYNs about their screening practices for psychosocial needs, how they respond in the event of a positive screen, and to analyze physician and practice characteristics associated with higher screening and intervention rates. We focused on four domains: IPV, depression, housing, and transportation.

These factors have been shown to have significant impacts on both reproductive health outcomes and overall health; depression has been associated with an increased risk for unintended pregnancy and maternal and infant morbidity,¹⁷ while experiencing IPV increases one's risk of sexually transmitted infections (STIs), contraceptive coercion, unintended pregnancy, and poor perinatal outcomes.¹⁸ Lack of reliable transportation affects patients' ability to access health care,¹⁹ while housing instability increases one's risk of poor health, including drug use and depression.²⁰

Our study aims to understand the state of psychosocial needs screening and intervention within OBGYN practices and inform future research.

Methods

This article presents findings from a subset of questions asked in the 2020 National Physician Survey on Reproductive Health. The survey was designed and analyzed by researchers at the Kaiser Family Foundation, working with an independent research company, SSRS. This survey asked OBGYNs questions about psychosocial needs screening; provision of services (e.g., contraception, STI testing, abortion, and gender-affirming care); insurance acceptance and share of their patient population with each insurance type; and basic physician and practice demographics (e.g., age, gender, race/ethnicity, practice setting, and location). All participants provided informed consent. Given we surveyed physicians, who participated voluntarily and anonymously with minimal risk to their privacy, we did not seek IRB approval for this survey.

Sampling data and collection

The sample frame was procured from the IQVIA OneKey database, a national physician database. The sample drawn for this survey consisted of those whose specialty was listed as OBGYN, with subspecialties in either OBGYN or GYN only. Participants were further screened using the survey questionnaire and deemed eligible if they (1) were board certified in OBGYN, (2) spent >60% of their work time providing direct patient care, and (3) provided sexual and reproductive health care to at least 10% of their patients in an office-based setting.

A two-wave sample release design was used to enable adjustments to the second release and improve representativeness as a result of nonresponse. We oversampled physicians expected to be practicing in rural areas, health centers/clinics, and lower income areas. OBGYNs were contacted by mail and email, receiving up to five communications. Participants could complete the survey online or by mail and were offered a $75 incentive. Twelve semistructured cognitive pretest interviews were conducted, before collecting responses from March 18 to September 1, 2020.

Weighting

To ensure a nationally representative sample, a multistage weighting process was applied. The base weight accounted for the disproportionately stratified samples and differing response rates across sample strata, which included urbanicity, private versus public practice, and income quintiles for the median income of the practice location as a proxy to identify practices who accepted more Medicaid patients. The sample was then poststratified to match the IQVIA frame on three physician variables (age, gender, and medical specialty), and six business variables (specialty, classification, facility type, ownership relationship, affiliation, and corporate parent's business facility type).

Finally, self-reported demographics (age, gender, and U.S. Census region) were matched to population parameters from the American Medical Association (AMA) Masterfile. Qualified respondents' weights were then rebalanced to the total sample size.

Outcome measures

To assess for screening for IPV (among female patients), depression, housing needs, and transportation needs, we asked, “At your practice, who is screened for each of the following health and social needs?” (Answer choices: “all patients are screened,” “some patients are screened,” and “no one is screened”). To assess for intervention practices for IPV, depression, housing needs, and transportation needs, we asked, “In the event a patient screens positive or discloses each of the following health and social needs, how does your practice typically respond?” (Answer choices: “you have resources or a social worker available onsite,” “you refer to appropriate resources/agencies,” and “you do not have resources to address nor refer”).

Predictor variables

We chose eight self-reported practice characteristics to analyze as predictor variables: (1) practice type: those who reported they work at a private practice or health maintenance organization were classified as “private practice,” while those who reported working in a community health center, reproductive health care or family planning clinic, or government-operated clinic were classified as “health center/clinic,” (2) practice size: 1–3 full-time equivalent (FTE) clinicians were classified as small, 4–10 as medium, and >10 as large, (3) urbanicity, defined by zip code, (4) region, defined by zip code, (5) location in a Medicaid expansion state versus not, defined by zip code, (6) share of total patients enrolled in Medicaid (managed care plans or fee-for-service) (≥50% vs. <50%), (7) share of uninsured patients (greater than the national average ≥11% vs. <11%), and (8) share of Medicaid patients enrolled in managed care organizations (MCOs) (≥50% vs. <50%).

As screening practices may vary by physician-level factors, we also chose three physician characteristics as predictor variables—gender, age, and race—determined by self-report.

Statistical analysis

First, we analyzed the share of OBGYNs who reported their practices screen all, some, or no patients for IPV, depression, housing and transportation needs. We then analyzed the share of OBGYNs who reported whether their practices had resources onsite to address each need in the event of a positive screen versus those who refer versus those who neither have resources nor refer. We then calculated the share of OBGYNs who reported screening all patients for all four needs and used unadjusted prevalence ratios (PRs) to analyze which of the aforementioned physician and practice characteristics were associated with screening for all four needs.

PRs were calculated using unadjusted quasi-Poisson regression models, accounting for survey weights. We then calculated the share of OBGYNs who reported having resources onsite to address all four needs and used unadjusted PRs to analyze which practice characteristics were associated with having this resource availability.

Results

Of the 6288 OBGYNs invited to complete the survey, 622 postal mailings were undeliverable and 181 were deemed ineligible because they were not board certified in OBGYN, spent ≤60% of their time providing direct patient care, or did not provide sexual and reproductive health care to at least 10% of their patients in an office-based setting. A total of 1210 surveys were completed. Overall, a 22% response rate was calculated using AAPOR's R3.²¹ There were no significant differences between responders and nonresponders by gender or specialty (OBGYN vs. GYN only).

There was also no significant differences between responders and nonresponders if they were younger than 55 years; however, a slightly higher share of OBGYNs age 55–64 were responders (33%) compared to the percentage of responders among OBGYNs age 65± (20%). The majority of OBGYNs surveyed were female, <55 years old, and White. The majority worked in urban practices, Medicaid expansion states, practices with 4–10 clinicians, and practices seeing <50% Medicaid patients (Table 1).

Table 1.

Demographics of Survey Respondents and Their Practices

	Unweighted, n (%)
Overall	1210 (100)
Practice characteristics
Practice type^a
Health Center/Clinic	168 (14)
Private practice	1028 (85)
Unspecified	14 (1)
Urbanicity^b
Urban	662 (55)
Suburban	253 (21)
Rural	260 (21)
Unspecified	35 (3)
Region^c
Northeast	201 (17)
Midwest	275 (23)
South	446 (37)
West	288 (24)
Medicaid expansion state^d
Yes	793 (66)
No	417 (34)
Share of patients with Medicaid (managed care or fee-for-service)^e
≥50%	228 (19)
<50%	966 (80)
Unspecified	16 (1)
Share of Medicaid patients in MCOs^f
≥50%	615 (51)
<50%	326 (27)
Unspecified or do not accept Medicaid	269 (22)
Share of uninsured patients^e
>11%	98 (8)
≤11%	1096 (91)
Unspecified	16 (1)
Practice size^g
Large	225 (19)
Medium	558 (46)
Small	401 (33)
Unspecified	26 (2)
Clinician characteristics
Gender^h
Female	618 (51)
Male	587 (49)
Prefer to self-describe or unspecified	5 (0.4)
Age^h
<45	268 (22)
45–54	333 (28)
55–64	405 (33)
65+	186 (15)
Unspecified	18 (1)
Race^h
White	858 (71)
Asian	140 (12)
Black	96 (8)
Other	116 (10)

Data from 2020 National Physician Survey on Reproductive Health (Fielding March 18 to September 1, 2020). Total sample: 1210 OBGYNs.

Those who indicated they work in private practice or a health maintenance organization classified as “private practice,” while those in a community health center, a family planning clinic, or a government-operated health department classified as “health center/clinic.”

Determined by zip code, using U.S. census definitions.

Determined by zip code, using U.S. census breaks.

Determined by zip code, based on states that had expanded Medicaid by November 2020.

Determined by physician self-reported estimate.

Question asked only of physicians participating in Medicaid, determined by physician self-reported estimate.

Determined by number of FTE physicians or advance practice clinicians (small ≤3, medium 4–10, and large >10).

Determined by self-report.

OBGYNs, obstetrician-gynecologists; FTE, full-time equivalent; MCOs, Managed Care Organizations.

Screening and intervention patterns

Only 195 (16%) OBGYNs reported all patients at their practice were screened for IPV, depression, housing instability, and transportation needs (Table 2), and 168 (14%) reported their practice had resources or a social worker onsite to address all four needs (Table 3). Even fewer (n = 81, 7%) said all patients at their practice were screened for all four needs and their practice had resources onsite to address all four needs.

Table 2.

Characteristics of Obstetrician-Gynecologists and Their Practices That Report Screening All Patients for Psychosocial Needs

	Report screening all patients for IPV, depression, housing and transportation needs	Unadjusted PR (95% CI)
	n (%)	Unadjusted PR (95% CI)
Overall	195 (16)	n/a
Have resources onsite to address all four needs
Yes	81 (48)	4.39 (3.04–6.34)
No	114 (11)	Ref
Practice type
Health center/clinic	46 (32)	2.22 (1.43–3.45)
Private practice	149 (14)	Ref
Urbanicity
Urban	103 (15)	0.92 (0.52–1.63)
Suburban	57 (20)	1.27 (0.69–2.37)
Rural	24 (16)	Ref
Region
Northeast	55 (22)	3.49 (1.66–7.34)
Midwest	60 (25)	4.03 (1.97–8.23)
South	62 (14)	2.31 (1.12–4.80)
West	17 (6)	Ref
Medicaid expansion state
Yes	137 (17)	1.12 (0.73–1.71)
No	58 (15)	Ref
Share of patients with Medicaid
≥50%	48 (23)	1.62 (1.02–2.58)
<50%	140 (14)	Ref
Share of uninsured patients
>11%	19 (22)	1.44 (0.77–2.68)
≤11%	169 (15)	Ref
Share of Medicaid patients in MCOs
≥50%	83 (14)	0.70 (0.44–1.11)
<50%	63 (20)	Ref
Practice size
Large	52 (22)	1.73 (0.98–3.08)
Medium	97 (16)	1.26 (0.77–2.06)
Small	42 (13)	Ref
Gender
Female	132 (17)	1.17 (0.76–1.80)
Male	62 (15)	Ref
Age
<45	80 (18)	1.62 (0.76–3.44)
45–54	40 (13)	1.15 (0.52–2.55)
55–64	48 (18)	1.62 (0.74–3.58)
65+	21 (11)	Ref
Race
White	129 (16)	1.44 (0.70–2.97)
Asian	25 (17)	1.55 (0.66–3.61)
Black	30 (25)	2.33 (1.01–5.42)
Other	11 (11)	Ref

Data from 2020 National Physician Survey on Reproductive Health (Fielding March 18 to September 1, 2020). Total sample: 1210 OBGYNs.

CI, confidence interval; IPV, intimate partner violence; n/a, not applicable; PR, prevalence ratio.

Table 3.

Characteristics of Obstetrician-Gynecologist Practices That Report Having Resources Onsite to Address Psychosocial Needs

	Report having resources or a social worker onsite to address IPV, depression, housing and transportation needs	Unadjusted PR (95% CI)
	n (%)	Unadjusted PR (95% CI)
Overall	168 (14)	n/a
Screens all patients for all four needs
Yes	81 (41)	4.84 (3.13–7.49)
No	86 (9)	Ref
Practice type
Health center/clinic	58 (40)	3.99 (2.56–6.22)
Private practice	104 (10)	Ref
Urbanicity
Urban	87 (12)	0.91 (0.48–1.71)
Suburban	34 (12)	0.90 (0.42–1.93)
Rural	21 (14)	Ref
Region
Northeast	48 (19)	1.51 (0.78–2.93)
Midwest	55 (23)	1.86 (0.99–3.48)
South	30 (7)	0.57 (0.26–1.24)
West	34 (12)	Ref
Medicaid expansion state
Yes	142 (17)	2.60 (1.45–4.65)
No	26 (7)	Ref
Share of patients with Medicaid
≥50%	38 (18)	1.38 (0.81–2.34)
<50%	129 (13)	Ref
Share of uninsured patients
>11%	25 (30)	2.30 (1.31–4.04)
≤11%	142 (13)	Ref
Share of Medicaid patients in MCOs
≥50%	89 (15)	1.04 (0.60–1.80)
<50%	46 (15)	Ref
Practice size
Large	62 (26)	3.37 (1.63–6.95)
Medium	77 (13)	1.63 (0.81–3.31)
Small	26 (8)	Ref

Data from 2020 National Physician Survey on Reproductive Health (Fielding March 18 to September 1, 2020). Total sample: 1210 OBGYNs.

The overwhelming majority of OBGYNs reported all female patients at their practice were screened for IPV (n = 848, 70%), rather than some patients (n = 310, 26%) or no patients (n = 43, 4%). This was similar for depression screening, where 863 (71%) of OBGYNs reported all patients at their practice were screened, 318 (26%) said some patients were screened, and 23 (2%) said no patient was screened. By contrast, few OBGYNs reported their practice screened all patients for housing instability or transportation needs; 229 (19%) said their practice screened all patients for housing needs, 405 (33%) said some patients were screened, and 566 (47%) said no patient was screened. Similarly, 211 (17%) said their practice screened all patients for transportation needs, 448 (37%) said their practice screened some patients, and 541 (45%) said no patient was screened (Table 4).

Table 4.

Screening and Intervention Practices of Obstetrician-Gynecologists for Four Psychosocial Needs

	IPV^a	Depression	Housing	Transportation
	Weighted, n (%) [95% CI]
At your practice, who is screened for each of the following health and social needs?
All patients	848 (70) [66–74]	863 (71) [68–75]	229 (19) [15–22]	211 (17) [14–21]
Some patients	310 (26) [22–29]	318 (26) [23–30]	405 (33) [30–37]	448 (37) [33–41]
No one	43 (4) [2–5]	23 (2) [1–3]	566 (47) [43–51]	541 (45) [41–49]
Missing	8 (1)	6 (1)	10 (1)	9 (1)
In the event a patient screens positive or discloses each of the following health and social needs, how does your practice typically respond?
Resources or a social worker available onsite	261 (22) [18–25]	372 (31) [27–35]	201 (17) [13–20]	215 (18) [14–21]
Refer to appropriate resources/agencies	913 (75) [72–79]	804 (66) [62–70]	660 (55) [50–59]	646 (53) [49–58]
Do not have resources to address nor refer	22 (2) [1–3]	11 (1) [0.1–2]	328 (27) [24–31]	322 (27) [23–30]
Missing	6 (1)	12 (1)	17 (1)	22 (2)

Data from 2020 National Physician Survey on Reproductive Health (Fielding March 18 to September 1, 2020). Total sample: 1210 OBGYNs. Totals may not add up to 100% given a small number of unspecified responses.

Asked for female patients specifically.

In the event a patient screens positive or discloses one of these needs, a minority of OBGYNs said their practice had resources or a social worker available onsite to address IPV (n = 261, 22%), depression (n = 372, 31%), housing (n = 201, 17%), or transportation (n = 215, 18%). Rather, most said their practice referred to appropriate resources or agencies to address IPV (n = 913, 75%), depression (n = 804, 66%), housing (n = 660, 55%), and transportation (n = 646, 53%). Very few said their practice neither had resources nor referred for IPV (n = 22, 2%) and depression (n = 11, 1%), but this was far more common for housing (n = 328, 27%) and transportation (n = 322, 27%) (Table 4).

Characteristics of OBGYNs who screen and have resources for psychosocial needs

Screening for all four needs was positively associated with having resources onsite to address all four needs compared to those without resources onsite (PR: 4.39, 95% confidence interval [CI]: 3.04–6.34). Other factors associated with screening for all four needs included the following: working in health centers/clinics compared to private practice (PR: 2.22, 95% CI: 1.43–3.45), practicing in the Northeast (PR: 3.49, 95% CI: 1.66–7.34), Midwest (PR: 4.03, 95% CI 1.97–8.23), and South (PR: 2.31, 95% CI: 1.12–4.80) compared to the West, and having a practice with ≥50% Medicaid patients compared to <50% (PR 1.62, 95% CI: 1.02–2.58) (Table 2).

Having resources onsite to address all four needs was associated with screening all patients for all four needs compared to not screening for all four needs (PR 4.84, 95% CI: 3.13–7.49). Other factors associated with having resources onsite for all four needs included the following: working in health centers/clinics compared to private practice (PR: 3.99, 95% CI: 2.56–6.22), working in Medicaid Expansion states compared to nonexpansion states (PR: 2.60, 95% CI: 1.45–4.65), working in practices with >11% uninsured patients compared to not (PR 2.30, 95% CI: 1.31–4.04), and working in a large practice compared to a small practice (PR: 3.37, 95% CI: 1.63–6.95) (Table 3).

Discussion

We aimed to better understand the screening and intervention practices of OBGYNs as it pertains to IPV, depression, housing, and transportation, and to identify OBGYNs with high screening rates and resource availability for these needs. Despite the recognized impact of psychosocial needs on reproductive health, only a small fraction of OBGYNs reported their practices universally screened patients for these needs, and few had resources available onsite to respond to a positive screen.

Screening and resource availability

Most OBGYNs did not routinely screen for all four needs. The majority reported screening all their patients for IPV and depression, but less than a quarter did so for housing or transportation. This could be because physicians may see IPV and depression as within their scope of practice, but may not feel as prepared to address housing and transportation needs.

Barriers to screening have been well documented in the literature and perhaps help explain why integration of psychosocial needs into care remains relatively uncommon. These include provider discomfort, lack of training, lack of knowledge of resources, fear that screening causes more harm than good, lack of time, and lack of consensus over best practices, among others.^22,23

Additionally, the ACA required that preventive services recommended by the USPSTF, Women‘s Preventive Services Initiative, and Advisory Committee on Immunization Practices (ACIP) be covered without cost sharing by most private insurance plans and for Medicaid expansion populations. Since USPSTF has formal screening recommendations for IPV¹⁰ and depression,¹¹ but not for housing and transportation, there may be a financial reimbursement incentive for providers to screen for IPV and depression, but not transportation or housing.

Most OBGYN practices appeared underresourced to address psychosocial needs within the clinical care context. Similar to screening patterns, more OBGYNs reported resources onsite to address IPV and depression than housing and transportation, and few had resources to address all four needs. Rather, most relied on a screen and refer model. However, referrals could be considered ineffective in the absence of close follow-up and ensuring patient contact with outside resources. There is also mixed evidence on whether the screen and refer model leads to improved health outcomes.^24,25

Our findings appear largely consistent with prior studies investigating how often physicians address social needs, yet it is challenging to compare, given scant data in the field and wide variation in outcome measures.²⁶ A survey by Fraze et al. found just 16% of physician practices across multiple specialties reported screening for IPV, housing, transportation, food insecurity, and utility needs.²⁷ A survey of U.S. pediatricians found that a minority routinely screen low-income families for transportation barriers (28%), housing (19%), food insecurity (19%), and utilities (14%).²⁸

Meanwhile, a study of health professionals at Kaiser Permanente found that 23% reported always screening patients for social needs.²⁹ Several studies of physicians have found that the vast majority do not feel equipped to address their patients' social needs, despite recognizing their importance.^30,31 Many clinicians may feel as if these efforts are beyond their control or scope of practice, particularly in the absence of available, effective interventions. Our findings contribute to existing evidence that addressing psychosocial needs remains fairly uncommon in the clinical context.

Predictors of screening and intervention patterns

Screening and resource availability for IPV, depression, housing, and transportation were notably more common among certain groups of OBGYNs. Screening for all four needs was strongly associated with having resources for all four needs, and vice versa, alluding to a link between screening and intervention practices. This could suggest that having resources available onsite makes OBGYNs more likely to screen patients and connect them to services; prior studies suggest lack of resources to address social needs can prevent some clinicians from screening patients in the first place.²⁹ Alternatively, it could suggest that OBGYNs who have implemented screening practices have ensured they can intervene when patients screen positive. We could not determine directionality from this cross-sectional survey.

Practice type also emerged as a strong predictor of high screening rates and resource availability; OBGYNs in health centers/clinics more often reported screening and having resources for psychosocial needs compared to those in private practice. This may reflect differences in reporting requirements and financial incentives. For example, certain publicly funded clinics, like federally qualified health centers (FQHCs), are required to report the number of patients who screen positive for transportation needs, housing insecurity, food insecurity, and financial strain to the Bureau of Primary Health Care, likely leading to higher screening in these settings.³² Similarly, the aforementioned study by Fraze et al. found screening for social needs was more common among FQHCs compared to other practice types.²⁷

Differences in patient populations between practice types could also potentially explain differences in screening and resource availability; health centers/clinics primarily serve low-income individuals, and therefore, may see more patients experiencing needs like housing instability and lack of transportation compared to private practices. Having a majority of patients with Medicaid was associated with higher screening rates for psychosocial needs, but was not statistically significant when it came to resource availability for all four needs.

Meanwhile, OBGYNs with a share of uninsured patients greater than the national average (>11%) were more likely to have resources onsite to address all four needs compared to those with fewer uninsured patients.

The association between the share of uninsured patients and screening for all four needs was not significant, possibly due to the small sample size. Similarly, practicing in a state with Medicaid Expansion was associated with higher resource availability for psychosocial needs, but not screening. Despite the multitude of initiatives by Medicaid-managed care plans to address the social determinants of health,⁴ having a high share of Medicaid patients who were enrolled in MCOs did not appear to impact screening practices or resource availability in our study.

Limitations

The survey findings should be interpreted with limitations in mind. We present self-reported data and have not independently validated the accuracy of physicians' responses. In addition, the survey's response rate may contribute to non-response bias. We anticipated a low response rate given trends in physician surveys,³³ and encouraged responses using incentives, invitation letters, recontact attempts, and offering the survey through two modes. We confirmed the sample frame's representativeness by comparing the sample universe from IQVIA to provider benchmarks from the AMA. We assessed the risk of nonresponse bias by comparing the weighted distributions of our respondents to the IQVIA sampling frame, as well as AMA benchmarks, and no significant differences were found with respect to key physician demographics.

We limited survey length to reduce response burden, and therefore could not assess for the full array of psychosocial needs that OBGYNs may encounter, like food insecurity and utility needs, nor the reasons why OBGYNs may practice in certain ways. We also were not able to survey other types of reproductive health providers, who may practice differently than OBGYNs.

We acknowledge that screening and having resources for psychosocial needs do not necessarily equate with higher quality of care, nor improve health outcomes; in fact, some believe screening without trained staff and effective interventions may lead to unintended consequences like perpetuating stigma.²⁴ In addition, efforts to address individual patients' psychosocial needs may not impact social determinants of health on a community level.

Public health implications

To our knowledge, our findings represent the first nationally representative data on psychosocial needs screening and intervention practices among U.S. OBGYNs. While there is a mounting push for health care providers to incorporate social needs screening and intervention within clinical care, our study suggests that barriers persist in doing so. This calls into question what strategies could support providers in these efforts, particularly for those in smaller, less-resourced practices.

Various care models have been promoted to better integrate social needs into clinical care; some have called for better integration of mental health care into OBGYN.³⁴ Others have supported the co-location of health and social services, and pushed to strengthen referral networks to address social needs.²² ACOG has voiced support for many of these innovative approaches, including medical-legal partnerships and strengthening collaborations between OBGYN, psychiatry, and community organizations focused on social needs.⁸

These efforts, however, take financial investment, time, and workforce buy-in. A consensus report by the National Academies of Science, Engineering and Medicine concluded that effectively integrating social care into health care requires capacity building between providers, and reconfiguring financial models to incentivize this sort of work; for example, switching from fee-for-service models to alternative payment methods like bundled payments and accountable health organizations could help support providers to incorporate social needs care into clinical care.⁶

Addressing psychosocial needs will likely require a broad range of actions and investments at the provider, practice, plan, community, and policy level,²² and it remains an ongoing debate about whether the health care system is the right place to address social needs, and if physicians are the right providers to do so. Lessons may be learned from practices that are already engaging in this work, particularly health centers/clinics.

Conclusions

OBGYNS play a key role in the health care system for many people of reproductive age. However, our findings reveal that screening for IPV, depression, housing, and transportation needs is far from universal among OBGYNs, and when screening does occur, most follow a “screen and refer” model rather than having onsite resources available. Further research is warranted to better understand how to address and integrate psychosocial needs within the field of OBGYN and the broader health care system.

Footnotes

Authors' Contributions

G.W. led the article writing and project management for the survey.

B.F. led the data analysis and participated in survey design and article writing.

U.R. participated in survey design and article writing.

A.S. led the survey design and participated in article writing.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The study was paid for by the Henry J. Kaiser Family Foundation.

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