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Social Work Research and Its Relevance to Practice: “The Gap Between Research and Practice Continues to be Wide”

• Journal of Social Service Research 43(1):1-19

• City University of New York - College of Staten Island

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 The following open access journals are available to you:

Addictive Behaviors Reports is an open-access and peer reviewed online-only journal offering an interdisciplinary forum for the publication of research in addictive behaviors.

Peer-reviewed articles on current issues, challenges, and responses facing social work practice and education.

Articles that advance the scientific analysis of human social behavior, particularly with regard to understanding and influencing important social problems.

An interdisciplinary peer-reviewed platform for research, multimedia and art “aimed at furthering the ideals of social justice, broadly defined.” Ceased publication in Spring 2018.

An open access, peer-reviewed online journal that provides an international platform for communication on child and adolescent mental health across different cultural backgrounds.

an annual peer-reviewed journal for up-and-coming scholars in the field of social work to share their research on social work practice, education, research, policy and theory.

Published by the University of North Dakota Center for Rural Education and Communities in collaboration with the National Rural Social Work Caucus. This journals focus is on the promotion of excellence in rural social work practice.

Critical Social Work is an international peer-reviewed journal hosted by the School of Social Work at the University of Windsor (Ontario). It aims to explore the current and future potentials for social justice which includes legal, moral and economic issues.

Publishes critical and research work by current graduate students in the Human Services as well as articles by guest scholars. Full open access

Online peer-reviewed journal, featuring articles related to the development, care, and education of children with an emphasis on practice-related research and development, issues related to practice, parent participation, and policy. Ceased publication in 2015.

This open access journal has been published by the First Nations Caring Society of Canada since 2004. It covers aboriginal social work issues related to child protection, child development, adoption, and mental health from a First Nations Aboriginal perspective.

Depression Research and Treatment is a peer-reviewed, open access journal that publishes original research articles, review articles, and clinical studies related to all aspects of depression.

The Future of Children is published by Princeton University’s Woodrow Wilson School of Public and International Affairs and the Brookings Institution. It covers child health, education and welfare public policy issues.

Global Social Work

Harm Reduction Journal is an open access, peer-reviewed, online journal whose focus is on the prevalent patterns of psychoactive drug use, the public policies meant to control them, and the search for effective methods of reducing the adverse medical, public health, and social consequences associated with both drugs and drug policies.

An interdisciplinary, cross-national journal that is committed to scholarly excellence in the field of research about and services for children, youth, families and their communities.

The IJCV provides a forum for scientific exchange and public dissemination of up-to-date scientific knowledge on conflict and violence. The IJCV is independent, peer reviewed, and open access.

n open access, online journal that provides a home for the latest mental health system research, policy and debates, as well as for articles with educational intent that will build capacity for mental health system research and development.

Examines the ethical and values issues that affect and are interwoven with social work practice, research, and theory development. Full open access

Intersectionalities is a peer-reviewed, open access journal sponsored by Memorial University’s School of Social Work. The journal is international in scope, and publishes articles relating to social work analysis, research, polity, and practice. Full open access

The Journal of Community Practice is an interdisciplinary journal grounded in social work. It is designed to provide a forum for community practice, including community organizing, planning, social administration, organizational development, community development, and social change. Open access to selected articles

"This journal publishes two types of peer-reviewed scientific articles on subjects of importance for social work, with a special emphasis on comparative research on different aspects. This includes: Comparative studies and single site studies that also generate insight and knowledge in various geographical/cultural and national settings."

The Journal of Family Strengths (JFS), formerly Family Preservation Journal, is an open-access, double-blind peer-reviewed online journal...devoted to presenting theoretical, practice, and evaluation articles on the strengths perspective in family-centered practice to improve services that promote and sustain family systems.

Formerly the Journal of Indigenous Voices in Social Work. JISD publishes on education, practice, research and policy making relevant to indigenous peoples’ social and economic well-being.

This journal aims to highlight engaged scholarship and the very important social change work done by professionals and activists. It is published by the Lewis & Clark College Graduate School of Education and Counseling, Department of Counseling Psychology

Publishes articles that contribute to current knowledge and understanding of the social processes that marginalise individuals, families and communities

JSWGC is a scholarly peer reviewed journal designed to promote research in the practice of social work that has international and/or local significance with a focus on social change. JSWGC provides high level research, literature and book reviews and thought pieces related to the field of social work and social change.

This journal publishes refereed articles on innovative individual, family, group work, and community practice models for treating and preventing substance abuse and other addictions in diverse populations. Open access to selected articles

JSSWR is a peer-reviewed publication dedicated to timely dissemination of innovative interdisciplinary research on pressing and complex social problems, methodological advances, and programs, interventions, and policies that contribute to meaningful and actionable social change.

This journal publishes original research articles, reviews and letters in the field of pre-clinical and clinical addiction and substance abuse research. Topics covered in this interdisciplinary journal include: pharmacology; neuroscience; co-dependence; epidemiology; genetics; psychiatry; diagnosis; prevention; therapy; policy of addiction and substance abuse. Ceased publication in 2014.

A peer-reviewed, open-access journal of original empirical research articles by both established and emerging scholars. It is designed to promote cross-disciplinary collaborations on timely issues of interest to academics, policymakers, and the public at large.

"Social Affairs is an open access, peer-reviewed, bi-annual academic journal for the Social Sciences dedicated to publishing academic papers of the finest quality."

Dedicated to critical analysis of the relationship between social work, social policy, the state and economic forces.

This interdisciplinary, peer-reviewed journal covers issues dealing with the social, cultural, economic, political, and philosophical problems associated with the struggle for social justice.

SATPP is an open access, peer-reviewed online journal that encompasses all aspects of research concerning substance abuse, with a focus on policy issues.

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Characteristics and Outcomes of School Social Work Services: A Scoping Review of Published Evidence 2000–June 2022

1 Steve Hicks School of Social Work, The University of Texas at Austin, 1925 San Jacinto Blvd 3.112, Austin, TX 78712 USA

Estilla Lightfoot

2 School of Social Work, Western New Mexico University, Silver City, NM USA

Ruth Berkowitz

3 School of Social Work, University of Haifa, Haifa, Israel

Samantha Guz

4 Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, IL USA

Cynthia Franklin

Diana m. dinitto.

School social workers are integral to the school mental health workforce and the leading social service providers in educational settings. In recent decades, school social work practice has been largely influenced by the multi-tiered systems of support (MTSS) approach, ecological systems views, and the promotion of evidence-based practice. However, none of the existing school social work reviews have examined the latest characteristics and outcomes of school social work services. This scoping review analyzed and synthesized the focuses and functions of school social workers and the state-of-the-art social and mental/behavioral health services they provide. Findings showed that in the past two decades, school social workers in different parts of the world shared a common understanding of practice models and interests. Most school social work interventions and services targeted high-needs students to improve their social, mental/behavioral health, and academic outcomes, followed by primary and secondary prevention activities to promote school climate, school culture, teacher, student, and parent interactions, and parents’ wellbeing. The synthesis also supports the multiple roles of school social workers and their collaborative, cross-systems approach to serving students, families, and staff in education settings. Implications and directions for future school social work research are discussed.

Introduction

This scoping review examines the literature on school social work services provided to address children, youth, and families’ mental/behavioral health and social service-related needs to help students thrive in educational contexts. School social work is a specialty of the social work profession that is growing rapidly worldwide (Huxtable, 2022 ). They are prominent mental/behavioral health professionals that play a crucial role in supporting students’ well-being and meeting their learning needs. Although the operational modes of school social work services vary, for instance, operating within an interdisciplinary team as part of the school service system, or through non-governmental agencies or collaboration between welfare agencies and the school system (Andersson et al., 2002 ; Chiu & Wong, 2002 ; Beck, 2017 ), the roles and activities of school social work are alike across different parts of the world (Allen-Meares et al., 2013 ; International Network for School Social Work, 2016, as cited in Huxtable, 2022 ). School social workers are known for their functions to evaluate students’ needs and provide interventions across the ecological systems to remove students’ learning barriers and promote healthy sociopsychological outcomes in the USA and internationally (Huxtable, 2022 ). In the past two decades, school social work literature placed great emphasis on evidence-based practice (Huxtable, 2013; 2016, as cited in Huxtable, 2022 ); however, more research is still needed in the continuous development of the school social work practice model and areas such as interventions, training, licensure, and interprofessional collaboration (Huxtable, 2022 ).

The school social work practice in the USA has great influence both domestically and overseas. Several core journals in the field (e.g., the International Journal of School Social Work, Children & Schools ) and numerous textbooks have been translated into different languages originated in the USA (Huxtable, 2022 ). In the USA, school social workers have been providing mental health-oriented services under the nationwide endorsement of multi-tiered systems of support (MTSS) (Avant & Lindsey, 2015 ; Barrett et al., 2020 ). In the past two decades, efforts at developing a school social work practice model recommended that school social workers have a master’s degree, embrace MTSS and use evidence-based practices (EBP) (Frey et al., 2012 ). Similar licensure requirements have been reported in other parts of the world (International Network for School Social Work, 2016, as cited in Huxtable, 2022 ), but the current state of research on MTSS and EBP applications in other countries is limited (Huxtable, 2022 ). Furthermore, although previous literature indicated more school social workers applied EBP to primary prevention, including trauma-informed care, social–emotional learning, and restorative justice programs in school mental health services (Crutchfield et al., 2020 ; Elswick et al., 2019 ; Gherardi, 2017 ), little research has been done to review and analyzed the legitimacy of the existing school social work practice model and its influence in the changing context of school social work services. The changing conditions and demands of social work services in schools require an update on the functions of school social workers and the efficacy of their state-of-the-art practices.

Previous Reviews on School Social Work Practice and Outcomes

Over the past twenty years, a few reviews of school social work services have been conducted. They include outcome reviews, systematic reviews, and one meta-analysis on interventions, but none have examined studies from a perspective that looks inclusively and comprehensively at evaluations of school social work services. Early and Vonk ( 2001 ), for example, reviewed and critiqued 21 controlled (e.g., randomized controlled trial [RCT] and quasi-experimental) outcome studies of school social work practice from a risk and resilience perspective and found that the interventions are overall effective in helping children and youth gain problem-solving skills and improve peer relations and intrapersonal functioning. However, the quality of the included studies was mixed, demographic information on students who received the intervention, such as race/ethnicity, socioeconomic status, and special education enrollment were missing, and the practices were less relevant to the guidelines in the school social work practice model (National Association of Social Workers [NASW], 2012 ). Later, Franklin et al. ( 2009 ) updated previous reviews by using meta-analytic techniques to synthesize the results of interventions delivered by social workers within schools. They found that these interventions had small to medium treatment effects for internalizing and externalizing problems but showed mixed results in academic or school-related outcomes. Franklin et al. ( 2009 ) approached the empirical evidence from an intervention lens and did not focus on the traits and characteristics of school social workers and their broad roles in implementing interventions; additionally, demographic information, symptoms, and conditions of those who received school social work services were lacking. Allen-Meares et al. ( 2013 ) built on Franklin and colleagues’ ( 2009 ) meta-analysis on school social work practice outcomes across nations by conducting a systematic review with a particular interest in identifying tier 1 and tier 2 (i.e., universal prevention and targeted early intervention) practices. School social workers reported services in a variety of areas (e.g., sexual health, aggression, school attendance, self-esteem, depression), and half of the included interventions were tier 1 (Allen-Meares et al., 2013 ). Although effect sizes were calculated (ranging from 0.01–2.75), the outcomes of the interventions were not articulated nor comparable across the 18 included studies due to the heterogeneity of metrics.

Therefore, previous reviews of school social work practice and its effectiveness addressed some aspects of these interventions and their outcomes but did not examine school social workers’ characteristics (e.g., school social workers’ credentials) or related functions (e.g., interdisciplinary collaboration with teachers and other support personnel, such as school counselors and psychologists). Further, various details of the psychosocial interventions (e.g., service type, program fidelity, target population, practice modality), and demographics, conditions, or symptoms of those who received the interventions provided by school social workers were under-researched from previous reviews. An updated review of the literature that includes these missing features and examines the influence of current school social work practice is needed.

Guiding Framework for the Scoping Review

The multi-tiered systems of support model allows school social workers to maximize their time and resources to support students’ needs accordingly by following a consecutive order of prevention. MTSS generally consists of three tiers of increasing levels of preventive and responsive behavioral and academic support that operate under the overarching principles of capacity-building, evidence-based practices, and data-driven decision-making (Kelly et al., 2010a ). Tier 1 interventions consist of whole-school/classroom initiatives (NASW, 2012 ), including universal positive behavior interventions and supports (PBIS) (Clonan et al., 2007 ) and restorative justice practices (Lustick et al., 2020 ). Tier 2 consists of targeted small-group interventions meant to support students at risk of academic or behavioral difficulties who do not respond to Tier 1 interventions (National Association of Social Workers, 2012 ). Finally, tier 3 interventions are intensive individual interventions, including special education services, meant to support students who do not benefit sufficiently from Tier 1 or Tier 2 interventions.

The current school social work practice model in the USA (NASW, 2012 ) consists of three main aspects: (1) delivering evidence-based practices to address behavioral and mental health concerns; (2) fostering a positive school culture and climate that promotes excellence in learning and teaching; (3) enhancing the availability of resources to students within both the school and the local community. Similar expectations from job descriptions have been reported in other countries around the world (Huxtable, 2022 ).

Moreover, school social workers are specifically trained to practice using the ecological systems framework, which aims to connect different tiers of services from a person-in-environment perspective and to activate supports and bridge gaps between systems (Huxtable, 2022 ; Keller & Grumbach, 2022 ; SSWAA, n.d.). This means that school social workers approach problem-solving through systemic interactions, which allows them to provide timely interventions and activate resources at the individual, classroom, schoolwide, home, and community levels as needs demand.

Hence, the present scoping review explores and analyzes essential characteristics of school social workers and their practices that have been missed in previous reviews under a guiding framework that consists of the school social work practice model, MTSS, and an ecological systems perspective.

This scoping review built upon previous reviews and analyzed the current school social work practices while taking into account the characteristics of school social workers, different types of services they deliver, as well as the target populations they serve in schools. Seven overarching questions guided this review: (1) What are the study characteristics of the school social work outcome studies (e.g., countries of origin, journal information, quality, research design, fidelity control) in the past two decades? (2) What are the characteristics (e.g., demographics, conditions, symptoms) of those who received school social work interventions or services? (3) What are the overall measurements (e.g., reduction in depression, anxiety, or posttraumatic stress disorder [PTSD], improvement in parent–child relationships, or school climate) reported in these studies? (4) What types of interventions and services were provided? (5) Who are the social work practitioners (i.e., collaborators/credential/licensure) delivering social work services in schools? (6) Does the use of school social work services support the promotion of preventive care within the MTSS? (7) What are the main outcomes of the diverse school social work interventions and services?

To the authors’ knowledge, this is the first scoping review to examine these aspects of school social work practices under the guidance of the existing school social work practice model, MTSS, and an ecological systems perspective.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension guidelines for completing a scoping review (Tricco et al., 2018 ) were followed for planning, conducting, and reporting the results of this review. The PRISMA scoping review checklist includes 20 essential items and two optional items. Together with the 20 essential items, the optional two items related to critical appraisal of included sources of evidence were also followed to assure transparency, replication, and comprehensive reporting for scoping reviews.

Search Strategy

The studies included in this review were published between 2000 and June 2022. These studies describe the content, design, target population, target concerns, delivery methods, and outcomes of services, practices, and interventions conducted or co-led by school social workers. This time frame was selected since it coincides with the completion of the early review of characteristics of school social work outcomes studies (Early & Vonk, 2001 ); furthermore, scientific approaches and evidence-based practice were written in the education law for school-based services since the early 2000s in the USA, which greatly impacted school social work practice (Wilde, 2004 ), and was reflected in the trend of peer-reviewed research in school practice journals (Huxtable, 2022 ).

Following consultation with an academic librarian, the authors systematically searched relevant articles in seven academic databases (APA PsycINFO, Education Source, ERIC, Academic Search Complete, SocINDEX, CINAHL Plus, and MEDLINE) between January 2000 and June 2022. These databases were selected due to the relevance of the outcomes and the broad range of relevant disciplines they cover. When built-in search filters were available, the search included only peer-reviewed journal articles or dissertations written in English and published between 2000 and 2022. The search terms were adapted from previous review studies with a similar purpose (Franklin et al., 2009 ). The rationale for adapting the search terms from a previous meta-analysis (Franklin et al., 2009 ) was to collect outcomes studies and if feasible (pending on the quality of the outcome data and enough effect sizes available) to do a meta-analysis of outcomes. Each database was searched using the search terms: (“school social work*”) AND (“effective*” OR “outcome*” OR “evaluat*” OR “measure*”). The first author did the initial search and also manually searched reference lists of relevant articles to identify additional publications. All references of included studies were combined and deduplicated for screening after completion of the manual search.

Eligibility Criteria

The same inclusion and exclusion criteria were used at all stages of the review process. Studies were included if they: (1) were original research studies, (2) were published in peer-reviewed scientific journals or were dissertations, (3) were published between 2000 and 2022, (4) described school social work services or identified school social workers as the practitioners, and (5) reported at least one outcome measure of the efficacy or effectiveness of social work services. Studies could be conducted in any country and were included for full-text review if they were published in English. The authors excluded: (1) qualitative studies, (2) method or conceptual papers, (3) interventions/services not led by school social workers, and (4) research papers that focused only on sample demographics (not on outcomes). Qualitative studies were excluded because though they often capture themes or ideas, experiences, and opinions, they rely on non-numeric data and do not quantify the outcomes of interventions, which is the focus of the present review. If some conditions of qualification were uncertain based on the review of the full text, verification emails were sent to the first author of the paper to confirm. Studies of school social workers as the sample population and those with non-accessible content were also excluded. If two or more articles (e.g., dissertation and journal articles) were identified with the same population and research aim, only the most recent journal publication was selected to avoid duplication. The protocol of the present scoping review can be retrieved from the Open Science Framework at  https://osf.io/4y6xp/?view_only=9a6b6b4ff0b84af09da1125e7de875fb .

A total of 1,619 records were initially identified. After removing duplicates, 834 remained. The first and the fourth author conducted title and abstract screening independently on Rayyan, an online platform for systematic reviews (Ouzzani et al., 2016 ). Another 760 records were removed from the title and abstract screening because they did not focus on school social work practice, were theory papers, or did not include any measures or outcomes, leaving 68 full-text articles to be screened for eligibility. Of these, 16 articles were selected for data analysis. An updated search conducted in June 2022 identified two additional studies. The combined searches resulted in a total of 18 articles that met the inclusion criteria. The first and the fourth author convened bi-weekly meetings to resolve disagreements on decisions. Reasons and number for exclusion at full-text review were reported in the reasons for exclusion in the PRISMA chart. The PRISMA literature search results are presented in Fig.  1 .

PRISMA Literature Search Record

Data Extraction

A data extraction template was created to aid in the review process. The information collected from each reference consists of three parts: publication information, program features, and practice characteristics and outcomes. Five references were randomly selected to pilot-test the template, and revisions were made accordingly. To assess the quality of the publication and determine the audiences these studies reached, information on the publications was gathered. The publication information included author names, publication year, country/region, publication type, journal name, impact factor, and the number of articles included. The journal information and impact factors came from the Journal Citation Reports generated by Clarivate Analytics Web of Science (n.d.). An impact factor rating is a proxy for the relative influence of a journal in academia and is computed by dividing the number of citations for all articles by the total number of articles published in the two previous years (Garfield, 2006 ). Publication information is presented in Table ​ Table1. 1 . Program name, targeted population, sample size, demographics, targeted issues, treatment characteristics, MTSS level, and main findings (i.e., outcomes) are included in Table ​ Table2. 2 . Finally, intervention features consisting of study aim and design, manualization, practitioners’ credential, fidelity control, type of intervention, quality assessment, and outcome measurement are presented in Table ​ Table3. 3 . Tables ​ Tables2 2 and ​ and3 3 are published as open access for review and downloaded in the Texas Data Repository (Ding, 2023 ).

Journals Reviewed, Impact Factor, and Number of Articles Selected for Review

* The definition of impact factor (IF) is from Journal Citation Reports produced by Clarivate Analytics. IF is calculated based on a two-year period by dividing the number of citations in the JCR year by the total number of articles published in the two previous years

General Information on the Included School Social Work Practices

Note. Bx behavior, ed education, yo years old, yr = year. tx treatment, w  with, T treatment group, C control group, INT intervention, CON control, FRPL Free/Reduced prices lunch, IEP Individualized education program, CBT cognitive behavior therapy, BST Behavior skill training, HADS-A Hospital anxiety and depression scale

Characteristics of the Included Research Studies

Note. NR Not reported, NA Not applicable, h hours, tx treatment, wk week, SSW School social work, IOA Interobserver agreement, SS single subject, AB baseline and intervention, SBC Student behavior checklist, GPA Grade point average, SRAS-C-R School refusal assessment scale-children-revised, SRAS-P-R School refusal assessment scale-parent-revised, CD-RISC Connor-davidson resilience scale, FAD-GFS McMaster family assessment device general functioning scale, PSS Perceived stress scale, PTSD Post-traumatic stress disorder, PC-PTSD Primary care post-traumatic stress disorder screen, RYDM Resilience youth development module, CHKS The California healthy kids survey, CPSS Child PTSD symptom scale, CDI Children depression inventory, TRF Teacher report form, BRIC Behavior rating index for children, HPC  Problem checklist, BERS The behavioral and emotional rating scale, SSRS The social skills rating system. SSP The school success profile, BDI Beck depression inventory. DAS Dysfunctional attitudes scale, PGIS-II Personal growth initiative scale II, GHQ-12 Chinese general health questionnaire-12, Q-LES-Q-18 Abbreviated quality of life enjoyment and satisfaction questionnaire, PSI Parenting stress index- parent domain, PSOC Parenting sense of competence scale- efficacy subscale

The 18 extracted records were coded based on the data extraction sheet. The first and the fourth authors acted as the first and the second coder for the review. An inter-rater reliability of 98.29% was reached after the two coders independently completed the coding process.

Quality Assessment

The quality of the eligible studies (e.g., methodological rigor, intervention consistency) was assessed using the Quality Assessment Tool for Quantitative Studies (Evans et al., 2015 ). Specifically, each included study was assessed for selection bias, study design, confounders, blinding, data collection method, dropouts or withdrawals, intervention integrity, and analyses. The first and fourth authors rated each category independently, aggregated ratings, and came to a consensus to assign an overall quality rating of strong, moderate, or weak for each of the 18 studies.

Data Analysis

Due to the heterogeneity of the interventions, study purposes, methods, and measurements of the selected studies, and the lack of outcome data to calculate effect sizes, a meta-analysis was not feasible. Hence, the authors emphasized the scoping nature of this review, data were narratively synthesized, and descriptive statistics (frequencies, percentage, mode, minimum, maximum, and range) were reported. Characteristics of included studies include topics, settings, participants, practice information (e.g., type of services, practitioner credential, MTSS modality, and other characteristics), and program efficacy. Within each reported category of interest, consistency and differences regarding the selected studies were synthesized. Unique features and reasons for some particular results were explained using analysis evidence according to the characteristics of the study.

Overall Description of Included Studies

Of the 18 included studies, 16 were reported in articles that appeared in 11 different peer-reviewed journals, and two were dissertations (Magnano, 2009 ; Phillips, 2004 ). Information on each of the 11 journals was hand-searched to insure thoroughness. Of the 11 journals, seven were in the field of social work, with one journal covering social work as it relates to public health; one was a school psychology journal; one a medical journal covering pediatric psychiatry; and one journal focused on child, adolescent, and family psychology. The most frequently appearing journal was Children & Schools , a quarterly journal covering direct social work services for children (Oxford University Press, 2022 ). An impact factor (IF) was identified for six of the 11 journals. Of the six journals with an IF rating, four were social work journals. The IF of journals in which the included studies were published ranged from 1.128 to 12.113 (Clarivate Analytics, n.d.). Of the 18 studies, 5 studies (28%) were rated as methodologically strong, 8 studies were rated as moderate (44%), and 5 studies were rated as weak (28%).

The studies were conducted in five different geographical areas of the world. One study was conducted in the Middle East (5.56%), one in north Africa (5.56%), one in Eastern Europe (5.56%), two in East Asia (11.11%), and the rest (13 studies) in the USA (72.22%).

Research Design and Fidelity Control

Concerning research design, most included studies used a pre-posttest design without a comparison group ( n  = 10, 61.11%), one used a single case baseline intervention design (5.56%), six (33.33%) used a quasi-experimental design, and one (5.56%) used an experimental design. For the control or comparison group, the experimental design study and four of the six quasi-experimental design studies used a waitlist or no treatment control/comparison group; one quasi-experimental design study offered delayed treatment, and one quasi-experimental design study offered treatment as usual. Nine studies (50%) reported that training was provided to the practitioners prior to the study to preserve fidelity of the intervention, four studies (22.22%) reported offering both training and ongoing supervision to the practitioners, and one study (5.56%) reported providing supervision only.

Study Sample Characteristics

Across the 18 included studies, the total number of participants was 1,194. In three studies, the participant group (sample) was no more than ten, while in nine studies, the intervention group was more than 40. Overall, there was a balance in terms of students’ sex, with boys comprising an average of 55.51% of the total participants in all studies. There were slightly more studies of middle school or high school students ( n  = 8) than pre-K or elementary school students ( n  = 5). Across the eight studies that reported students’ race or ethnicity, 13.33% of the students were Black, 18.41% were White, 54.60% were Latinx, 12.38% were Asian, and 1.27% were categorized as “other.” Although the studies reviewed were not restricted to the USA, the large number of Latinx participants from two studies (Acuna et al., 2018 ; Kataoka et al., 2003 ) might have skewed the overall proportions of the race/ethnicity composition of the study samples. As an indicator of socioeconomic status, eight studies reported information on free/reduced-price lunches (FRPL). The percentage of students who received interventions that qualified for FRPL varied from 53.3 to 87.9%. Five studies reported the percentage of students enrolled in an Individualized Education Program (IEP) or special education, ranging from 15.4% to 100%.

Variation in School Social Work Services

The services carried out or co-led by school social workers varied greatly. They included services focused on students’ mental health/behavioral health; academic performance; school environment; student development and functioning in school, classroom, and home settings; and parenting. More specifically, these interventions targeted students’ depression and anxiety (Kataoka et al., 2003 ; Phillips, 2004 ; Wong et al., 2018a ), social, emotional, and behavioral skills development (Acuna et al., 2018 ;Chupp & Boes, 2012 ; Ervin et al., 2018 ; Magnano, 2009 ; Newsome, 2005 ; Thompson & Webber, 2010 ), school refusal and truancy (Elsherbiny et al., 2017 ; Newsome et al., 2008 ; Young et al., 2020 ), trauma/PTSD prevention, community violence, and students’ resilience (Al-Rasheed et al., 2021 ;Ijadi-Maghsoodi et al., 2017 ; Kataoka et al., 2003 ; Wong et al., 2018a ), homework completion and grade-point average improvement (Chupp & Boes, 2012 ; Magnano, 2009 ; Newsomoe, 2005 ), parental stress (Fein et al., 2021 ; Wong et al., 2018b ), family functioning (Fein et al., 2021 ), and parenting competence and resilience (Wong et al., 2018b ). All of the studies were school-based (100%), and the most common setting for providing school social work services was public schools.

Diverse Interventions to Promote Psychosocial Outcomes

Services can be grouped into six categories: evidence-based programs or curriculums (EBP), general school social work services, case management, short-term psychosocial interventions, long-term psychosocial intervention, and pilot program. Seven studies (38.89%) were EBPs, and four (57.14%) of the seven EPBs were fully manualized (Acuna et al., 2018 ; Al-Rasheed et al., 2021 ; Fein et al., 2021 ; Thompson & Webber, 2010 ). Two EBPs (28.57%) were partially manualized (Ijadi-Maghsoodi et al., 2017 ; Kelly & Bluestone-Miller, 2009 ), one did not report on manualization (Chupp & Boes, 2012 ), and one is a pilot study trying to build the program’s evidence base (Young et al., 2020 ). The second-largest category was short-term psychosocial interventions reported in six (33.33%) of the studies; they included cognitive behavioral therapy (CBT), solution-focused brief therapy (SFBT), and social/emotional skills training. One study reported on a long-term psychosocial intervention (Elsherbiny et al., 2017 ), and one was a case management program (Magnano, 2009 ). Two studies included general school social work services (e.g., one-on-one interventions with children and youth, group counseling, phone calls, official and informal conversations with teachers and parents, check-ins with students at school, and collaboration with outside agencies) (Newsome et al., 2008 ; Sadzaglishvili et al., 2020 ).

Program Population

Of the 18 interventions, seven (38.89%) involved students only (Al-Rasheed et al., 2021 ;Chupp & Boes, 2012 ; Ervin et al., 2018 ; Newsome, 2005 ; Phillips, 2004 ; Wong et al., 2018a ; Young et al., 2020 ). One program (5.56%) worked with parent–child dyads (Acuna et al., 2018 ), and two (11.11%) worked directly with students’ parents (Fein et al., 2021 ; Wong et al., 2018b ). Four interventions (22.22%) involved students, parents, and teachers (Elsherbiny et al., 2017 ; Kataoka et al., 2003 ; Magnano, 2009 ), two (11.11%) were with students and their teachers (Kelly & Bluestone-Miller, 2009 ; Thompson & Webber, 2010 ), and two (11.11%) were more wholistically targeted at students, parents, and their families as service units (Newsome et al., 2008 ; Sadzaglishvili et al., 2020 ).

Practitioners and Credentials

School social workers often collaborate with school counselors, psychologists, and schoolteachers in their daily practice. As for the titles and credentials of those providing the interventions, twelve interventions were conducted solely by school social workers (Acuna et al., 2018 ; Fein et al., 2021 ; Ijadi-Maghsoodi et al., 2017 ; Kataoka et al., 2003 ; Kelly & Bluestone-Miller, 2009 ; Magnano, 2009 ; Newsome, 2005 ; Newsome et al., 2008 ; Phillips et al., 2004 ; Sadzaglishvili et al., 2020 ; Wong et al., 2018a , 2018b ). Four social service programs were co-led by school social workers, school counselors and school psychologists (Al-Rasheed et al., 2021 ; Chupp & Boes, 2012 ; Elsherbiny et al., 2017 ; Young et al., 2020 ). School social workers and schoolteachers collaborated in two interventions (Ervin et al., 2018 ; Thompson & Webber, 2010 ).

The most common credential of school social workers in the included studies was master’s-level licensed school social worker/trainee, which accounted for 62.50% of the studies (Acuna et al., 2018 ; Fein et al., 2021 ; Kataoka et al., 2003 ; Newsome, 2005 ; Phillips, 2004 ). Two studies did not specify level of education but noted that the practitioners’ credential was licensed school social worker (Ijadi-Maghsoodi et al., 2017 ; Wong et al., 2018a ). One intervention was conducted by both master’s and bachelor’s level social work trainees; however, the first author confirmed that they were all registered school social workers with the Hong Kong Social Work Registration Board (Wong et al., 2018b ).

Services by Tier

The predominant level of school social work services was tier 2 interventions (55.56%), with 10 interventions or services offered by school social workers falling into this category (Acuna et al., 2018 ; Elsherbiny et al., 2017 ; Ervin et al., 2018 ; Fein et al., 2021 ; Kataoka et al., 2003 ; Newsome, 2005 ; Phillips, 2004 ; Thompson & Webber, 2010 ; Wong et al., 2018a , 2018b ). The second largest category was tier 1 interventions, with five studies (27.78%) falling into this category (Al-Rasheed et al., 2021 ;Chupp & Boes, 2012 ; Ijadi-Maghsoodi et al., 2017 ; Kelly & Bluestone-Miller, 2009 ; Sadzaglishvili et al., 2020 ). Only three (16.67%) were tier 3 services (Magnano, 2009 ; Newsome et al., 2008 ; Young et al., 2020 ).

Intervention Modality and Duration under MTSS

Most services ( n  = 15, 83.33%) were small-group based or classroom-wide interventions (Al-Rasheed et al., 2021 ; Chupp & Boes, 2012 ; Elsherbiny et al., 2017 ; Ervin et al., 2018 ; Fein et al., 2021 ; Ijadi-Maghsoodi et al., 2017 ; Kataoka et al., 2003 ; Kelly & Bluestone-Miller, 2009 ; Newsome, 2005 ; Phillips, 2004 ; Sadzaglishvili et al., 2020 ; Thompson & Webber, 2010 ; Wong et al., 2018a , 2018b ). One tier 2 intervention was carried out in both individual and group format (Acuna et al., 2018 ). Of the three tier 3 intervention studies, one reported using case management to serve individual students (Magnano, 2009 ), and two included both individual intervention, group counseling, and case management (Newsom et al., 2008 ; Young et al., 2020 ).

Intervention length and frequency varied substantially across studies. Services were designed to last from 6 weeks to more than 13 months. There were as short as a 5- to 10-min student–school social worker conferences (Thompson & Webber, 2010 ), or as long as a three-hour cognitive behavioral group therapy session (Wong et al., 2018b ).

Social Behavioral and Academic Outcomes

Most of the interventions focused on improving students’ social, behavioral, and academic outcomes, including child behavior correction/reinforcement, social–emotional learning (SEL), school attendance, grades, and learning attitudes. Ervin and colleagues ( 2018 ) implemented a short-term psychosocial intervention to reduce students’ disruptive behaviors, and Magnano ( 2009 ) used intensive case management to manage students’ antisocial and aggressive behaviors. Both interventions were found to be effective, i.e., there were statistically significant improvements at the end of treatment, with Ervin et al. ( 2018 ) reporting a large effect size using Cohen’s d. The SEL programs were designed to foster students’ resilience, promote self-esteem, respect, empathy, and social support, and teach negotiation, conflict resolution, anger management, and goal setting at a whole-school or whole-class level (Al-Rasheed et al., 2021 ; Chupp & Boes, 2012 ; Ijadi-Maghsooodi et al., 2017 ; Newsome, 2005 ). Students in all SEL interventions showed significant improvement at the end of treatment, and one study reported medium to small effect sizes (Cohen’s d) for problem-solving and overall internal assets, such as empathy, self-efficacy, problem-solving, and self-awareness (Ijadi-Maghsooodi et al., 2017 ).

Four studies measured the intervention’s impact on students’ academic performance. Magnano and colleagues ( 2009 ) reported that at the completion of the school social work case management intervention, academic skills were improved among both the intervention group students and the cross-over (control) group students who received the intervention at a later time. One study specifically addressed students’ school refusal behaviors and attitudes and found improvement in the treatment group at posttest and six-month follow-up (Elsherbiny et al., 2017 ). Two studies that addressed students’ absenteeism and truancy exhibited efficacy. School social work services significantly reduced risk factors related to truant behaviors (Newsome et al., 2008 ), and attendance increased post-program participation and was maintained after one, two, and three months (Young et al., 2020 ).

Students’ Psychological Distress

The studies that addressed students’ mental health focused on psychological distress, especially adolescents’ depression and anxiety. In three studies, school social workers conducted short-term psychosocial interventions, all using group-based CBT (Kataoka et al., 2003 ; Phillips, 2004 ; Wong et al., 2018a ). Kataoka and colleagues ( 2003 ) reported that bilingual, bicultural school social workers delivered group CBT in Spanish to help immigrant students cope with depressive symptoms due to violence exposure. Similarly, Wong and colleagues ( 2018a ) delivered group CBT in Chinese schools using their native language to address teenagers’ anxiety disorders. In the Kataoka et al. ( 2003 ) study, all student participants were reported to have made improvements at the end of the intervention, although there was no statistically significant difference between the intervention group and waitlisted comparison group. Phillips ( 2004 ) reported an eta-squared of 0.148 for cognitive-behavioral social skills training, indicating a small treatment effect. One study used a resilience classroom curriculum to relieve trauma exposure and observed lower odds of positive PTSD scores at posttest, but the change was not statistically significant (Ijadi-Maghsoodi et al., 2017 ).

School Climate and School Culture

Regarding school social workers’ interest in school climate and school culture, Kelly and Bluestone-Miller ( 2009 ) and Sadzaglishvili and colleagues ( 2020 ) specifically focused on creating a positive learning environment and promoting healthy school culture and class climate. Kelly and Bluestone-Miller ( 2009 ) used Working on What Works (WOWW), a program grounded in the SFBT approach to intervene in a natural classroom setting to build respectful learning. Students were allowed to choose how to respond to expectations regarding their classroom performance (e.g., students list the concrete small goals to work upon in order to create a better learning environment), and teachers were coached to facilitate, ask the right questions, and provide encouragement and appropriate timely feedback. Sadzaglishvili and colleagues ( 2020 ) used intensive school social work services (e.g., case management, task-centered practice, advocacy, etc.) to support students’ learning, whole-person development, and improve school culture. At the end of the services, both studies reported a more positive school and class climate that benefited students’ behaviors and performance at school.

Teacher, Parent, and Student Interaction

Four studies addressed interactions among teachers, parents, and students to achieve desired outcomes. For instance, two studies provided a mesosystem intervention (e.g., a parent’s meeting with the teacher at the public school the child attended, which encompasses both the home and school settings). Acuna and colleagues ( 2018 ) provided a school-based parent–child interaction intervention to improve children’s behaviors at school and home, boost attendance, and improve academic outcomes. Similarly, Thompson and Webber ( 2010 ) intervened in the teacher–student relationship to realign students’ and teachers’ perceptions of school and classroom norms and improve students’ behaviors. Additionally, two interventions targeted the exosystem (e.g., positive environmental change to improve students’ stability, in order to promote school behaviors and academic performance). Kelly and Bluestone-Miller ( 2009 ) modeled solution-focused approaches as a philosophy undergirding classroom interactions between teachers and students. The positive learning environment further improved students’ class performance. Magnano and colleagues ( 2009 ) used a case management model by linking parents, teachers, and outside school resources to increase students’ support and achieve improvements in academic skills and children’s externalizing behaviors.

Parents’ Wellbeing

Most school counselors or school psychologists focus solely on serving students, while school social workers may also serve students’ parents. Two studies reported working directly and only with parents to improve parents’ psychological outcomes (Fein et al., 2021 ; Wong et al., 2018b ). Fein and colleagues ( 2021 ) reported a school-based trauma-informed resilience curriculum specifically adapted for school social workers to deliver to racial/ethnic minority urban parents of children attending public schools. At curriculum completion, parents’ overall resilience improved, but significance was attained in only one resilience item (“I am able to adapt when changes occur”) with a small effect size using Cohen’s d. Wong et al. ( 2018b ) studied school-based culturally attuned group-based CBT for parents of children with attention deficit/hyperactivity disorder (ADHD); significantly greater improvements in the CBT parent group were found in distress symptoms, quality of life, parenting stress, competence, and dysfunctional beliefs post-intervention and at three-month follow-up .

This scoping review examined school social work practice by systematically analyzing the services school social workers delivered based on 18 outcome studies published between 2000 and 2022. The programs, interventions, or services studied were conducted by school social workers in five different countries/regions. These studies captured the essence of school social workers’ roles in mental health/behavioral health and social services in education settings provided to children, youth, families, and schoolteachers, and the evidence on practice outcomes/efficacy was presented.

Although using EBP, promoting a healthy school climate and culture, and maximizing community resources are important aspects of the existing school social work practice model in the USA (NASW, 2012 ), this review revealed and validated that school social workers in other countries used similar practices and shared a common understanding of what benefits the students, families, and the schools they serve (Huxtable, 2022 ). The findings also support the broad roles of school social workers and the collaborative ways they provide social and mental health services in schools. The review discussed school social workers’ functions in (1) helping children, youth, families, and teachers address mental health and behavioral health problems, (2) improving social–emotional learning, (3) promoting a positive learning environment, and (4) maximizing students’ and families’ access to school and community resources. Furthermore, although previous researchers argued that the lack of clarity about school social worker’s roles contributed to confusion and underutilization of school social work services (Altshuler & Webb, 2009 ; Kelly et al., 2010a ), this study revealed that in the past two decades, school social workers are fulfilling their roles as mental/behavioral health providers and case managers, guided by a multi-tiered, ecological systems approach. For example, in more than 80% of the studies, the services provided were preventive group work at tier 1 or 2 levels and operated from a systems perspective. Additionally, the findings suggest that while school social workers often provide services at the individual level, they frequently work across systems and intervene at meso- and exo-systems levels to attain positive improvements for individual students and families.

Evidence-based School Social Work Practice and MTSS

The present review supported school social workers’ use of evidence-based programs and valid psychosocial interventions such as CBT, SFBT, and social–emotional learning to foster a positive learning environment and meet students’ needs. Most of the included EBPs (85.71%) were either fully or partially manualized, and findings from the current review added evidence to sustain the common elements of general school social work practice, such as doing case management, one-on-one individual and group counseling, collaborations with teachers, parents, and community agencies. One pilot study examined the effectiveness of a school social worker-developed program (Young et al., 2020 ), which provided a helpful example for future research practice collaboration to build evidence base for school social work practice. However, although school social workers often work with Black, Indigenous, and People of Color (BIPOC) student populations facing multiple risk factors, demographic information on race/ethnicity, special education enrollment, and socioeconomic status were missing in many included studies, which obstructed examination of the degree of match between the target population’s needs and evidence-based services or interventions provided.

Previous school social work national surveys conducted in the USA (Kelly et al., 2010a , 2015 ) found a discrepancy between the actual and ideal time expense on tier 1, tier 2, and tier 3 school social work activities. Even though school social workers would like to spend most of their time on primary prevention, they actually spent twice their time on secondary and tertiary prevention than on primary prevention (Kelly et al., 2010a ). However, the present review found that most interventions or evidence-based programs conducted by school social workers were tier 1 and tier 2, especially tier 2 targeted interventions delivered in a group modality. This discrepancy could be due to the focus of this review’s limited services to those provided by professionals with a school social worker title/credential both in the USA and internationally, and tier 2 and 3 activities were grouped together as one category called secondary and tertiary prevention in the school social work survey (Kelly et al., 2010a ). Our review highlights that tier 2 preventive interventions are a significant offering in school social worker-led, school-based mental health practice. Unlike tier 1 interventions that are designed to promote protective factors and prevent potential threats for all students, or intensive tier 3 interventions that demand tremendous amounts of time and energy from practitioners and often involve community agencies (Eber et al., 2002 ), tier 2 interventions are targeted to groups of students exhibiting certain risk factors and are more feasible and flexible in addressing their academic and behavioral needs. Moreover, considering the discrepancy between the high demand for services on campuses and the limited number of school social workers, using group-based tier 2 interventions that have been rigorously examined can potentially relieve practitioners’ caseload burdens while targeting students’ needs more effectively and efficiently.

School Social Work Credential

Recent research on school social workers’ practice choices showed that school social workers who endorsed primary prevention in MTSS and ecologically informed practice are more likely to have a graduate degree, be regulated by certification standards, and have less than ten years of work experience (Thompson et al., 2019 ). Globally, although data are limited, having a bachelor's or master’s degree to practice school social work has been reported in countries in North America, Europe, and the Middle East (Huxtable, 2022 ). Even though all practitioners in the present review held the title of “school social worker,” and the majority had a master’s degree, we suggest future research to evaluate school social work practitioners’ credentials by reporting their education, certificate/licensure status, and years of work experience in the education system, as these factors may be essential in understanding school social workers’ functioning.

Interdisciplinary Collaboration

School social workers are an integral part of the school mental health workforce in education settings and often work in interdisciplinary teams that include schoolteachers, administrators, school counselors, and school psychologists (Huxtable, 2022 ). This scoping review found that one-third of interventions school social workers conducted were either co-led or delivered in collaboration with school counselors, school psychologists, or schoolteachers. Future research examining characteristics and outcomes of school social work practice should consider school social workers’ efforts in grounding themselves in ecological systems by working on interdisciplinary teams to address parent–child interactions, realign teacher–student classroom perceptions, or student–teacher–classroom culture to improve students’ mental health and promote better school performance.

Study Limitations and Directions for Future Research

A scoping review is a valuable method for exploring a field that has not yet been extensively reviewed or is heterogeneous. Thus, a scoping review was chosen as the research method to examine school social work practice outcomes for this study. Although scoping reviews are generally considered rigorous, transparent, and replicable, the present study has several limitations. First, only published dissertations and journal articles published between 2000 and 2022 that were included in the seven aforementioned databases were reviewed. Government reports and other gray literature excluded from the present review might generate more results requiring critical evaluation and discussion. Second, although school social work practice is ecological system-centered, all studies analyzed in the present scoping review were school-based programs. The search terms did not include possible alternative settings. More extensive searches might identify additional results by specifying home or community settings. Third, this paper focused on the outcomes and efficacy of the most current school social work practices so that qualitative studies or studies that focus on practitioners’ demographics were excluded even though they might provide additional information on the characteristics of social workers. Last, evidence to support school social work interventions was based primarily on pre-posttest designs without the use of a control group, and some of the identified evidence-based programs or brief psychosocial interventions lacked sufficient information on participants’ characteristics (e.g., demographics, changes in means in outcomes), which are important in calculating practice effect sizes and potential moderators for meta-analysis to examine school social workers’ roles and effectiveness in carrying out these interventions.

The present scoping review found significant variation in school social work services in the US and other countries where school social work services have been studied. Social workers are a significant part of the mental health and social services workforce. Using schools as a natural hub, school social workers offer primary preventive groups or early interventions to students, parents, and staff. Their interests include but are not restricted to social behavioral and academic outcomes; psychological distress; school climate and culture; teacher, parent, and student interactions; and parental wellbeing. Future school mental health researchers who are interested in the role of school social work services in helping children, youth, and families should consider the changing education landscape and the response to intervention after the COVID-19 pandemic/endemic (Capp et al., 2021 ; Kelly et al., 2021 ; Watson et al., 2022 ). Researchers are also encouraged to collaborate with school social work practitioners to identify early mental health risk factors, recognize appropriate tier 2 EBPs, or pilot-test well-designed programs to increase students’ success.

Declarations

We have no conflicts of interest to disclose.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References marked with an asterisk indicate studies included in the scoping review.

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• Open access
• Published: 13 September 2024

Centering the role of community health workers in social risk screening, referral, and follow-up within the primary care setting

• Emily K. Larson 1 ,
• Maia Ingram 1 ,
• Erin Dougherty 2 ,
• Maria Velasco 2 ,
• Vanessa Guzman 3 ,
• Azel Jackson 3 ,
• Kiran Patel 1 ,
• Scott C. Carvajal 1 &
• Ada M. Wilkinson-Lee 1 , 4  

BMC Primary Care volume  25 , Article number:  338 ( 2024 ) Cite this article

Metrics details

Community health workers (CHWs) remain an underutilized resource in social risk diagnostics in the primary care setting. This process evaluation study seeks to assess the role of CHWs in social risk screening, referral, and follow-up through process mapping to identify barriers to the process for future quality improvement efforts.

Researchers at the Arizona Prevention Research Center (AzPRC) engaged with two Federally Qualified Health Centers (FQHCs) in two of Arizona’s major urban areas to evaluate their internal processes for social risk screening and intervention. The Consolidated Framework for Implementation Research (CFIR) was used to direct a process mapping exercise to visually describe the workflow, gaps, and barriers to identifying and addressing social risk.

The process unveiled key areas for health system improvements in the community setting, the organizational setting, and in the implementation of social risk screening, referral, and follow-up. Further, process maps highlight the potential resources needed for effective CHW integration to address social risk in the primary care setting.

Conclusions

Our findings demonstrate the importance of organizational tools, such as process mapping, to assist primary care settings in evaluating internal processes for quality improvement in addressing social risk and in effectively integrating the CHW workforce. Subsequent research will evaluate rates of social risk screening, referral, and follow-up within all of Arizona’s FQHCs and propose models for CHW integration to address social risk in primary care and strengthen social risk screening reach and effectiveness.

Peer Review reports

The concept of social prescribing in the medical field is not a new one, yet it remains an understudied and underutilized tool for expanding a healthcare provider’s practice into the social areas that affect a patient’s health outcomes [ 1 ]. Social prescription is most commonly defined as the referral of patients in primary care to non-clinical, local services for social health and well-being, such as housing and nutrition [ 2 ]. Key to the success of social prescription is the inclusion of strategies to ensure that the appropriate social needs of the patient are identified, that there is a response to those needs through direct assistance or referral, and that there is follow up to ensure that the patient received related services to their satisfaction [ 3 ].

In 1997, the Bromley by Bow Centre in the United Kingdom (UK) developed the Health Living Centre, one of the first documented primary care offices using the model of social prescribing as a driving force for a healthy community [ 4 ]. This service was conceptualized as an approach to address health inequality by acknowledging the strong connection between socioeconomic factors and a person’s mental and physical well-being [ 5 ]. Behavioral health care settings have traditionally taken a more holistic approach to addressing social risk factors in direct relation to mental health, while it is only in the past two decades that attention to social determinants of health (SDOH) have become central in medical settings [ 6 ]. While there is growing attention to SDOH in health care settings, physicians are not well positioned to respond within the context of a medical visit. According to The Physician Foundation’s Part One of Three: 2022 Survey of America’s Physicians, 61% of physicians feel they have “little to no time and ability to effectively address their patient’s [social] determinants of health”, while 87% report a desire for greater time and ability to discuss such matters [ 7 ]. While these numbers alone are staggering, 83% of physicians report that trying to address a patient’s determinants of health contribute to the physician’s experience of burnout [ 7 ].

Acknowledging the role of social determinants of health (SDOH) in conversations around improving health equity is paramount, as an estimated 80% of health outcomes remain attributable to a person’s socioecological context [ 8 ] Given the important influence that issues such as housing and food access, for example, have on a patient’s health outcomes, it is of critical importance that public health bridges the relationship between primary care and a public health system-guided confrontation of social risk. Despite the desire of providers to have the capacity to address their patients social risks, other staff within the primary care setting may be better situated to take the time to address these needs [ 7 ]. Therefore, there is a growing need to develop effective systems-level approaches to identifying, integrating, and following up on social risks in patient care, which requires the commitment of several levels of staff in the clinical setting [ 8 ].

There is robust research documenting the positive impact of CHWs as members of healthcare teams on issues such as chronic disease risk and management [ 9 , 10 , 11 , 12 ]. However, their role in identifying and addressing social risk, as an integral part of primary care teams, is neglected in the literature. A key role for the CHW workforce is to create a bridge between community members and health and human services [ 13 ]. CHWs are highly-skilled leaders, who can naturally communicate with their community and draw on resources to address social needs [ 14 ]. While a surplus of evidence exists to indicate the strength of CHWs in addressing social risks by connecting patients to community resources, there remains a lack of literature on effective ways to integrate CHWs into primary care services for the purpose of social risk screening, referral, and follow-up to ensure that social risk is addressed [ 15 , 16 , 17 , 18 , 19 , 20 , 21 ]. Common issues around social risk identification and intervention as an organizational norm include unclear referral channels between healthcare providers and CHWs, not having dedicated time for patients to complete the screening, mounting and existing administrative burden, and concerns with identifying proper billing codes in the electronic health record (EHR) [ 15 , 16 , 17 , 18 , 19 , 20 , 21 ].

The objective of this process evaluation study is to assess the role of CHWs in screening, referral, and follow-up for social risk within two FQHCs in order to identify barriers to the process for future quality improvement efforts.

Using a community-based participatory research (CBPR) approach, academic partners collaborated with staff of two FQHCs interested in evaluating organizational procedures for social risk and the role of CHWs from screening to follow-up. CBPR is best described as a research methodology, which combines knowledge and action to encourage social change [ 22 ]. CBPR is founded on the principle that community partners and academic researchers are equal collaborators [ 22 ]. This CBPR study grew out of a larger academic-community research partnership between several FQHCs and county health departments to develop a CHW-driven community-clinical linkage (CCL) model [ 23 , 24 ]. The research study coincided with national efforts to increase social risk screenings in FQHCs, leading to additional questions about the internal social risk screening process for two of the partner FQHCs [ 25 ]. Both FQHCs expressed interest in evaluating the role of CHWs in the social risk screening, referral, and follow-up processes for future quality improvement efforts.

Each author on this paper had a key role in the elaboration of this study. The following describes the roles of the five academic and four community partners (two from each FQHC) on this CBPR study. The second and senior authors worked on the original CCL study and suggested the process mapping as a collaborative research method. The fifth and sixth authors were involved in integrating CHWs into their clinical services in FQHC 1 and supervised the CHWs.The third author is the research and grants manager at FQHC 2. The fourth author, an experienced CHW, was involved in the CCL study at FQHC 2.The first author is a graduate research associate and PhD student who joined the study based on her previous work as a medical assistant in family medicine and her interest in health research. At the time of the study, the seventh author was an undergraduate public health student who helped to implement the process map with FQHC 1 as part of an independent study.

FQHC settings

FQHC 1 currently has seven locations serving a metropolitan area of central Arizona and offers adult medicine, pediatrics, behavioral health, crisis intervention, and other social services. FQHC 1 initially provided behavioral health services and expanded to include primary care in recent years. FQHC 1 serves approximately 5000 patients across its locations. FQHC 2 currently has thirteen locations to serve a metropolitan area of southern Arizona and offers adult medicine, behavioral health, dental services, family medicine, pediatrics, and other specialized services, such as addiction treatment and family planning. FQHC 2 serves approximately 128,500 patients across its locations. Both FQHCs are located in major urban areas and deliver primary care services to lower income and historically underserved populations. FQHC 1 began employing CHWs at their organization in 2012, but did not implement formal social risk screening until 2019. FQHC 2 began formally working with CHWs in 2010 and implemented formal social risk screening at their organization in 2018. Both clinics had a history of working with CHWs to conduct community outreach, health promotion initiatives, and address clinical priorities. Therefore, once each clinic began formally screening for social risk, CHWs were a natural fit for this role.

Process mapping for organizational evaluation

The academic and community partners decided to engage in process mapping as a means to describe strengths and identify barriers to social risk screening and follow-up. Process mapping is a process evaluation tool designed to assist health organizations in evaluating systems-level interventions to improve the quality of health care service delivery [ 26 ]. In a systematic review, Antonacci et al. (2021) identified five stages of process mapping that include (1) preparation and planning; (2) gathering data; (3) map generation; (4) map interpretation; and (5) application of results [ 26 ].

Phase I: preparation and planning

The community and academic partners collectively met monthly over the course of several months for one hour via Zoom to share the history of social risk screening in their respective organizations, develop study aims, and determine a framework to guide the study. The community partners selected the Consolidated Framework for Implementation Research (CFIR 2009) due to their familiarity with the framework and it’s fit for their clinical context. CFIR helped the partners broadly consider factors internal and external to the clinical settings that needed to be explored. The partners utilized the 2009 version of the framework, although it should be noted that an updated version (2022) does exist [ 27 , 28 ]. Subsequently, the CBPR team developed questions for the process map evaluation, designed to document the flow of social risk screening, referral, and follow-up across departments in their organizations, including barriers and facilitators to the process.These questions were used at both FQHC’s process mapping activity and were used to prompt and probe the process map development. Question development was designed to identify aspects of the inner and outer context that might influence social risk screening, referral, and follow-up procedures (Table 1 ) and were based on CFIR domains [ 27 ]. The CFIR (2009) domains include: intervention characteristics, outer setting, inner setting, characteristics of individuals involved, and the process of implementation [ 27 ]. Definitions for each domain can be found in Table 1 .

For the purposes of this study, questions were developed for only three CFIR domains, as decided by our CBPR team: outer setting, inner setting, and the process of implementation. The team concluded that the two excluded CFIR domains were outside the scope of the process map that we aimed to develop for this study.

Process map guiding questions

Additionally, each community partner took the lead in determining who from their staff should participate in the data gathering phase, determining ideal times for the activity, and inviting participation of appropriate organizational members from the respective FQHC. Process map participants were invited across all locations for each FQHC. Process map participants from FQHC 1 included: a site supervisor, chief operating advisor, director of operations, regional supervisor, clinical supervisor, clinical director, peer support supervisor, and two CHWs. In contrast, FQHC 2 made an internal decision to divide the process map evaluation into two sessions: the first with CHWs and a CHW supervisor only; the second with clinical staff only. Process map participants for FQHC 2 included: one CHW supervisor and four CHWs. Subsequent process mapping at our second partnered FQHC included: one dentist, one internal medicine physician, and a research and grants manager.

Phase II: gathering data

The academic partner took the lead in facilitating the process map evaluation activity separately at each FQHC. The process mapping exercise took place over the employees’ lunch hour with food and refreshments provided by the academic partner team. Using the CFIR questions developed by the CBPR team to guide conversation, one academic team member drew the workflow and various pathways of the organization’s procedures for social risk screening, referral, and follow-up efforts on a whiteboard, making note of the context and situations in which these procedures might occur. The other academic team member(s) took careful notes of the actual responses to the questions in order to capture contextual factors to the map and the participants’ insights and perspectives. The notes taken during the process mapping activity were used to identify common barriers to social risk screening, referral, and follow-up procedures across both FQHCs. This process was not recorded or transcribed.

Phase III: map generation

Members of the academic partner team created a visual diagram of the process maps for each FQHC with Lucid.app software. The visual diagram represented the various pathways of the organization’s procedures for social risk screening, referral, and follow-up efforts by using different colors and symbols. The academic partners then delivered the process map of each organization’s workflow to each partnering FQHC.

Phase IV & V: map interpretation & application of results

Academic partners met with each partnering FQHC individually via Zoom for one hour, within the following month after the process mapping occurred, to make adjustments and clarify any map inaccuracies. During this time, academic and community partners also met to discuss the themes extrapolated from the process mapping notes. Final process map products were delivered to each FQHC partner for their internal use in Phase V of the study, which included organizational system improvements to address inefficiencies and opportunities for improvement identified during the process evaluation (Fig.  1 and 2 ).

The process evaluations at our partnering FQHCs resulted in two process maps of each organizations’ workflow of social risk screening, referral, and follow-up. The generated process maps also focused on the integral role of CHWs from screening to follow-up of social risks. The process maps for FQHC 1 and FQHC 2 are found in Fig.  1 and 2 , respectively. It is of note that each process map is an individual representation of the FQHC. Further, each FQHC opted to create their process map based on their needs and included their identified participants to fit their clinical context. Thus, the two process maps differed in format as they reflected the unique operations and needs of each clinic. In addition to the generated process maps for each partnering FQHC, the academic partners identified barriers to the social risk screening, referral, and follow-up processes. These findings are grouped generally by CFIR domain and described in Table  2 .

Process maps Figs.  1 and 2

Depicts the process map generated by FQHC 1

Depicts the process map generated by FQHC 2

Along with the creation of two unique process maps that provided each FQHC with a visual representation of how patients are assessed and treated for their social needs, the academic partner team identified common barriers to social risk procedures for the three CFIR domains utilized in this study: outer setting, inner setting, and process of implementation. The themes and contextual information were extracted from process map activity notes and were directly related to the resources required for adequate CHW integration for social risk diagnostics and treatment in the primary care setting.

Outer setting: accessing resources

The understanding of social risk screening, referral, and follow-up within the organization did not change CHW perspectives on the promise that social risk identification can have on meeting patient needs in their community. There appeared to be consensus that when social risk screening was completed by the CHW there was generally not an issue addressing the identified need. However, CHWs acknowledged the struggle to secure community resources, especially for complex social risks. For example, the CHWs portrayed a confidence that if issues around nutrition were identified, they could locate community resources to alleviate that social pressure. However, for social risks such as homelessness, locating resources for those already experiencing homelessness proves harder than locating resources for those at risk of homelessness due to lack of community resources. This discussion further confirmed the necessity of early and consistent use of social risk screening throughout the organization.

Inner setting: Lack of standard entry points, lack of standard screening policy, and variation in provider understanding of CHWs

The staff involved in the process mapping reflected on the patient entry points for social risk screening at their organization. There was an emphasis on the need to cast a greater net for social risk screening upon entrance to any clinic service provided at the FQHC. Similarly, FQHC staff highlighted that leadership awareness of areas that are lacking efficient social risk screening, referral, and follow-up is necessary. For example, at one of the partnering FQHCs, a dental clinician was unaware of the scope of CHWs’ work and how they can be relied on as a resource at their organization to support patients. Therefore, there was a call from FQHC staff for a formal way for clinicians to refer patients to CHWs, document community resources available, and centralize community referrals for increased follow-up. In that respect, there was also a discussion on the importance of considering the lost-to-follow-up for patients who do not recurrently receive services at the FQHC and how to best serve this dynamic population. FQHC staff noted the importance of capturing the needs and utilization of services by the most vulnerable patients, which starts with streamlining efforts between clinical staff, from dental to primary care, with CHWs to effectively screen for and address social risks.

Process of implementation: IT challenges, screening tool changes, lack of communication, use of social risk data concerns, and administrative burden

Across the iterative rounds of process mapping, IT challenges in the EHR were consistently cited as barriers to implementation of social risk screening and responsive actions as a policy standard. More specifically, changes in the type of EHR was one cause of a fragmented method of social risk screening at FQHC 2. CHWs expressed that the previous EHR system their organization used was more comprehensive in capturing social risk information. Thus, with a change to their new system, the previous social risk screening protocol was discontinued, leading to CHW dissatisfaction and concerns that there was lower reach for social risk screening and treatment in their community. Similarly, CHWs lacked a comprehensive understanding of the policies of other departments in routine screening and next steps after social risk was identified. Further, CHWs confirmed that there was limited communication between their team and providers or clinical staff after CHWs received an internal patient referral for an identified social risk.

Additionally, across CHWs and clinical teams, there was concern over the usefulness of the EHR to document the social risk if there was no standard plan on how the data would inform organizational policy. That is, without a clear procedure for action once social risk is identified, the administrative time necessary to use a social risk survey tool in the EHR may not serve the patient, CHW, or the clinical provider, which may undermine the understanding and importance of using this assessment in a standardized manner. However, CHWs and clinical staff recognized the importance of documenting issues of social risk to provide continuum of care to patients. Both expressed a desire to act on the identified social risks with the belief that this action can make a difference in patients’ lives.

Impact of process mapping on partnering FQHCs

This process evaluation study on process mapping of social risk identification and intervention prompts a discussion around the role of CHWs in screening, referral, and follow up, and the resources required for improvements to the current system. More specifically, both process maps highlight key methods to improve addressing social risk within FQHCs. This process map evaluation revealed that CHWs should be integral members of the primary care teams, with respect to their ability to identify barriers to current processes for social risk screening, referral, and follow up. The process evaluation, which relied heavily on the expertise of CHWs, has been shared with upper-level FQHC leadership so that action may be taken to expand the patient population reached and improve on ways to address the identified social risks of patients. Since completion of the process mapping, one of the partnering FQHCs has used the results to investigate their internal processes and make operational modifications, such as locating CHWs into their primary care offices for greater ease of communication with clinicians on patients’ social risks and needs.

It is also worth noting that it was important that community partners led the process map activity conceptualization and implementation through CBPR principles, as each organization has a unique workflow and different insight into their processes. This uniqueness is captured in Fig.  1 and 2 , as they vary drastically in their representation of internal processes. The community partners on the research team were invested in the success and accuracy of the evaluation with the goal of improving patient care. Without a CBPR approach, our team likely would not have captured the variations in clinic operations to understand current procedures around social risk screening, referral, and follow up. Further, process mapping has given our partnering FQHCs the ability to assess their internal systems, identify weaknesses and opportunities for improvement, and strengthen the role of CHWs in their primary care teams.

Limitations

There are several limitations related to this process evaluation. First, while the study aims to understand the role of CHWs in screening, referral, and follow-up of social risks, the process evaluation was only done at two FQHCs in Arizona. Therefore, this study does not seek to be generalizable in its findings. This study was based on the experiences within FQHCs, which have a unique role in providing care to underserved populations. This approach may be useful for other care models, such as integrated health systems, but process mapping would need to be repeated in this setting. Additionally, participants for the process mapping activity were self-selected or were selected by community partners of the same organization to participate. This should be noted as a potential limitation, as the data gathered reflects those most likely to be involved in social risk screening, referral, and follow-up procedures to begin with, thereby potentially skewing the organizational perspective. However, as a process evaluation, it was our goal to reflect upon potential areas for quality improvement for CHWs integration into primary care and improvement in social risk identification and intervention. Therefore, while our team made efforts to hear the voices of diverse FQHC staff, this was shaped by organizational culture and decision-making.

Further, the scope of this study did not include surveying each FQHCs’ patient population to understand the patient perception of social risk screening, referral, and follow-up. Similarly, this study did not extend past the partnering FQHC to community-based organizations to garner information on how to feasibly and effectively establish channels for following up or “closing the loop”. Future research should extend the process evaluation to the collaborative work between referring CHWs and community-based organizations.

Lastly, our CBPR team used an older version of CFIR (2009) because of the team’s lack of awareness of the 2022 version at the time of study conceptualization. However, we simply used CFIR as a guiding framework in developing questions for process mapping and contextualizing information. Future research and efforts to replicate should see the 2022 version of CFIR [ 28 ].

The social risk process evaluation at two of Arizona’s major urban FQHCs revealed key opportunities to improve the reach and effectiveness of social risk screening and intervention for some of the most vulnerable populations in healthcare. The results of this process evaluation further support the critical role that CHWs can have, as integral members of primary care teams, in improving the social risk screening, referral, and follow-up procedures. Findings underscore the importance of collaborative primary care teams to streamline social risk screening, referral, and follow-up within healthcare delivery organizations. Integration of CHW efforts in primary care teams to address social risk, with clear processes for social risk screening, referral, and follow-up, may improve communication across teams and provide a method to introduce social prescription into medical decision-making for clinicians. More work must be done to further document the efficacy and effectiveness of CHW integration into primary care teams in order to incorporate social prescription into the healthcare delivery model. Our CBPR team aims to use the initial FQHC process maps of this study to develop a statewide survey in which Arizona FQHCs will document their own organizational processes for social risk screening, referral, and follow-up. This data will be used to propose models for CHW integration into primary care in the FQHC setting for a centralized social risk screening tool and an accessible community resource referral system.

Data availability

All data generated or analyzed during this study are included in this published article.

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Acknowledgements

The authors thank their community partners, Valle del Sol Community Health Center and El Rio Health Center, for their partnership in study design, scheduling, data collection, and interpretation of results.

This study was supported by the Grant or Cooperative Agreement Number, DP005002 under the Health Promotion and Disease Prevention Research Centers Program, funded by the Centers for Disease Control and Prevention.

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El Rio Health Center, 839 W. Congress Street, Tucson, Arizona, 85745, USA

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Valle Del Sol Community Health Center, 3877 N 7th St, Phoenix, AZ, 85014, USA

Vanessa Guzman & Azel Jackson

Department of Mexican American Studies, College of Social and Behavioral Sciences, University of Arizona, 1110 E. James Rogers Way, Tucson, AZ, 85721, USA

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Conceptualization: EKL, MI, ED, VG, MV, AJ, AMWL; methodology: MI, AMWL, ED, MV VG; formal analysis: EKL, MI, AMWL; writing—original draft preparation: EKL; writing—review and editing: MI, SCC, ED, AMWL; visualization: EKL, KP; project administration: EKL, MI, ED, MV, VG, AJ, AMWL; funding acquisition: MI, SCC, AMWL. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Emily K. Larson .

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The University of Arizona Institutional Review Board approved all evaluation and program improvement for our community study partners. (IRB Protocol Number 1911175303). All community partners consented to collaborative participation in this study. All research methods were in accordance with the Public Health Code of Ethics.

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The authors declare no competing interests.

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Larson, E.K., Ingram, M., Dougherty, E. et al. Centering the role of community health workers in social risk screening, referral, and follow-up within the primary care setting. BMC Prim. Care 25 , 338 (2024). https://doi.org/10.1186/s12875-024-02590-3

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Received : 13 May 2024

Accepted : 02 September 2024

Published : 13 September 2024

DOI : https://doi.org/10.1186/s12875-024-02590-3

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