Pediatric Screening Research Articles

Detecting familial hypercholesterolemia: An observational study leveraging mandatory universal pediatric total cholesterol screening in Slovakia

In Slovakia, a mandatory national universal pediatric total cholesterol (TC) screening program is in place to identify cases of familial hypercholesterolemia (FH). However, the program's effectiveness has not been systematically assessed. This study aimed to estimate the prevalence of FH among parents of children that had elevated TC levels identified during screening. This prospective, non-interventional, observational study enrolled parents of 11-year-old children who underwent TC screening in 23 selected pediatric outpatient clinics between 2017 and 2018. FH was diagnosed using the Dutch Lipid Clinic Network (DLCN) criteria and targeted next-generation sequencing. The primary objective was to estimate the proportion of children with a TC level of >188 mg/dL (>4.85 mmol/L) who had a parent with a confirmed diagnosis of FH. A total of 112 parents of 56 children with an elevated TC level were enrolled. Five children (8.9%) had a parent in whom FH was genetically confirmed. Without genetic analysis, all five parents would only be diagnosed with "possible FH" by DLCN criteria. Of parents, 83.9% (n = 94/112) had an low-density lipoprotein cholesterol (LDL-C) level of >116 mg/dL (>3 mmol/L), but only 5.3% (n = 5/94) received lipid-lowering therapy. Among the five parents with genetically confirmed FH, all had an LDL-C level >116 mg/dL (>3 mmol/L), with a mean (±SD) of 191 (±24) mg/dL (4.94 [±0.61] mmol/L). Only two of these parents received lipid-lowering therapy. The present study demonstrates the significance of mandatory universal pediatric TC screening in identifying families with FH and other at-risk families in need of lipid-lowering therapy.

Tracking of serum lipid levels from childhood to adulthood: Systematic review and meta-analysis

Background and aimsThe utility of lipid screening in pediatric settings for preventing adult atherosclerotic cardiovascular diseases partly depends on the lifelong tracking of lipid levels. This systematic review aimed to quantify the tracking of lipid levels from childhood and adolescence to adulthood. MethodsWe systematically searched MEDLINE, Embase, Web of Science, and Google Scholar in March 2022. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO; ID: CRD42020208859). We included cohort studies that measured tracking of lipids from childhood or adolescence (<18 years) to adulthood (≥18) with correlation or tracking coefficients. We estimated pooled correlation and tracking coefficients using random-effects meta-analysis. Risk of bias was assessed with a review-specific tool. ResultsThirty-three studies of 19 cohorts (11,020 participants) were included. The degree of tracking from childhood and adolescence to adulthood differed among lipids. Tracking was observed for low-density lipoprotein cholesterol (pooled r = 0.55–0.65), total cholesterol (pooled r = 0.51–0.65), high-density lipoprotein cholesterol (pooled r = 0.46–0.57), and triglycerides (pooled r = 0.32–0.40). Only one study included tracking of non-high-density lipoprotein cholesterol (r = 0.42–0.59). Substantial heterogeneity was observed. Study risk of bias was moderate, mostly due to insufficient reporting and singular measurements at baseline and follow-up. ConclusionsEarly-life lipid measurements are important for predicting adult levels. However, further research is needed to understand the tracking of non-high-density lipoprotein cholesterol and the stability of risk classification over time, which may further inform pediatric lipid screening and assessment strategies.

Caregiver Preferences for Primary Care Clinic-Based Food Assistance: A Discrete Choice Experiment

ObjectiveThe American Academy of Pediatrics recommends that pediatric providers screen families for food insecurity and connect them to appropriate resources. However, it is unclear how clinics can best provide families with resources consistent with their needs and preferences. In this study, we elicited caregiver preferences for clinic-based food assistance. MethodsWe conducted a cross-sectional discrete choice experiment in which caregivers at 2 pediatric primary care clinics were asked to choose between hypothetical food programs. Programs varied across 4 categories: 1) resources provided (eg, food delivery, food in clinic, assistance enrolling in benefits); 2) support staff providing resources (eg, social worker, community health worker, physician, or nurse); 3) outreach modality (eg, phone, email, text); and 4) outreach frequency. Multinomial logistic regression was used to assess caregiver preferences within each category and the relative importance of each category to caregiver decisions. ResultsWe surveyed 142 caregivers who were predominantly Black (87%) and Medicaid-insured (90%). Caregiver preferences for food programs were most strongly influenced by the food resources provided. Caregivers preferred food delivery over other forms of food supports, such as food provided in clinic. They preferred assistance from a benefits enrollment specialist, community health worker, or social worker to assistance from a physician or nurse. ConclusionsPediatric clinics serving families at risk of food insecurity should use caregiver preferences to inform the design of family-centered interventions. Clinics should consider connecting caregivers with food delivery programs, and pediatric payors should adopt reimbursement models that support multidisciplinary team-based care to address food insecurity.

Comparison of Clinical Decision Support Tools to Improve Pediatric Lipid Screening

ObjectiveTo test whether different clinical decision support tools increase clinician orders and patient completions relative to standard practice and each other. Study designA pragmatic, patient-randomized clinical trial in the electronic health record was conducted between October 2019 and April 2020 at Geisinger Health System in Pennsylvania, with four arms: care gap—a passive listing recommending screening; alert—a panel promoting and enabling lipid screen orders; both; and a standard practice—no guideline-based notification—control arm. Data were analyzed for 13,346 9 to 11 year-old patients seen within Geisinger primary care, cardiology, urgent care, or nutrition clinics, or who had an endocrinology visit. Principal outcomes were lipid screening orders by clinicians and completions by patients within one week of orders. ResultsActive (care gap and/or alert) versus control arm patients were significantly more likely (p<.05) to have lipid screening tests ordered and completed, with odds ratios ranging from 1.67 (95% CI: 1.28–2.19) to 5.73 (4.46–7.36) for orders and 1.54 (1.04–2.27) to 2.90 (95% CI: 2.02–4.15) for completions. Alerts, with or without care gaps listed, outperformed care gaps alone on orders, with odds ratios ranging from 2.92 (95% CI: 2.32–3.66) to 3.43 (2.73–4.29). ConclusionsElectronic alerts can increase lipid screening orders and completions, suggesting clinical decision support can improve guideline-concordant screening. The study also highlights electronic record-based patient randomization as a way to determine relative effectiveness of support tools.

Developing a General Population Screening Programme for Paediatric Type 1 Diabetes: Evidence from a Qualitative Study of the Perspectives and Attitudes of Parents

Introduction. With reliable tests and preventative treatments now available the United Kingdom has introduced a prototype population-based paediatric (ages 3–13) screening programme for type 1 diabetes (T1D). To aid its ethical and sustainable implementation this work explores parental views around the concept of this programme to determine how their involvement might be encouraged and supported. Research Design and Methods. Qualitative interviews were undertaken with 38 parents and the data were analysed using a purposely developed “Burden of Screening” framework, which presented the data within three domains describing the various elements of screening participation; pre-screening tasks designated to participants; factors influencing engagement with screening; and consequences of screening participation. Results. Regarding pre-screening tasks designated to participants, the importance of clear communication about the condition were apparent with parents expressing uncertainty of the benefits of screening against the potential anxiety engendered. In factors influencing their engagement with screening participants described their preference for less invasive testing techniques, the reassurance of structured support from healthcare professionals inherent within the programme, and the potential benefit of peer support. Regarding the consequences of screening participation parents described how a positive result might lead to overly protective behaviours, and anxiety from watching and waiting for the onset of symptomatic T1D. Conclusions. The benefits of T1D screening need to be clearly communicated to facilitate uptake. To this end the use of decision-support tools and better targeted educational materials should be explored. Post-testing, parents expressed preferences for peer support and access to psychological counselling.

Domestic violence as a risk factor of maternal filicide.

This paper will investigate precursors to maternal filicide, focusing on domestic violence. While psychosis is often well described, less frequently explored are the connections between prior trauma, domestic violence, depression, and filicide. We will discuss reasons why a woman may not disclose domestic violence and suggest possible areas for intervention. We present a case involving domestic violence, its impact on mental health, and eventual filicide. We then present an alternative scenario of the same case where filicide is considered, but is avoided. The case of the mother who experienced domestic violenceand was accused and sentenced for filicide is seen in greater relief by presenting the case in an alternative scenario with effective interventions. It is clear the availability and the ability to access community supports, such as obstetric and pediatric screening, psychiatric treatment, domestic violence shelters, intimate partner violence outreach services, parenting support groups, and hospital social work case management, tragedies such as filicide can be prevented. Traumatic early childhood experiences predispose people to a stress-response system that is more prone to inactivity and impulsivity. This can cause women in domestic violence relationships to stay, limit their options for family planning, become increasingly depressed, not seek community support, and risk impulsive action of harming their child. This risk can be mitigated by building stable relationships with their medical team, treating depression, connecting with home visitation programs, and being empowered to access contraception.

Pain screening in youth with sickle cell disease: A quality improvement study.

Youth with sickle cell disease (SCD) face several challenges as they age, including increased pain frequency, duration, and interference. The purpose of this study was to (i) determine the feasibility of routine pain screening; (ii) identify and describe various clinical pain presentations; and (iii) understand preferences/resources related to engaging in integrative health and medicine (IHM) modalities within an outpatient pediatric SCD clinic. During routine outpatient visits, patients aged 8-18 completed measures of pain frequency, duration, and chronic pain risk (Pediatric Pain Screening Tool [PPST]). Participants screening positive for (i) persistent or chronic pain or (ii) medium or high risk for persistent symptoms and disability on the PPST were asked to complete measures of pain interference, pain catastrophizing, and interest in/resources for engaging in IHM modalities. Between March 2022 and May 2023, 104/141 (73.8%) patients who attended at least one outpatient visit were screened. Of these 104 (mean age 12.46, 53.8% female, 63.5% HbSS), 34 (32.7%) reported persistent or chronic pain, and 48 (46.2%) reported medium or high risk for persistent symptoms and disability. Patients completing subsequent pain screening measures reported a mean pain interference T-score of 53.2±8.8 and a mean pain catastrophizing total score of 24.3±10.2. Patients expressed highest interest in music (55.6%) and art therapy (51.9%) and preferred in-person (81.5%) over virtual programming (22.2%). Comprehensive pain screening is feasible within pediatric SCD care. Classifying patients by PPST risk may provide a means of triaging patients to appropriate services to address pain-related psychosocial factors.

Preferences for Pediatric and Perinatal HCV Screening and Treatment from Focus Group with Sex Workers

Preferences for Pediatric and Perinatal HCV Screening and Treatment from Focus Group with Sex Workers

Pediatric obstructive sleep apnea screening and management practices among Brazilian Dental Specialists

Pediatric obstructive sleep apnea screening and management practices among Brazilian Dental Specialists

Interprofessional education within a nurse practitioner led paediatric service: A multi-methods study

AimThis project explored whether a nurse practitioner led mobile paediatric screening service in early learning centres could incorporate allied health and nursing students and develop their confidence in interprofessional collaboration. BackgroundInterprofessional collaboration is essential for health professionals across all contexts of care, including early childhood screening and intervention that enables children to thrive. MethodsThis multi-methods study (pre-test/post-test design) was conducted with nursing, physiotherapy, occupational therapy and nutrition and dietetics students attending clinical placement within the nurse practitioner led mobile paediatric service. Data were collected via pre and post placement surveys (ISVS-21) and post placement semi-structured interviews. ResultsTwelve students participated from July to December 2022. Survey findings demonstrated students improved inter-professional socialisation and readiness, supported by qualitative findings that uncovered unique mechanisms for how positive experiences were achieved. Unique pedagogical elements included 1) the nurse practitioner’s professional attributes and 2) the mobile nature of the service leveraging learning opportunities within the shared commute. ConclusionsThis study provides proof-of-concept of a placement model that facilitates interprofessional collaboration in nursing and allied health students. Further research should explore longer-term outcomes and scalability.

Patient and Community Health Global Burden in a World With More Celiac Disease

Celiac disease is one of the commonest life-long disorders worldwide, with a prevalence mostly ranging between 0.7 and 2.9 % in the general population and a higher frequency in females and in well-defined at-risk groups, such as relatives of affected individuals and patients with autoimmune co-morbidities. Increasing clinical detection is facilitated by improving awareness, implementation of a case-finding approach, and serology availability for screening at risk patients, among other factors. Nevertheless, due to huge clinical variability many CeD cases still escape diagnosis in most countries, unless actively searched by proactive policies. The burden of celiac disease is increasing as well as the need for better longitudinal care. Pediatric screening of the general population could represent the road ahead for an efficient intervention of secondary prevention aimed to reduce the social and health burden of celiac disease. This review analyses the epidemiology of celiac disease continent by continent, discusses current strategies to improve the detection of celiac disease, and highlights challenges related to the burden of celiac disease globally.

Malnutrition care in hospitalized pediatric inpatients: comparison of perceptions and experiences across two pediatric academic health sciences centres.

Malnutrition affects up to one in three Canadian children admitted to hospital. Awareness among pediatric healthcare providers (HCPs) of the prevalence and impacts of hospitalized malnutrition is critical for optimal management. The purpose of this study was to determine perceptions of malnutrition among pediatric HCP across two major academic health sciences centres, and to determine how the use of a standardized pediatric nutritional screening tool at one institution affects responses. Between 2020 and 2022, 192 HCPs representing nursing, dietetics, medicine, and other allied health were surveyed across McMaster Children's Hospital and The Hospital for Sick Children. 38% of respondents from both centres perceived rates of malnutrition between approximately one in three patients. Perceptions of the need for nutritional screening, assessment, and management were similar between centres. All respondents identified the need for better communication of hospitalized malnutrition status to community providers at discharge, and resource limitations affecting nutritional management of pediatric inpatients. This study represents the largest and most diverse survey of inpatient pediatric HCPs to date. We demonstrate high rates of baseline knowledge of hospital malnutrition, ongoing resource challenges, and the need for a systematic approach to pediatric nutritional management.

Maternal neighbourhood-level social determinants of health and their association with paediatric hepatitis C screening among children exposed to hepatitis C in pregnancy.

Current guidelines recommend HCV screening by 18 months of age for those exposed to HCV in utero; yet, screening occurs in the minority of children. To evaluate the association between maternal neighbourhood-level social determinants of health (SDOH) and paediatric HCV screening in the general population in a publicly funded healthcare system in Canada. Retrospective cohort study using administrative healthcare data held at ICES. Children born to individuals positive for HCV RNA in pregnancy from 2000 to 2016 were identified and followed for 2 years. Major SDOH were identified, and the primary outcome was HCV screening in exposed children (HCV antibody and/or RNA). Associations between SDOH and HCV screening were determined using multivariate Poisson regression models adjusting for confounding. A total of 1780 children born to persons with +HCV RNA were identified, and 29% (n = 516) were screened for HCV by age two. Most mothers resided in the lowest income quintile (42%), and most vulnerable quintiles for material deprivation (41%), housing instability (38%) and ethnic diversity (26%) with 11% living in rural locations. After adjustment for confounding, maternal rural residence (risk ratio [RR] 0.82, 95% confidence interval [CI] 0.62, 1.07) and living in the highest dependency quintile (RR 0.83, 95% CI 0.65, 1.07) were the SDOH most associated with paediatric HCV screening. Younger maternal age (RR 0.98 per 1-year increase, 95% CI 0.97, 0.99), HIV co-infection (RR 1.69, 95% CI 1.16, 2.48) and GI specialist involvement (RR 1.18, 95% CI 1.00, 1.39) were associated with higher probabilities of screening. Among children exposed to HCV during pregnancy, rural residences and living in highly dependent neighbourhoods showed a potential association with a lower probability of HCV screening by the age of 2. Future work evaluating barriers to paediatric HCV screening among rural residing and dependent residents is needed to enhance the screening.

Adverse Childhood Experiences and Related Events are Associated with Asthma Symptoms in Children

ObjectiveTo examine the association between adverse childhood experiences (ACEs) and related events and asthma symptom burden in children. MethodsThis is a cross-sectional study of baseline data from 147 participants with asthma from a cohort of children enrolled in the Pediatric ACEs Screening and Resiliency Study. Participants completed the PEdiatric ACEs and Related Life Events Screener (PEARLS) tool, a 17-item questionnaire, capturing 3 domains of childhood adversity—child maltreatment, household challenges, and social context. Asthma symptom burden was assessed using the International Study of Asthma and Allergies in Childhood core questionnaire, which asks participants to identify the presence and frequency of severe wheezing that limits speech, wheezing with exercise, nocturnal wheezing, and nocturnal cough in the last 12 months. Using multivariable logistical regression models, we examined the relationship between reported PEARLS and asthma symptoms. ResultsOf children with asthma, 86% reported at least 1 adversity, with 48% reporting 4 or more. The odds of severe wheeze limiting speech increased by 19% with each additional reported adversity captured by the PEARLS tool (95% confidence intervals (CI) 1.01–1.41). Increasing PEARLS scores were also associated with 16% increased odds of reporting wheeze with exercise (95% CI 1.03–1.31). Wheezing with exercise was associated with the household challenges domain (odds ratio (OR) 1.34; 95% CI 1.05–1.72), while severe wheeze limiting speech was associated with the social context domain (OR 1.75; 95%CI 1.02–3.02). ConclusionsChildhood adversities are associated with increased asthma symptom burden, suggesting the tool may be helpful in identifying children at risk for poorly controlled asthma.

Artificial intelligence enhanced ophthalmological screening in children: insights from a cohort study in Lubelskie Voivodeship

This study aims to investigate the prevalence of visual impairments, such as myopia, hyperopia, and astigmatism, among school-age children (7–9 years) in Lubelskie Voivodeship (Republic of Poland) and apply artificial intelligence (AI) in the detection of severe ocular diseases. A total of 1049 participants (1.7% of the total child population in the region) were examined through a combination of standardized visual acuity tests, autorefraction, and assessment of fundus images by a convolutional neural network (CNN) model. The results from this artificial intelligence (AI) model were juxtaposed with assessments conducted by two experienced ophthalmologists to gauge the model's accuracy. The results demonstrated myopia, hyperopia, and astigmatism prevalences of 3.7%, 16.9%, and 7.8%, respectively, with myopia showing a significant age-related increase and hyperopia decreasing with age. The AI model performance was evaluated using the Dice coefficient, reaching 93.3%, indicating that the CNN model was highly accurate. The study underscores the utility of AI in the early detection and diagnosis of severe ocular diseases, providing a foundation for future research to improve paediatric ophthalmic screening and treatment outcomes.

Efeitos tardios do uso de cafeína no sono de crianças nascidas prematuras

ABSTRACT Objective: This study aimed to evaluate whether the therapeutic use of caffeine for premature newborns is associated with changes in sleep habits and the presence of obstructive sleep apnea in childhood. Methods: This is a cross-sectional single-center study in which the caretakers of 87 children aged 5–10 years, born full-term or preterm, treated or not with caffeine in the neonatal period, answered questionnaires to screen for obstructive sleep apnea (Pediatric Obstructive Sleep Apnea Screening Tool [PosaST]) and to characterize the sleep habits (Children's Sleep Habits Questionnaire [CSHQ]) of their children. ANOVA and linear regression tests were performed to verify possible differences between the groups. Results: Children born prematurely who were treated with caffeine woke up significantly later on weekdays than those born at term (09h±00h58 and 07h43±1h15, respectively, p=0.022) and had longer total daily sleep time also compared to those born at term (10h24±1h08 and 09h29±1h08, respectively, p&lt;0.001). There was no significant difference between the three groups in overall PosaST and CSHQ scores. Conclusions: Caffeine use in the neonatal period did not impair sleep habits later in life and did not lead to increased obstructive sleep apnea scores in prematurely born children compared to those born at term.

Pediatric hearing screening: Exploring the need for a three-tier screening strategy

Abstract Pediatric hearing impairment is a global health problem and has implications on the individual as well as the society. Undiagnosed hearing impairment has immense economic burden on the family, society, and nation. The challenge lies in diagnosing pediatric hearing impairment early so that effective treatment or rehabilitation can be initiated. Even though universal newborn hearing screening has been implemented in many countries, yet the coverage of the program has not been uniform throughout. Further, many cases of childhood deafness are known to manifest later in the school going age. As such, reliance on hearing screening in the newborn period alone will lead to many undiagnosed cases of hearing impairment. Therefore, a viewpoint is provided here for a three-tiered screening strategy so that maximum cases of hearing impairment can be diagnosed and effective treatment can be initiated, thereby reducing the global economic burden of pediatric hearing impairment.

Sleep habits and orofacial myofunctional self-assessment of children at risk for sleep breathing disorders.

To identify orofacial myofunctional complaints and sleep-disordered breathing and correlate them with sleep habits in childhood. The study included 71 parents/guardians of public school children aged 6 to 11 years. They answered a form with semi-structured medical history questions and the Nordic Orofacial Test-Screening - interview, the Pediatric Obstructive Sleep Apnea Screening Tool Questionnaire, and the Children's Sleep Habits Questionnaire - all of them in their Portuguese/Brazilian versions in an online format. Statistical analyses used Spearman's correlation, setting the significance level at 5%. There were 29 female children (40.8%) and 42 male ones (59.2%), with a mean age of 8.52 years. The study found orofacial myofunctional complaints related to breathing functions (35.2%), chewing and swallowing (32.4%), and deleterious habits (33.8%). All children were at a low risk of sleep-disordered breathing. As for sleep habits, 23 children (32.39%) had a lower total score, whereas 48 children (67.61%) exceeded 41 points. There was a correlation between the risk of sleep-disordered breathing in children with complaints of orofacial myofunctional disorders and poor sleep quality/habits.

Children Anxiety and Pain while Performing Interim Therapeutic Restorations with Hand Instruments compared to Rotary Instruments: A Randomised Clinical Trial

Introduction: Children with dental anxiety may avoid visiting the dentist until a more serious and painful condition develops. Dentists could use less stressful techniques, like Interim Therapeutic Restorations (ITR), to treat dental cavities in difficult or young patients. ITR performed with hand tools may be preferred due to the absence of handpiece vibration, sound, or smell. Aim: To assess the anxiety and pain levels experienced by children during ITR procedures performed with hand instruments compared to rotary instruments. Materials and Methods: The present randomised clinical trial was conducted in the Department of Pediatric Dentistry at King Abdulaziz University Dental Hospital in Jeddah, Saudi Arabia. The inclusion criteria consisted of children aged 3-12 years visiting the dental clinic for the first time and having a carious primary anterior (incisor or canine) tooth. Patients were recruited from the paediatric screening clinic and randomly assigned to either the “Hand instrument group” or the “Rotary instrument group.” Caries excavation was performed using a hand instrument in the former group, while a low-speed handpiece was used in the latter group. Anxiety levels were assessed using Venham’s anxiety rating scale before and after the procedure. Heart rate was measured using pulse oximetry every two minutes. Pain levels were evaluated using the Wong-Baker Faces Pain Rating Scale after completing the procedure. Results: The study included 60 patients, with a mean age of 5.87±2.09 years. The anxiety score after the procedure was significantly lower in the hand instrument group compared to the rotary instrument group (p=0.007). Although the heart rate was lower in the hand instrument group compared to the rotary instrument group, the difference was not statistically significant. The subjects in the hand instrument group reported lower pain levels compared to those in the rotary instrument group (p=0.029). Conclusion: Performing ITR using hand instruments resulted in reduced anxiety and pain levels among young children compared to ITR performed using rotary handpieces.

Utility of a Pediatric Psychosocial Screener in an Outpatient Burn Clinic.

Psychosocial concerns are common among youth who sustained a burn injury. Detecting psychosocial distress early is essential to ensure appropriate treatment and referrals. Thus far, research has focused largely on the long-term outcomes of pediatric burn survivors. The current quality improvement initiative details the implementation and outcomes of brief, pragmatic screening to assess psychosocial concerns among pediatric burn survivors in an outpatient setting. A primary caregiver completed an age-appropriate psychosocial screener for youth aged 4-10 years (n = 69), while patients aged 11-17 years (n = 72) completed a self-report screener. Total scores were used to categorize patients as acute risk (i.e., emotional concerns requiring immediate attention), moderate risk (i.e., elevated symptoms, but no immediate safety concerns), or low risk (i.e., endorsing few to no symptoms). Patients with acute risk were evaluated by medical staff to determine the need for immediate psychiatric intervention or social services referrals. Patients with moderate risk met with the on-site psychology team during their clinic visit or were contacted by telephone within 1 week. Patients in the low-risk category warranted no additional follow-up post-screening. Most patients scored in the low-risk category (n = 120; 85%), while 11% (n = 16) and 4% (n = 5) endorsed symptoms consistent with moderate and acute risk, respectively. Results demonstrate the utility of implementing pediatric psychosocial screening in an outpatient burn clinic, the importance of detecting psychosocial concerns in this context, and usage of referrals to address concerns. Findings also shed light on key caveats of psychosocial screening, barriers to accessing psychosocial support, and the potential benefits of embedded psychological support during medical visits.