Identifying Social Needs in Social Prescribing Pathways in Viet Nam: When Screening Helps, When Conversation Matters, and What Should Happen Next

Identifying Social Needs in Social Prescribing Pathways in Viet Nam: When Screening Helps, When Conversation Matters, and What Should Happen Next

Category: Implementation & Practice

Social prescribing usually begins before a referral is made. Someone first has to recognize that a person's health, well-being or everyday life may be affected by circumstances that clinical treatment alone cannot address. That recognition may emerge from a structured questionnaire, a routine consultation, a “what matters” conversation, a social-work assessment, a caregiver's concern or something the person raises themselves. The method matters, but what matters even more is what the organization does with what it learns.

This distinction is particularly important for Viet Nam. Social prescribing has not been established as a national service model, and there is no evidence-based requirement that everyone should complete a standardized social-needs screening tool before entering a social-prescribing pathway. International experience with structured social-needs screening is much more developed, particularly in the United States, but recent systematic reviews show substantial variation in who is screened, how screening is delivered, what happens after a positive response and whether people actually receive assistance. Current evidence does not justify simply importing one universal screening model into another health system.

A more useful question for Viet Nam is therefore not “Which screening tool should we adopt?” It is: “What do we need to understand about this person's circumstances, how should we ask, and what are we prepared to do when a need becomes visible?”

Social determinants, social risks and social needs are related, but not identical

The terminology can become confusing quickly. Social determinants of health refer broadly to the social, economic and structural conditions that shape people's lives and health, including income, housing, education, employment, transport, social inclusion and public policy. At the individual level, people may experience particular adverse circumstances, often described in healthcare literature as social risks, such as housing instability, financial strain, transport barriers or social isolation.

In one widely used healthcare lexicon, social needs are distinguished from social risks by incorporating the person's own priorities and preferences for assistance. This distinction is useful rather than absolute because terminology varies across countries, disciplines and health systems. Its practical importance is that a positive answer on a questionnaire should not automatically be treated as a need for intervention.

Someone may experience several social risks but want assistance with only one of them. A screening form might identify transport difficulty, financial strain and loneliness, but the person may explain that transport is manageable with family help, finances are not something they want to discuss, while social isolation has become the issue affecting them most. Another person with exactly the same screening responses may have entirely different priorities. A screening result can therefore open a conversation; it should not replace one.

When can structured screening help?

Structured screening can have real advantages. It can help organizations ask consistently about issues that busy professionals might otherwise overlook, provide people with opportunities to disclose difficulties, identify patterns across a population and reduce dependence on whether an individual clinician happens to think of a particular question. It can also create a useful starting point for navigation when the pathway has clearly defined responses to the issues being identified.

Recent evidence also shows why screening should not be treated as a simple technical intervention. A 2026 Annals of Internal Medicine systematic review examined 23 U.S. primary-care studies involving structured screening and intervention for issues such as food insecurity, transportation and housing insecurity. Screening and assistance rates varied substantially. Programs focused on smaller, defined populations and those with additional staffing tended to screen and assist a higher proportion of people, while clinical and healthcare-use outcomes were reported less consistently and findings were mixed. The heterogeneity between programs prevented straightforward recommendations for universal implementation.

A complementary systematic review by the same research team, published in September 2026 in Preventive Medicine, examined contextual factors across 29 studies reported in 41 articles. Implementation was supported by standardized but adaptable workflows, dedicated multidisciplinary staffing, leadership support, staff training, practice champions and coordination with community organizations. Common barriers included limited time, staff shortages, increased caseloads generated by screening, workflow and referral-tracking problems and insufficient community resources. Patients valued individualized assistance, navigation, timely follow-up and trusting relationships.

These studies come from U.S. primary care and should not be interpreted as evidence that Viet Nam should reproduce those programs. Their more transferable lesson is simple: screening creates work downstream. If an organization asks more people about social difficulties, it needs enough capability to respond to what it finds.

Screening is therefore most useful when its purpose is clear, the population and domains are appropriate, staff understand what happens next, meaningful responses are available and the organization is prepared to learn from the process. It becomes much less useful when introduced mainly because collecting social data appears innovative or because an organization wants to increase referral numbers.

Screening everyone is not automatically better, and selective screening also has risks

One difficult implementation question is who should be asked. Universal screening can provide a consistent opportunity for disclosure and reduce the risk that professionals rely on assumptions about who “looks socially vulnerable.” Selective identification, particularly when based informally on appearance, neighborhood, occupation or perceived socioeconomic circumstances, can create stigma and inequity.

At the same time, universal screening can create substantial workload and may identify needs that an organization has little ability to address. Recent implementation evidence suggests that smaller or more focused programs may sometimes be more feasible, particularly where staff and community capacity are limited. That does not demonstrate that targeted screening is inherently superior. It shows that reach without response capacity is not necessarily meaningful implementation.

For an early Vietnamese pilot, the choice between broader and more targeted identification should therefore be deliberate. A hospital might initially focus on a clearly defined population where social circumstances are particularly relevant to discharge or continuity of care. A primary-care service might integrate a small number of questions into an existing chronic-care pathway. Another setting may rely more heavily on person-centered conversation and professional judgment, with structured questions used when concerns arise.

The important point is to avoid two extremes: profiling people based on assumptions and screening everyone simply because technology makes it possible.

Conversation matters because questionnaires cannot determine what matters

Structured tools can identify patterns, but they are much less able to determine context, priority and readiness for assistance. A qualitative study published in September 2026 explored standardized social-needs screening among 195 adults across four Canadian provinces. Participants were generally open to being asked, but privacy, financial information, housing, employment and how the information would be used emerged as important concerns. Trust, clarity about why questions were being asked and confidence that the information would serve a useful purpose were central to acceptability.

This is Canadian evidence, not evidence about Vietnamese patients. The implementation lesson is nevertheless relevant. Questions about money, housing, family relationships, isolation or personal safety can be sensitive. People may worry about judgment, confidentiality or whether disclosing a problem could affect the care they receive. They may also simply not want healthcare to become involved in a particular part of their lives.

A person-centered conversation should therefore explain why an issue is being discussed, give the person an appropriate opportunity not to answer, clarify what support is realistically available and leave room for priorities that a standardized tool may have missed. It should distinguish between a difficulty that exists and a difficulty the person wants help addressing now.

This is where the “what matters” principle becomes particularly important. The aim is not to generate the longest possible list of deficits. It is to understand what may be affecting the person's health or everyday life and whether healthcare, professional social work, navigation, community resources or another service can offer an appropriate response.

Do not ask a question without thinking about the response

One of the most important implementation principles is to design the response pathway before expanding the identification process. Imagine asking thousands of people whether they struggle with transport, food, caregiving, loneliness, debt or housing while staff have no current resource directory, no navigator, insufficient social-work capacity, no escalation process and no way to follow what happens next. The organization may generate useful prevalence data, but the person may experience something very different: a problem was identified and then nothing meaningful happened.

The 2026 implementation review is particularly relevant here because insufficient community resources, staffing constraints, screening-generated caseloads and weak referral tracking repeatedly affected implementation. Organizations should therefore consider likely responses before deciding which domains to screen. If there is no credible pathway for a particular issue, leaders need to decide whether there is still a justified reason to collect that information and what they will tell the person about the limits of available support.

This does not mean healthcare should ask only about problems it can solve itself. Many determinants of health are far beyond the legitimate capacity of a healthcare organization. There is, however, an important difference between recognizing a need that requires another sector and collecting information with no plan for what happens afterward.

Social prescribing should not promise to solve poverty, inadequate housing, unemployment or structural inequality. Its contribution is narrower: it may help some people navigate existing support, strengthen social or community connections and make the interface between healthcare and community resources more workable.

A positive screen does not automatically mean social prescribing

Once a social risk or need becomes visible, the next decision should not automatically be “refer to social prescribing.” Different findings require different responses. Severe psychological distress, acute clinical deterioration, abuse, violence or another urgent safety concern may require immediate clinical, protective, emergency or other formal action. Complex psychosocial assessment, counseling, case management or specialized intervention may fall within professional social work or another regulated service. Administrative or insurance difficulties may require institutional information or assistance rather than community navigation. Medication-related problems require clinical review, not a community activity.

Social prescribing may be relevant when a priority can reasonably be supported through non-clinical community resources and navigation, and when the person wants that kind of support. Even then, the intensity of support should vary. One person may need only information or signposting, while another may need active navigation, help overcoming access barriers and appropriate follow-up to see whether a connection occurred.

Sometimes the appropriate outcome is simply no further action for now. A person may acknowledge a difficulty but not want assistance. Unless a separate clinical, legal, protection or safety obligation requires action, respecting that decision is part of person-centered care.

The practical sequence is therefore closer to identify → understand → prioritize → determine the appropriate response → agree what happens next, rather than screen → positive → refer.

Viet Nam already has relevant professional structures, social prescribing should not duplicate them

This issue is particularly important in hospitals because Viet Nam already has a formal regulatory framework for hospital social work. Circular No. 51/2024/TT-BYT, effective from 1 March 2025, applies to medical examination and treatment establishments licensed to operate in the form of hospitals. Its provisions include assessment of psychological and social risks and needs for screening and classification, coordination of support and, where necessary, referral to appropriate organizations, alongside other social-work interventions.

Decree No. 110/2024/ND-CP on Social Work, effective since 15 October 2024, provides the broader regulatory framework for social work and social-work practice. Circular No. 29/2026/TT-BYT, effective from 25 August 2026, further regulates social-work practice and the updating of social-work knowledge.

These instruments do not establish social prescribing in Viet Nam. They do mean that a hospital developing a social-prescribing pathway should not create a parallel social-needs assessment system without examining how the new process relates to existing hospital social-work functions and responsibilities.

A brief navigation question intended to understand whether someone would like support reconnecting with community activity is not automatically equivalent to a professional psychosocial assessment. But if a new “social prescribing screen” begins assessing complex family circumstances, psychological risk, abuse, crisis needs or situations requiring professional case management, the distinction becomes much more important.

The relevant question is therefore not what the form or role is called. It is what functions are actually being performed, by whom and within which professional and organizational framework.

Emerging Vietnamese evidence supports attention to social needs, but not a national screening model

Recent Vietnamese research provides useful local context, but it should not be mistaken for evidence that social-prescribing screening has been validated in Viet Nam.

A 2026 cross-sectional study involving 360 patients aged 60 years and older at Thu Duc General Hospital found moderately high perceived need for hospital social-work services. Policy, insurance and administrative guidance ranked highest, followed by resource linkage and post-discharge support and psychosocial support. Perceived needs varied with factors including education, living arrangement, income or pension, self-care capacity and treatment or support circumstances. The authors proposed a tiered response combining universal information, targeted social-needs screening and more intensive coordination for patients with particular vulnerabilities.

Another 2026 cross-sectional study involving 369 adult inpatients at Hanoi Medical University Hospital reported substantial demand for social-work services. The highest reported need was counseling about warning signs requiring follow-up care and appointment reminders, followed by administrative guidance and treatment-cost counseling, financial assistance with hospital fees and support related to rehabilitation services.

These studies matter because they show that Vietnamese patients may have significant needs extending beyond immediate clinical treatment. But both concern hospital social work and patient support, not the effectiveness of social prescribing, and neither establishes a social-needs screening instrument that should be adopted nationally.

Their more appropriate contribution is to show why social circumstances deserve systematic attention in Vietnamese healthcare — and why the response may need to combine clinical care, professional social work, administrative support, rehabilitation, family support and community navigation rather than route every identified issue into social prescribing.

Identification needs to be equitable, not simply standardized

Standardization can improve consistency, but it does not automatically create equity. A questionnaire may be more difficult for someone with limited literacy, visual impairment, cognitive difficulties or limited digital access. Questions translated literally may not carry the same meaning across languages or cultural contexts. Someone accompanied by family may not feel comfortable disclosing financial problems, family conflict or interpersonal safety concerns. A person who has experienced stigma in healthcare may be less willing to disclose difficulties even when a questionnaire is technically accessible.

A 2024 mixed-methods study involving 511 primary-care patients in western Colorado found that receiving an explanation about social-needs screening was associated with greater comfort and perceived helpfulness. People reporting three or more needs were less likely to feel comfortable with screening, while qualitative interviews highlighted the influence of previous stigmatizing experiences and the quality of relationships with healthcare teams. These findings reinforce the importance of how screening is introduced, not simply whether it is administered.

An equitable identification process therefore requires more than giving everyone the same form. It should consider how questions are explained, who is present, whether assistance is available, whether people can respond privately, whether the wording is understandable and whether alternative ways of discussing social circumstances are available.

Organizations should also pay attention to who is not being reached. A screening process can produce a high overall completion rate while disproportionately missing people with disability, limited literacy, poor digital access or particular language needs. A high headline number can therefore conceal an equity problem.

Social-needs data should not become “collect first, decide later”

Social-needs identification creates a data-governance responsibility. A screening process or conversation may collect identifiable information about housing, employment, finances, relationships, disability, health, caregiving or personal safety. These data do not all necessarily fall into the same legal category, but when they relate to an identifiable or identifiable natural person they may constitute personal data, while some information may fall within categories requiring heightened protection.

Viet Nam's Law No. 91/2025/QH15 on Personal Data Protection has been in force since 1 January 2026. Article 26 requires the data subject's consent for the collection and processing of personal data relating to health, except in the circumstances specified in Article 19(1). Decree No. 356/2025/ND-CP, also effective from 1 January 2026, includes health status among categories of sensitive personal data.

For a Vietnamese social-prescribing pathway, the practical implication goes beyond placing a consent statement beside a questionnaire. Organizations need to define why each data element is being collected, who needs access, whether the information is necessary for the intended purpose or merely interesting for evaluation, how it will be protected, how long it should be retained and what information, if any, needs to move to a community organization.

A community group does not automatically need a person's full social-needs screening record merely because it receives a referral. Information sharing should follow the function of the pathway. If a community partner only needs contact information and enough context to understand the requested support, sharing substantially more information may create unnecessary privacy risk.

Collecting more social data is not the same as understanding people better.

What could an early identification pathway in Viet Nam look like?

An early pilot does not need a questionnaire covering 20 domains. It might begin in one setting, with one clearly defined population and a small number of social issues that are relevant to the purpose of the pathway and for which credible responses exist.

Before implementation, the organization would decide why those issues matter, how people will be asked, who reviews the responses, which findings require urgent escalation, which belong to professional social work or another service, which may be suitable for community navigation and what happens when the person does not want assistance. Staff need enough preparation to explain the questions, respond respectfully to disclosure and avoid making promises that the pathway cannot fulfill.

Structured questions could be combined with a simple person-centered prompt asking whether any of the issues identified are something the person would actually like help with. The wording should be tested locally rather than translated uncritically from an international instrument.

Early cases should then be reviewed closely. Are people comfortable with the questions? Are some domains routinely misunderstood? Are staff avoiding questions because they feel too sensitive or because consultation time is limited? Are positive responses generating more workload than the navigator or social-work team can manage? Are available resources genuinely accessible? Do people who ask for help reach appropriate support?

If a question repeatedly identifies a problem for which the organization has no credible response, that should trigger a decision about the design of the pathway rather than simply becoming another number in a dataset.

Measure the quality of identification, not just the screening rate

A program can report that 95% of eligible patients completed a questionnaire and still tell us very little about whether the process is useful. Evaluation should therefore extend beyond completion and positivity rates.

An early Vietnamese pilot could examine how many people were offered the process, how many participated, how many identified one or more social risks, how many said they wanted assistance, what forms of response were appropriate, how many accepted navigation or referral, how many actually reached support and how many remained unresolved.

The differences between these numbers matter. If many people screen positive but few want assistance, the tool may be identifying social risks rather than person-prioritized needs. If many people request help but few receive an appropriate response, the bottleneck may be staffing or workflow. If referrals are made but connections rarely occur, the problem may lie in navigation, community capacity or accessibility.

The organization should also examine whether completion, disclosure, requests for assistance and successful connections differ between groups in ways that suggest inequity. Staff experience matters as well: How much time does the process require? Does it fit normal workflow? Do professionals know what to do when someone discloses an urgent or complex problem? Are community partners receiving appropriate referrals?

This turns social-needs identification from a measurement exercise into a learning system.

Identification should lead to a conversation, not a label

The value of identifying social needs lies neither in the questionnaire itself nor in producing a more complete social profile of every patient. Its value lies in helping healthcare recognize when something outside conventional clinical treatment may matter, giving people a safe opportunity to say what is important to them and connecting those who want assistance with an appropriate response.

Sometimes that response will involve social prescribing. Sometimes it will be professional social work, clinical care, rehabilitation, administrative or financial assistance, protection or emergency support, or another specialized service. Sometimes the person will choose not to act.

For Viet Nam, the responsible next step is therefore not to choose a national screening tool and begin asking everyone the same questions. It is to test how social needs can be identified respectfully, selectively or systematically where appropriate, linked to real response capacity, governed safely and interpreted through conversation rather than scores alone.

A useful test for any organization considering social-needs screening is:

If someone answers “yes,” do we understand what that answer means for this person, and do we know what should happen next?

If the answer to the second question is unclear, adding more screening may not be the first problem to solve.

References

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