Screening Children for SocialDeterminants of Health: ASystematic ReviewRebeccah Sokol, PhD,a Anna Austin, PhD,b Caroline Chandler, MPH,b Elizabeth Byrum, BA,b,c Jessica Bousquette, BA,b
Christiana Lancaster, BS,b Ginna Doss, MPH,b Andrea Dotson, MD,d Venera Urbaeva, MPH,b Bhavna Singichetti, MPH,b
Kanisha Brevard, PhD,c Sarah Towner Wright, MLS,e Paul Lanier, PhD,c Meghan Shanahan, PhDb
abstractCONTEXT: Screening children for social determinants of health (SDOHs) has gained attention inrecent years, but there is a deficit in understanding the present state of the science.
OBJECTIVE: To systematically review SDOH screening tools used with children, examine theirpsychometric properties, and evaluate how they detect early indicators of risk and inform care.
DATA SOURCES: Comprehensive electronic search of PubMed, Cumulative Index to Nursing andAllied Health Literature, Embase, Cochrane Central Register of Controlled Trials, and Web ofScience Core Collection.
STUDY SELECTION: Studies in which a tool that screened children for multiple SDOHs (definedaccording to Healthy People 2020) was developed, tested, and/or employed.
DATA EXTRACTION: Extraction domains included study characteristics, screening toolcharacteristics, SDOHs screened, and follow-up procedures.
RESULTS: The search returned 6274 studies. We retained 17 studies encompassing 11 screeners.Study samples were diverse with respect to biological sex and race and/or ethnicity. Screeningwas primarily conducted in clinical settings with a parent or caregiver being the primaryinformant for all screeners. Psychometric properties were assessed for only 3 screeners. Themost common SDOH domains screened included the family context and economic stability.Authors of the majority of studies described referrals and/or interventions that followedscreening to address identified SDOHs.
LIMITATIONS: Following the Healthy People 2020 SDOH definition may have excluded articles thatother definitions would have captured.
CONCLUSIONS: The extent to which SDOH screening accurately assessed a child’s SDOHs waslargely unevaluated. Authors of future research should also evaluate if referrals andinterventions after the screening effectively address SDOHs and improve child well-being.
aSchool of Public Health, University of Michigan, Ann Arbor, Michigan; bGillings School of Global Public Health, cSchool of Social Work, dSchool of Medicine, and eHealth Sciences Library,University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Dr Sokol defined the review scope; participated in the title and abstract review, full-text screen, and data abstraction; drafted sections of the initial manuscript; andmanaged the review team; Dr Austin defined the review scope; participated in the title and abstract review, full-text screen, and data abstraction; and drafted sectionsof the initial manuscript; Ms Chandler, Ms Bousquette, Ms Lancaster, Ms Doss, and Ms Byrum participated in the title and abstract review, full-text screen, and dataabstraction; Dr Dotson and Ms Urbaeva participated in full-text screen and data abstraction; Ms Singichetti and Dr Brevard participated in the title and abstract reviewand full-text screen; Ms Wright conducted the initial literature search and drafted sections of the initial manuscript; (Continued)
To cite: Sokol R, Austin A, Chandler C, et al. Screening Children for Social Determinants of Health: A Systematic Review. Pediatrics. 2019;144(4):e20191622
PEDIATRICS Volume 144, number 4, October 2019:e20191622 REVIEW ARTICLE by guest on October 21, 2020www.aappublications.org/newsDownloaded from
Social determinants of health(SDOHs), according to the WorldHealth Organization, are “theconditions in which people are born,grow, work, live, and age, and thewider set of forces and systemsshaping the conditions of daily life.”1
Healthy People 2020 organizes SDOHinto 5 key domains: economicstability (eg, poverty and foodinsufficiency), education (eg, highschool graduate and early childhoodeducation), social and communitycontext (eg, concerns aboutimmigration status and socialsupport), health and health care (eg,health insurance status and access toa health care provider), andneighborhood and built environment(eg, neighborhood crime and qualityof housing).2 Although SDOHsinfluence health and well-beingamong individuals of all ages, it isparticularly important to considerSDOHs among children and youthgiven that the physical, social, andemotional capabilities that developearly in life provide the foundationfor life course health and well-being.3
Thus, identifying and intervening onthe basis of these factors early couldserve as a primary prevention againstfuture health conditions.
Much controversy surroundsscreening children and youth forSDOHs, however. Some experts claimscreening is unethical if done withoutensuring that identified social needsare met, likewise generatingunfulfilled expectations.4,5 Othersargue that even in the absence ofreferrals, screening has benefits suchas improving diagnostic algorithms,identifying children and youth whoneed more support, improvingpatient-provider relationships, andcollecting data for an epidemiologicalpurpose.6–8 Although many childservice professionals feel ill-equippedto address patients’ social needswithin the current systems,9,10
several care teams cite that theyidentify unmet social needs and offerlinkages to social services.11,12 This
screening debate is largely centeredon a deficit in understanding thepresent state of the science: whatscreening tools exist? How accurateare they? How do screening resultsinform care? In the presentsystematic review, we aim to answerthese questions. Although authors ofprevious reports have outlineddifferent SDOH screening tools usedamong children in clinical settings,13,14
there has been no systematic reviewof SDOH screeners used amongchildren in various settings. In thisreview, we aim to systematicallycatalog the different SDOH screeningtools used to assess social conditionsamong children and youth, examinetheir psychometric properties, andevaluate how they are used to detectearly indicators of risk andinform care.
METHODS
Search Strategy
Authors of studies in this reviewdeveloped and/or used a tool toscreen children and youth for SDOHs.We systematically reviewed theliterature using a protocol informedby the Preferred Reporting Items forSystematic Reviews and Meta-Analysis (PRISMA) guidelines tosearch research databases, screenpublished studies, apply inclusionand exclusion criteria, and selectrelevant literature for review.15 Atrained clinical health scienceslibrarian (S.T.W.) performed ourcomprehensive electronic search ofpublications using the followingdatabases: PubMed, Cumulative Indexto Nursing and Allied HealthLiterature via EBSCO, Embase viaElsevier, Cochrane Central Register ofControlled Trials, and Web of ScienceCore Collection. Our search wasrestricted to English-only articles. Alldatabase results were collected fromthe inception of the database throughNovember 2018. Search terms wereused to retrieve articles addressingthe 3 main concepts of the search
strategy: (1) SDOHs, (2) pediatricpopulation, and (3) screeningadministered by a child serviceprovider (eg, a clinician, socialworker, or teacher) or in a serviceprovider setting (eg, self-administered at a pediatrician’soffice). The exact search strategy usedin each of the electronic databases isreported in the SupplementalInformation. Results weredownloaded to EndNote, andduplicates were removed. Allreferences were uploaded toCovidence systematic reviewsoftware (https://www.covidence.org), a web-based tool designed tofacilitate and track each step of theabstraction and review process.
Inclusion Criteria
We included studies in which a toolthat screened children (or caregiversand/or informants on behalf ofchildren) for multiple SDOHs wasdeveloped, described, tested, and/oremployed, where SDOHs are definedaccording to Healthy People 2020.2Given Healthy People 2020 guidedour understanding of SDOHs (anAmerican framework), to be includedin this review, studies had to beconducted within the United States,be peer-reviewed, and be publishedin English. Following these inclusioncriteria, we excluded studies ofscreeners that only screened for 1SDOH; did not conduct screeningamong children (age 0–25 years) ortheir caregivers and/or informants;were not published in English; wereconducted outside of the UnitedStates; or were book chapters,reviews, letters, abstracts, ordissertations.
Study Selection and Data Extraction
We used Covidence, an onlineplatform, to manage screening andselection of studies. For the title andabstract screening, each title wasindependently and blindly screenedby 2 authors, and a third authorresolved discrepancies. Theauthorship team followed this same
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independent, blind review for thefull-text review. At the end of the titleand abstract screen and full-textreview phase, the lead investigatorsreviewed the included studies toconfirm that all studies met theinclusion criteria. For any articles inquestion, the lead investigatorsconvened to determine the articles’inclusion statuses. At the conclusionof the full-text review, study authorsreviewed the reference lists ofincluded studies to identify anyadditional studies for inclusion.
After reviewing the full texts of studies,the research team developed a dataextraction tool in REDCap (a secure webplatform for building and managingonline databases and surveys) to extractthe following information: studycharacteristics (ie, author andpublication year, study type, studysetting, age range of screened children,sample size of screened children,percent female sex of screened children,race and/or ethnicity of screenedchildren, and study aims); screening toolcharacteristics (ie, average time tocomplete screener, screening setting,screening method, informant, trainingrequired for screening professionals,languages available, appropriate for low-literacy populations [ie, sixth gradereading level or lower], and validation);what SDOH domains the screenermeasured (per Healthy People 2020guidelines; ie, economic stability,education, health and health care,neighborhood and build environment,and social and community context2);and screening follow-up procedures (ie,results were discussed withrespondents, referrals were offeredand/or scheduled, and/or interventionwas delivered). Each primary reviewerextracted data from a set of studies thatpassed the research team’s full-textreview, and secondary reviewersconfirmed the primary reviewers’extraction to ensure that the primaryreviewer recorded accurate information.The team resolved any discrepanciesthrough discussion and consensus.
RESULTS
Study Selection
The electronic search of databasesreturned 6274 references (of which1223 were duplicates), resulting in 5051studies. In the initial title and abstractscreen, the research team deemed 4977studies irrelevant, leaving 74 full texts toreview. A total of 15 studies passed thefull screen review, and we identified 2additional studies from the referencelists of included studies. We retainedand abstracted 17 studies. Figure 1reveals the PRISMA flow diagram.
Study Characteristics
Table 1 reveals various studycharacteristics from the 17 studiesthat span 11 unique screeners. Withthe exception of 1 study,16 all studiestook place in a medical setting. Amongthe 14 studies in which the ages ofscreened individuals were reported,
the majority (ie, 8 studies) includedscreening for SDOHs exclusivelyin young childhood (ages 0 to5 years).11,16–22 Study samples wereprimarily evenly divided with respectto biological sex. Among the 13 studiesin which the races and/or ethnicitiesof screened individuals were reported,10 study samples containeda majority nonwhite sample.11,12,17,18,20–25
Screener Characteristics
Table 2 depicts SDOH screenercharacteristics from the 11 uniquescreeners included in this review.Screening was conducted in a doctor’sor pediatrician’s office for the majorityof screeners (ie, 8 screeners), witha parent or caregiver being the primaryinformant for all screeners. Twoscreeners included additionalinformation reported by a socialworker16 or physician.20 Screeners werecompleted via a variety of methods,
FIGURE 1PRISMA flow diagram.
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TABLE1StudyCharacteristics
ScreeningTool
Author
andYear
StudyType
Setting
Age
Range,y
Sample
Size
Female
Sex,%
Race
andEthnicity
(%)
StudyAim
SEEK
PSQ
Dubowitz
etal18
2007
OCPediatricclinicservingan
urban,
low-income
population
0–5
216
44AfricanAm
erican
(92);w
hite
(3);multiracial(5)
Estim
atetheprevalence
ofparental
depressive
symptom
sam
ongparentsat
apediatric
primarycare
clinicandevaluate
aparental
depression
screen
Dubowitz
etal17
2009
RCT
Pediatricclinicservingan
urban,
low-income
populationin
Baltimore,
Maryland
0–5
308
46AfricanAm
erican
(93)
Evaluate
theefficacy
oftheSEEK
model
ofpediatricprimarycare
inreducing
the
occurrence
ofchild
maltreatm
ent
Dubowitz
etal19
2012
RCT
Pediatricpractices
serving
suburban,m
iddle-income
populations
0–5
595
50AfricanAm
erican
(4);white
(86);Asian
American
(2);
Hispanic(1);other(8)
Exam
ineiftheSEEK
modelismoreeffectivein
reducing
maltreatm
entthan
standard
pediatricpracticewhenimplem
entedin
amiddle-incomesuburban
population
Eism
annet
al26
2018
Observational
only
Pediatricpractice,family
medicinepractice,andFQHC
servingvariouspopulations
0–18
1057
NRNR
Assess
thegeneralizabilityoftheSEEK
modeland
identifybarriers
andfacilitatorsto
integrating
theSEEK
modelinto
standard
clinicalpractice
iScreen
Gottliebet
al27
2014
RCT
Pediatricem
ergency
departmentservingalow-
incomeurbanpopulationin
California
0–18
538
NRNR
Compare
psychosocial
andsocioeconomic
adversity
disclosure
ratesby
caregivers
ofchildrenin
face-to-face
interviewsversus
electronicform
ats
Gottliebet
al12
2016
RCT
Primarycare
orurgent
care
departments
insafety-net
hospitalsservinglow-income
populations
inCalifornia
0–18
1809
51AfricanAm
erican
(26);w
hite
(4);AsianAm
erican
(5);
Hispanic(57)
Evaluate
ifaddressing
social
issues
during
pediatricprimaryandurgent
health
care
visits
decreasesfamilies’social
needsand
improves
children’shealth
HealthBegins
Upstream
RisksScreeningTool
Hensleyet
al28
2017
Observational
only
FQHC
servingSouthw
estern
Ohio
andNorthern
Kentucky
NR114
NRNR
Exploretheprocessof
system
aticallyscreening
pediatricpatientsandtheirfamilies
forSDOH
risks
FMI
McKelveyet
al16
2016
Observational
only
Homevisitingprogramsserving
at-riskfamilies
inthe
Southern
UnitedStates
0–5
1282
51AfricanAm
erican
(22);w
hite
(60);H
ispanic(16);other
(2)
Developan
assessmentof
children’sexposure
toACEs
ASKTool
Selvaraj
etal23
2018
Observational
only
Pediatricprimarycare
clinic
servingan
urban,low-
incomepopulationin
Chicago,Illinois
0–18
2569
48AfricanAm
erican
(55);w
hite
(7);AsianAm
erican
(5);
Hispanic(21);other
(12)
Determ
inetheprevalence
ofanddemographic
characteristicsassociated
with
toxicstress
risk
factors,theimpact
ofscreeningon
referral
ratesto
community
resources,and
feasibilityandacceptabilityinamedicalhome
IHELP
Colvin
etal29
2016
Observational
only
Pediatrichospitalin
Kansas
City,M
issouri
NR347
46AfricanAm
erican
(22);w
hite
(55);Asian
American
(1);
other(22)
Determ
ineifabriefinterventionusingmultiple
behavioral
strategies
toincrease
intervention
intensity
couldimprovescreeningforsocial
needsby
pediatricresidents
WECARE
survey
instrument
Garg
etal242007
RCT
Hospital-based
pediatricclinic
servingalow-income,urban
population
0–10
100
NRAfricanAm
erican
(96);w
hite
(1);Hispanic(3)
Evaluate
thefeasibility
andimpact
ofan
interventionon
themanagem
entof
family
psychosocial
topics
atwell-child
care
visits
Garg
etal112015
RCT
Community
health
centers
servingan
urbanpopulation
inBoston,M
assachusetts
0–5
168
NRAfricanAm
erican
(44);w
hite
(24);Asian
American
(2);
Hispanic(23);Pacific
Evaluate
theeffect
ofaclinic-based
screening
andreferral
system
onfamilies’receiptof
community-based
resourcesforunmet
basic
needs
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TABLE1
Continued
ScreeningTool
Author
andYear
StudyType
Setting
Age
Range,y
Sample
Size
Female
Sex,%
Race
andEthnicity
(%)
StudyAim
Islander
and/or
Native
Hawaiian(1);Multiracial(4)
Zielinskiet
al30
2017
Observational
only
Primarycare
pediatricpractice
servingalow-income
populationinRochester,New
York
NR602
NRNR
Evaluate
thefeasibility
andacceptabilityof
integratingtheWECARE
screen
into
allwell-
child
visits
toincrease
thedetectionof
family
psychosocial
needsandresultant
social
work
referrals
FAMNEEDS
Uwem
edimoand
May
252018
Observational
only
Hospital-based
pediatric
ambulatory
practicein
New
York
City,N
ewYork
0–18
299
NRAfricanAm
erican
(30);w
hite
(8);Hispanic(34);other
(26)
Determ
ineiftheintegrationof
FAMNEEDSinto
routinepediatriccare
services
atahospital-
basedpracticeincreasesthereferral
toand
receiptof
social
serviceresourcesam
ong
childrenin
immigrant
families
Child
ACETool
Marie-Mitchell
and
O’Connor
20
2013
Observational
only
FQHC
servingan
urban
population
0–5
102
0.51
AfricanAm
erican
(57);Hispanic
(43)
Pilottest
atool
toscreen
forACEs
andexplore
theabilityofthistooltodistinguishearlychild
outcom
esbetweenlower-andhigher-risk
children
Social
HistoryTemplateof
theStandard
WellChild
Care
Form
embedded
inE-health
Record
Beck
etal212012
Observational
only
Hospital-based
pediatricclinic
servingan
urbanpopulation
inCincinnati,
Ohio
0–5
639
48AfricanAm
erican
(71);w
hite
(20);other
(9)
Determ
inesocial
risk
documentationrates
amongnewbornsusinganewelectronic
template
Health-Related
Social
Problemsscreener
Fleegler
etal22
2007
Observational
only
Outpatient
pediatricclinics
servingan
urbanpopulation
inBoston,M
assachusetts
andMaryland
0–6
205
52AfricanAm
erican
(28);Hispanic
(57);other
(15)
Characterize
families’cumulativeburdensof
health-related
social
problemsregarding
access
tohealth
care,h
ousing,foodsecurity,
incomesecurity,and
intim
atepartner
violence;assessfamilies’experiences
regardingscreeningandreferral
forsocial
problems;andevaluate
parental
acceptability
ofscreeningandreferral
Agerange,samplesize,percent
femalesex,andrace
and/or
ethnicity
inform
ationreflectsthatofscreened
individualsonly.ASK,AddressingSocialKeyQuestions
forHealth;FAM
NEEDS,Family
NeedsScreeningProgram;FMI,Family
Map
Inventories;
FQHC,federallyqualified
health
center;N
R,notreported;O
C,observationalwith
comparisongroup;
RCT,random
ized
controlledtrial.
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including paper and pencil,11,17–20,23–26,30
computer or tablet,17–19,22,26,27 face-to-face interview,12,16,21,27–29 andphone interview.12,27 All screenerswere available in English, with7 screeners also available inSpanish.11,12,17–20,22–27,30 Threescreeners had validity and/orreliability assessed in $1 study.18,24,29
With respect to the time frame thatrespondents were asked to reflect onwhen answering questions aboutSDOHs, the majority of screeners (ie, 6
screeners) did not have a clearlydefined referent period (eg, past 30days, past year, or lifetime); the referentperiods for other screeners varied byquestion,18,22,28 and only 2 screenershad a single, clearly defined referentperiod for all included questions.16,24
Regarding how the SDOH screeners weredeveloped, only 4 screeners reportedbeing informed by practice18,21,24 and/orexpert opinion.18,21,23,24 Remainingscreeners were solely adaptations ofprevious tools or did not report howthey were developed.
Table 3 reveals the specific SDOHdomains assessed in each screener.Because many screeners were used toassess adverse childhood experiences(ACEs) (events that typically occurwithin the family context), for thepurposes of this review, we added anadditional domain labeled familycontext to the Healthy People 2020domains included in Table 3. Thefamily context domain was assessedin all screeners, and the economicstability domain was assessed in allbut 1 screener.20 Common areas
TABLE 2 Screening Tool Characteristics
Screening Tool ScreeningSetting
ScreeningMethod
Informant Training forScreening
Professionals
AverageTime toCompleteScreener,
min
AvailableLanguages
Appropriatefor
Low-LiteracyPopulations
Validity and/or ReliabilityAssessed
SEEK PSQ17–19,26 Doctor’s orpediatrician’soffice
Paper and pencil;computer ortablet
Parent orcaregiver
Yes 3–4 English; Spanish NR Yes18
iScreen12,27 Hospital Computer ortablet; face-to-face interview;or phoneinterview
Parent orcaregiver
Yes 10 English; Spanish Yes No
HealthBegins UpstreamRisks ScreeningTool28
Doctor’s orpediatrician’soffice
Face-to-faceinterview
Parent orcaregiver
Yes 6 English NR No
FMI16 Home Face-to-faceinterview
Parent orcaregiver;socialworker
Yes NR English NR No
ASK Tool23 Doctor’s orpediatrician’soffice
Paper and pencil Parent orcaregiver
Yes NR English; Spanish NR No
IHELP29 Hospital Face-to-faceinterview
Parent orcaregiver
Yes NR English NR Yes (validityonly)29
WE CARE surveyinstrument11,24,30
Doctor’s orpediatrician’soffice
Paper and pencil Parent orcaregiver
NR 4–5 English; Spanish Yes Yes24
FAMNEEDS25 Doctor’s orpediatrician’soffice
Paper and pencil Parent orcaregiver
Yes NR English; Spanish;HaitianCreole; Urdu;Punjabi; Hindi;Arabic
NR No
Child ACE Tool20 Doctor’s orpediatrician’soffice
Paper and pencil Parent orcaregiver;physician
NR 5 English; Spanish NR No
Social History Templateof the Standard WellChild Care Formembedded in E-healthRecord21
Doctor’s orpediatrician’soffice
Face-to-faceinterview
Parent orcaregiver
NR NR English NR No
Health-Related SocialProblems screener22
Doctor’s orpediatrician’soffice
Computer ortablet
Parent orcaregiver
NR 20 English; Spanish Yes No
ASK, Addressing Social Key Questions for Health; FAMNEEDS, Family Needs Screening Program; FMI, Family Map Inventories; NR, not reported.
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TABLE3SDOH
Domains
ScreeningTool
Econom
icStability
Education
Health
andHealth
Care
Neighborhood
andBuilt
Environm
ent
Social
and
Community
Context
Family
Context
SEEK
PSQ1
7–19,26
Food
insufficiency
—Sm
okealarm
needed
——
Parental
intim
atepartner
violence
Contactinform
ationfor
Poison
Controlneeded
Parental
depression
Parental
stress
Parental
drug
oralcohol
problems
Tobaccousein
thehome
Gunin
thehome
Help
with
thechild
isneeded
iScreen1
2,27
Food
insufficiency
Concerns
thechild
isnot
gettingneeded
services
Noor
inadequate
health
insurance
Concerns
aboutphysical
conditionsof
housing
Concerns
about
immigrationstatus
Violence
towardthechild
inthehousehold
Housinginstability
Lack
ofchild
care
Difficulty
gettinghealth
care
forthechild
Transportationdifficulties
Drug
oralcoholproblems
inthehousehold
Difficulty
paying
bills
Concerns
aboutthechild’s
behavioral
ormental
health
Threatsto
thechild’ssafety
atschoolor
intheneighborhood
Incarcerationof
ahouseholdmem
ber
Troublefindingajobor
otherjob-related
problems
Concerns
abouttheirow
nmentalhealth
ormental
health
care
Difficulty
gettingbenefits
orservices
Problemswith
child
supportor
custody
Disabilityinterferingwith
theabilityto
work
Noregularhealth
care
provider
Concerns
aboutfi
ndingactivities
forthechild
afterschoolor
insummer
Difficulty
getting
assistance
from
incomesupport
programs
Concerns
aboutchild
exposure
totobacco
smoke
Concerns
about
pregnancy-related
workbenefits
Concerns
aboutthechild’s
physical
activity
HealthBegins
Upstream
Risks
ScreeningTool28
Food
insufficiency
Parental
education
Parental
physical
activity
Concerns
aboutphysical
conditionsof
housing
Concerns
about
immigrationstatus
Parental
intim
atepartner
violence
victimization
Housinginstability
Concerns
aboutthe
child’slearning
orbehavior
inschool
Parental
fruitandvegetable
consum
ption
Transportationdifficulties
Religious
ororganizational
affiliation
Parental
stress
Difficulty
makingends
meetor
meetingbasic
needs
Concerns
aboutneighborhood
safety
Parental
social
support
Parental
maritalstatus
Parental
employment
FMI16
Food
insufficiency
——
——
Child
physical
abuse
Housinginstability
Child
sexual
abuse
Child
emotionalabuse
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TABLE3
Continued
ScreeningTool
Econom
icStability
Education
Health
andHealth
Care
Neighborhood
andBuilt
Environm
ent
Social
and
Community
Context
Family
Context
Maternalintim
atepartner
violence
victimization
Mentalillness
inthe
household
Substanceabusein
the
household
Parental
separationor
divorce
Family
mem
bers
feelclose
ASKTool23
Food
insufficiency
Parental
education
—Child
witnessedviolence
—Child
physical
abuse
Housinginstabilityor
difficulty
paying
bills
Lack
ofchild
care
Child
experiencedbullying
Child
sexual
abuse
Parental
employment
Parental
mentalillness
orsubstanceabuse
Need
forlegalaid
Child
separationfrom
caregiver
Adultin
child’slifewho
cancomfort
thechild
whensad
IHELP2
9Food
insufficiency
Concerns
aboutthe
child’seducational
needs
Concerns
aboutthechild’s
health
insurance
Concerns
aboutphysical
conditionsof
housing
—Violence
inhousehold
Housinginstability
WECARE
survey
instrument11,24,30
Food
insufficiency
Parental
education
——
—Intim
atepartnerviolence
inthehousehold
Housinginstability
Lack
ofchild
care
Parental
depressive
symptom
sDifficulty
paying
bills
Alcoholabusein
the
household
Parental
employment
Drug
usein
thehousehold
FAMNEEDS2
5Food
insufficiency
Parental
education
Help
needed
ingettinghealth
insurance
Concerns
aboutphysical
conditionsof
housing
Parental
experience
ofdiscrimination
Parental
experience
ofviolence
Housinginstability
Help
needed
gettingchild
care
orcare
for
elderlyadult
Transportationproblemsthat
preventhealth
care
visits
Parental
social
support
Parental
depressive
symptom
s
Difficulty
paying
bills
Health
literacy
Parental
tobaccouse
Difficulty
meetingbasic
needs
Parental
alcoholuse
Help
needed
ingetting
publicbenefits
Parental
drug
use
Help
needed
infinding
ajob
Unfairlyfiredfrom
job
Need
forlegalaid
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TABLE3
Continued
ScreeningTool
Econom
icStability
Education
Health
andHealth
Care
Neighborhood
andBuilt
Environm
ent
Social
and
Community
Context
Family
Context
Child
ACETool20
—Parental
education
——
—Child
maltreatm
entis
suspected
Intim
atepartnerviolence
inthehousehold
Mentalillness
inthe
household
Substanceabusein
the
household
Householdmem
beris
incarcerated
Parental
maritalstatus
Social
HistoryTemplateof
the
Standard
WellChild
Care
Form
embedded
inE-health
Record
21
Food
insufficiency
——
Concerns
aboutphysical
conditionsof
housing
—Parental
depressive
symptom
s
Difficulty
makingends
meet
Parent
andchild
safety
Difficulty
getting
assistance
from
incomesupport
programs
Health-Related
Social
Problems
screener
22Food
insufficiency
—Parent
andchild
health
insurancestatus
Concerns
aboutphysical
conditionsof
housing
—Parental
intim
atepartner
violence
victimization
Housinginstability
Noregularhealth
care
provider
Difficulty
paying
bills
Problemsreceivinghealth
care
Useof
incomesupport
programs
Parental
employment
Householdincome
ASK,Addressing
Social
KeyQuestions
forHealth;FAM
NEEDS,Family
NeedsScreeningProgram;FMI,Family
Map
Inventories;—,not
assessed.
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TABLE 4 Follow-up Procedures
Screening Tool Author and Year ResultsDiscussed
ReferralOfferedand/or
Scheduled
InterventionDelivered
Description
SEEK PSQ Dubowitz et al18
2007— — — No follow-up reported.
Dubowitz et al17
2009X X — Trained residents worked with parents to address
identified problems, including providing parents withuser-friendly handouts that detailed local resources,involving a SEEK social worker, and making referralsto community agencies.
Dubowitz et al19
2012X X — Health practitioners provided parents with handouts for
identified problems (eg, substance abuse)customized with local agency listings. A licensedclinical social worker was available at each SEEKpractice (either in person or by phone), and healthpractitioners and parents together decided whetherto enlist the social worker’s help. The social workerprovided support, crisis intervention, and facilitatedreferrals.
Eismann et al26
2018X X X Providers performed a brief intervention (∼5–10 min)
with caregivers who had a positive PSQ result usingthe reflect-empathize-assess-plan approach, whichuses principles of motivational interviewing to helpengage caregivers. Providers offered resources andreferrals to caregivers on the basis of caregiverneeds and desire for additional help. A social workerwas available by phone to all practices for assistancewith referrals.
iScreen Gottlieb et al27
2014— — — No follow-up reported.
Gottlieb et al12
2016X X X After standardized screening, caregivers either received
written information on relevant community services(active control) or received in-person help to accessservices with follow-up telephone calls for additionalassistance if needed (navigation intervention).Navigators used algorithms to provide targetedinformation related to community, hospital, orgovernment resources addressing needs caregivershad prioritized. Resources ranged from providinginformation about child-care providers,transportation services, utility bill assistance, or legalservices to making shelter arrangements or medicalor tax preparation appointments to helpingcaregivers complete benefits forms or other programapplications. Follow-up meetings were offered every 2wk for up to 3 mo until identified needs were met orwhen caregivers declined additional assistance.
HealthBegins Upstream RisksScreening Tool
Hensley et al28
2017X X — After screening, at-risk results were cross-walked to
a community resources guide built to identify localagencies and programs that addressed the socialneeds covered by the screening tool. Patients andfamilies were offered assistance in making contactwith the referred community resources as well ashelp in accessing other supportive services not listedin the community resources guide.
FMI McKelvey et al16
2016— — X All participants were screened at the time of
implementation of home visiting programs (ie, 2-generation programs designed to serve at-riskfamilies with children ,5 years of age). Familiesincluded in the analysis voluntarily enrolled in 1 of3 evidence-based home visiting models: Healthy
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examined under the family contextdomain included violence in thehousehold,11,12,16–20,22,24–30 childabuse and neglect,16,20,23 and mental
illness or substance abuse amongparents or other householdmembers.11,12,16–21,23–27,30 AlthoughHealthy People 2020 identifies
interpersonal violence as an SDOHwithin the neighborhood and builtenvironment domain, we elected toinclude interpersonal violence in our
TABLE 4 Continued
Screening Tool Author and Year ResultsDiscussed
ReferralOfferedand/or
Scheduled
InterventionDelivered
Description
Families America, Parents as Teachers, or HomeInstruction for Parents of Preschool Youngsters.
ASK Tool Selvaraj et al23
2018X X — After completing the ASK Tool, clinicians discussed the
results with the caregiver. If ACEs and unmet socialneeds identified by the ASK Tool were substantiatedand required intervention based on this discussionand clinician judgment, the physician referredcaregivers to community resources usinga developed resource lists. Consultation with the on-site social worker was available for families withmultiple needs identified and/or significant socialcomplexity
IHELP Colvin et al29 2016 — X — After use of the IHELP tool, some interns providedreferrals for a social work consultation.
WE CARE survey instrument Garg et al24 2007 X X — Residents were instructed to review the WE CARE surveywith the parent during the visit and make a referral ifthe parents indicated that they wanted assistancewith any psychosocial problems.
Referrals came in the form of handing parents pagesfrom the Family Resource Book with moreinformation about 2–4 available communityresources on 1 of 10 potential topics of concernidentified in the screening.
Garg et al11 2015 X X — Clinicians reviewed the WE CARE survey with mothersand offered them a 1-page information sheet with 2–4free community resources for any needs for whichthe mother indicated she wanted assistance. Theinformation sheets contained the program name,a brief description, contact information, programhours, and eligibility criteria.
Zielinski et al30
2017— X — Positive results on the screen triggered a social work
referral at the time of the visit.FAMNEEDS Uwemedimo and
May25 2018X X X When a need was identified on the screening tool,
patient families who desired assistance wereinformed they would receive a follow-up phone callwithin 48 h from a resource navigator. Navigatorsprovided families with contact information of socialservice providers and made e-referrals. Navigatorscontinued to follow-up via phone with families whoreceived referral information every 2 wk for 8 wk toassess progress on the referral or provide newinformation. A final follow-up call to assess the statusof the referral was conducted at 3 mo after initialcontact with the navigator.
Child ACE Tool Marie-Mitchell andO’Connor20 2013
— — — No follow-up reported.
Social History Template of theStandard Well Child Care Formembedded in E-health Record
Beck et al21 2012 — — — No follow-up reported
Health-Related Social problemsscreener
Fleegler et al22
2007— X — All participants received a referral sheet listing local
agencies that could help with problems in each of theassessed social domains.
ASK, Addressing Social key Questions for Health; FAMNEEDS, Family Needs Screening Program; FMI, Family Map Inventories; —, not assessed.
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newly created family context domainbecause this SDOH occurs within thefamily unit. Common areas examinedunder the economic stability domainincluded food insufficiency,11,12,16–19,21–30
housing instability,11,12,16,22–25,27–30
and difficulty paying bills, makingends meet, or meeting basic needs.11,12,21–25,27,28,30 Seven screenersassessed the education domain,which included questions assessingparental education11,20,23–25,28,30 andaccess to child care.11,12,23–25,27,30 Sixscreeners assessed the health andhealth care domain, with parent andchild health insurance status12,22,25,27,29
being the most common areaexamined. Seven screeners assessedthe neighborhood and builtenvironment,12,21–23,25,27–29 withconcerns about the physicalconditions of housing being the mostcommon inquiry,12,21,22,25,27–29 followedby violence and safety.12,21,23,27,28 Threescreeners assessed social andcommunity context,12,25,27,28 whichincluded questions assessingconcerns about immigration status,12,27,28 discrimination,25 religious ororganizational affiliation,28 and socialsupport.25,28 Of note, 4 screenersassessed protective factors under thesocial and community context andfamily context domains, includingwhether family members feel close,16
if the child has a relationship witha caring adult,23 religious ororganizational affiliation,28 and ifparents have social support.25,28
Follow-up Procedures
Table 4 depicts various follow-upprocedures from the 17 studies inthis review. Authors of only 4 studiesreported no follow-up proceduresafter SDOH screening.18,20,21,27
Authors of 6 studies reported thatscreening results were discussed withcaregivers, and referrals to communityresources and outside agencies (eg,referrals to legal or transportationservices) were offered and/or scheduledfor caregivers but no interventionwas delivered.11,17,19,23,24,28 Authorsof 3 studies reported that referrals
were offered and/or scheduled forcaregivers without reporting thatscreening results were discussed withcaregivers and without reporting thatan intervention was delivered.22,29,30
Authors of only 3 studies reportedthat screening results were discussedwith caregivers, referrals wereoffered and/or scheduled, and anintervention was delivered.12,25,26
Interventions came in the form ofproviders using motivationalinterviewing to engage caregivers26
and navigators being assigned tocaregivers to help caregivers accessand understand resources.12,25
DISCUSSION
In the present review, we identified 11unique SDOH screeners. Although wesystematically searched databases fromtheir inception dates, all articles thatdetailed screeners were published inthe last 12 years. This growth of SDOHscreening within the research literaturein the last several years is paralleled byincreasing attention to SDOHs withinthe medical community. Since the early2000s, the American Academy ofPediatrics and other organizations haveencouraged pediatric providers todevelop standardized screening tools toassess social and behavioral risk factorsthat are relevant to their patientpopulations in an effort to identify andaddress risks.31–33 More recently, in2018, North Carolina announced it willsoon require Medicaid beneficiaries toundergo SDOH screening as part ofoverall care management, and morestates may soon follow.34 Therefore, itis important to inventory the screeningtools currently in use as well as assesstheir accuracy and impact on patientcare. The majority of screenersidentified in the present review wereeither validated, relevant to the prioritypopulation, or were accompanied byappropriate follow-up referrals orinterventions, but a minority ofscreeners included all 3 qualities.
A central theme among screenersincluded in this review is the extent
to which screening professionals (eg,primary care providers and socialworkers) can trust screening results.Only 3 out of the 11 screeners hadbeen tested for reliability and/orvalidity; thus, we do not know theextent to which most tools accuratelymeasured SDOHs.35 Several screeningtool features may impact aninformant’s ability to understandscreening questions, therebyinfluencing the tools’ ability tocorrectly evaluate a child’s SDOHs.These features include the followingquestions: (1) Is the tool available inan informant’s language of fluency?(2) Is the tool at or below aninformant’s reading level? and (3) Isthe tool worded in such a way that thereference period for SDOHs is clear?The majority of reviewed screeningtools were available in .1 language,and 3 of 7 tools that requiredinformants to read were appropriatefor low-literacy populations. However,a minority of screeners includeda clear and single reference period forreporting SDOHs (ie, the referenceperiod was not consistent acrossSDOHs assessed), and even fewerassessed SDOH chronicity or duration.Not only does information on thetiming and duration of SDOHexperiences guide interventions andreferrals, but the reference period caninfluence the accuracy of informants’reports; authors of previous researchhave found that reporting accuracydiminishes as the time between theexperience of interest and the reportincreases.36–38 Additional research isrequired to identify which SDOHreferent periods are the mostappropriate for informing interventionsand referrals while also simultaneouslyproducing valid responses.
Informants’ ability to understandscreening questions is necessary (butnot sufficient) to obtain accuratescreening results; informants mustalso answer truthfully. Parents and/or caregivers were the primaryinformants for all assessed tools; only2 screeners triangulated information
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with a physician or social workerreport. None included child self-report. Parents and caregivers oftenhold the most knowledge about theirchildren’s experiences and socialcontext; however, these informantsmay also be influenced by socialdesirability bias and fear ofintervention with child protectiveservices when answering questionsabout their children’s SDOHs.39,40
Furthermore, caregivers and childrenmay simply disagree regarding thesubjective assessment of the child’shealth.41 Triangulating parent and/orcaregiver reports with external datasources, however, requires additionalresources that may be beyond thescope of many screening settings.
To overcome the barrier of caregiverand/or parent fear or social desirability,many screeners included in this reviewwere developed in conjunction withinformation provided by communitymembers, experts, and/or practiceexperience. For example, creators of theSafe Environment for Every Kid (SEEK)Parent Screening Questionnaire (PSQ)not only reviewed the researchliterature to prioritize amenable riskfactors, but they also involvedcommunity pediatricians and parents inthe development of the SEEK PSQ. Onthe basis of this method of development,the PSQ began with a statement thatconveyed an empathetic tone towardcaregivers, highlighted the practice’sconcern about all children’s safety, andstated the practice’s willingness to helpwith any identified issues.18 Futureresearch should conduct SDOHscreening in tandem with a socialdesirability scale to empiricallyinvestigate if including empatheticlanguage at the beginning of an SDOHscreening tool allays concerns aboutsocial desirability bias.42
Because evidence is currently lacking onwhich specific SDOH factors have thelargest impact on child health, theAmerican Professional Society on theAbuse of Children encouragespediatricians to tailor SDOH screeningto their patients’ needs and available
community resources.43 The majority ofscreeners included in this reviewfollowed this recommendation. Forexample, the Well Child Care,Evaluation, Community Resources,Advocacy, Referral, Education (WECARE) screener only screened forSDOHs for which community resourceswere available.24 A criticism ofscreening children for ACEs is a lack ofappropriate follow-up interventionswhen screening tools identify ACEs.5 Wedid not find evidence supporting thiscritique within studies in which SDOHscreening was reported; the vastmajority of studies followed screeningwith immediate referrals and/orinterventions to address the identifiedSDOHs. What typically happens afterACE screening in practice is unknown.However, future research is needed toevaluate the effectiveness of thesereferrals and interventions in meetingfamily needs and improving child healthand well-being. Moreover, few screenersassessed protective factors; thus, mostfollow-up interventions were deficit-based rather than strength-based. Giventhe evidence in support of strength-based interventions,44 future screeningtools should incorporate the assessmentof more protective factors.
Although we did not restrict oursystematic search to clinical settings,all except 1 identified screener tookplace in either a pediatric clinic orhospital. Alternative settings,specifically educational settings, maybe well-equipped to conduct universalSDOH screening. Trauma screeningtools for use in educational settingsexist and may be applied to selectportions of student bodies.45 UniversalSDOH screening, however, has notgained the same traction ineducational settings that it has inmedical settings, despite evidence thatSDOHs can hinder optimal educationaldevelopment and well-being.46,47
The present review containslimitations. First, SDOH definitions vary.We elected to follow the HealthyPeople 2020 definition, and doing somay have resulted in excluding articles
that other SDOH definitions wouldhave encompassed. Second, because wefocused the review on SDOH measures,we did not collect information onoutcomes; it is still unknown whichSDOH domains impact child health andwell-being the most. We believe theselimitations, however, are offset bynumerous strengths. First, ourcomprehensive search strategy allowedus to identify the SDOH screening toolsthat have been the subject of bothresearch and practice. To ourknowledge, we are also the first reviewof tools to assess both thepsychometric properties of SDOHscreening tools and the follow-upprocedures that accompany the tools.
Many of the SDOH screening toolsidentified in this review includedquestions about SDOHs that wereimportant to the given population andsubsequently addressed identifiedSDOHs in an informed and appropriatemanner. We did find, however, that theextent to which SDOH screeningresults accurately assess a child’sSDOHs as well as the extent to whichthe referrals and interventions offeredafter SDOH screening are effective arepoints for additional research.Although SDOH screening is increasingin popularity within medical settings,SDOH screening tool developersshould consider creating tools for usein other childhood settings.
ABBREVIATIONS
ACE: adverse childhood experiencePRISMA: Preferred Reporting
Items for SystematicReviews and Meta-Analysis
PSQ: Parent ScreeningQuestionnaire
SDOH: social determinant of healthSEEK: Safe Environment for
Every KidWE CARE: Well Child Care
Evaluation CommunityResources AdvocacyReferral Education
PEDIATRICS Volume 144, number 4, October 2019 13 by guest on October 21, 2020www.aappublications.org/newsDownloaded from
Drs Shanahan and Lanier supervised this work and participated in the title and abstract review; and all authors reviewed and revised the manuscript and approved
the final manuscript as submitted and agree to be accountable for all aspects of the work.
DOI: https://doi.org/10.1542/peds.2019-1622
Accepted for publication Jul 10, 2019
Address correspondence to Rebeccah Sokol, PhD, Department of Health Behavior and Health Education, University of Michigan, 1415 Washington Heights, Ann Arbor,
MI 48109-2029. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2019 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This work was supported in part by an award to the University of North Carolina Injury Prevention Research Center from the National Center for Injury
Prevention and Control, Centers for Disease Control and Prevention (R49 CE002479). Ms Doss was supported in part by a training grant from the National Institute
of Child Health and Development (T32 HD52468). Ms Chandler was supported in part by a training grant from the National Institute of Child Health and Development
(T32 HD007376).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-2395.
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Bousquette, Christiana Lancaster, Ginna Doss, Andrea Dotson, Venera Urbaeva, Rebeccah Sokol, Anna Austin, Caroline Chandler, Elizabeth Byrum, Jessica
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