screening children for social determinants of health: a … · social determinants of health...

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

2 SOKOL et al by guest on October 21, 2020www.aappublications.org/newsDownloaded from

https://pediatrics.aappublications.org/lookup/suppl/doi:10.1542/peds.2019-1622/-/DCSupplemental/

https://pediatrics.aappublications.org/lookup/suppl/doi:10.1542/peds.2019-1622/-/DCSupplemental/

https://www.covidence.org

https://www.covidence.org

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


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.


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



NR 4–5 English; Spanish Yes Yes24

FAMNEEDS25 Doctor’s orpediatrician’soffice


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


Face-to-faceinterview

Parent orcaregiver

NR NR English NR No

Health-Related SocialProblems screener22


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.


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


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


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.


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


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.


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


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


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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DOI: 10.1542/peds.2019-1622 originally published online September 23, 2019; 2019;144;Pediatrics

ShanahanBhavna Singichetti, Kanisha Brevard, Sarah Towner Wright, Paul Lanier and Meghan

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Screening Children for Social Determinants of Health: A Systematic Review

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DOI: 10.1542/peds.2019-1622 originally published online September 23, 2019; 2019;144;Pediatrics

ShanahanBhavna Singichetti, Kanisha Brevard, Sarah Towner Wright, Paul Lanier and Meghan

Bousquette, Christiana Lancaster, Ginna Doss, Andrea Dotson, Venera Urbaeva, Rebeccah Sokol, Anna Austin, Caroline Chandler, Elizabeth Byrum, Jessica

Screening Children for Social Determinants of Health: A Systematic Review

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by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

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screening children for social determinants of health: a … · social determinants of health...

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