CONTEXT:

Screening children for social determinants of health (SDOHs) has gained attention in recent 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 their psychometric properties, and evaluate how they detect early indicators of risk and inform care.

DATA SOURCES:

Comprehensive electronic search of PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection.

STUDY SELECTION:

Studies in which a tool that screened children for multiple SDOHs (defined according to Healthy People 2020) was developed, tested, and/or employed.

DATA EXTRACTION:

Extraction domains included study characteristics, screening tool characteristics, 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. Screening was primarily conducted in clinical settings with a parent or caregiver being the primary informant for all screeners. Psychometric properties were assessed for only 3 screeners. The most common SDOH domains screened included the family context and economic stability. Authors of the majority of studies described referrals and/or interventions that followed screening to address identified SDOHs.

LIMITATIONS:

Following the Healthy People 2020 SDOH definition may have excluded articles that other definitions would have captured.

CONCLUSIONS:

The extent to which SDOH screening accurately assessed a child’s SDOHs was largely unevaluated. Authors of future research should also evaluate if referrals and interventions after the screening effectively address SDOHs and improve child well-being.

Social determinants of health (SDOHs), according to the World Health Organization, are “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”1 Healthy People 2020 organizes SDOH into 5 key domains: economic stability (eg, poverty and food insufficiency), education (eg, high school graduate and early childhood education), social and community context (eg, concerns about immigration status and social support), health and health care (eg, health insurance status and access to a health care provider), and neighborhood and built environment (eg, neighborhood crime and quality of housing).2 Although SDOHs influence health and well-being among individuals of all ages, it is particularly important to consider SDOHs among children and youth given that the physical, social, and emotional capabilities that develop early in life provide the foundation for life course health and well-being.3 Thus, identifying and intervening on the basis of these factors early could serve as a primary prevention against future health conditions.

Much controversy surrounds screening children and youth for SDOHs, however. Some experts claim screening is unethical if done without ensuring that identified social needs are met, likewise generating unfulfilled expectations.4,5 Others argue that even in the absence of referrals, screening has benefits such as improving diagnostic algorithms, identifying children and youth who need more support, improving patient-provider relationships, and collecting data for an epidemiological purpose.6,8 Although many child service professionals feel ill-equipped to address patients’ social needs within the current systems,9,10 several care teams cite that they identify unmet social needs and offer linkages to social services.11,12 This screening debate is largely centered on a deficit in understanding the present state of the science: what screening tools exist? How accurate are they? How do screening results inform care? In the present systematic review, we aim to answer these questions. Although authors of previous reports have outlined different SDOH screening tools used among children in clinical settings,13,14 there has been no systematic review of SDOH screeners used among children in various settings. In this review, we aim to systematically catalog the different SDOH screening tools used to assess social conditions among children and youth, examine their psychometric properties, and evaluate how they are used to detect early indicators of risk and inform care.

Authors of studies in this review developed and/or used a tool to screen children and youth for SDOHs. We systematically reviewed the literature using a protocol informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to search research databases, screen published studies, apply inclusion and exclusion criteria, and select relevant literature for review.15 A trained clinical health sciences librarian (S.T.W.) performed our comprehensive electronic search of publications using the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature via EBSCO, Embase via Elsevier, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection. Our search was restricted to English-only articles. All database results were collected from the inception of the database through November 2018. Search terms were used to retrieve articles addressing the 3 main concepts of the search strategy: (1) SDOHs, (2) pediatric population, and (3) screening administered by a child service provider (eg, a clinician, social worker, or teacher) or in a service provider setting (eg, self-administered at a pediatrician’s office). The exact search strategy used in each of the electronic databases is reported in the Supplemental Information. Results were downloaded to EndNote, and duplicates were removed. All references were uploaded to Covidence systematic review software (https://www.covidence.org), a web-based tool designed to facilitate and track each step of the abstraction and review process.

We included studies in which a tool that screened children (or caregivers and/or informants on behalf of children) for multiple SDOHs was developed, described, tested, and/or employed, where SDOHs are defined according to Healthy People 2020.2 Given Healthy People 2020 guided our understanding of SDOHs (an American framework), to be included in this review, studies had to be conducted within the United States, be peer-reviewed, and be published in English. Following these inclusion criteria, we excluded studies of screeners that only screened for 1 SDOH; did not conduct screening among children (age 0–25 years) or their caregivers and/or informants; were not published in English; were conducted outside of the United States; or were book chapters, reviews, letters, abstracts, or dissertations.

We used Covidence, an online platform, to manage screening and selection of studies. For the title and abstract screening, each title was independently and blindly screened by 2 authors, and a third author resolved discrepancies. The authorship team followed this same independent, blind review for the full-text review. At the end of the title and abstract screen and full-text review phase, the lead investigators reviewed the included studies to confirm that all studies met the inclusion criteria. For any articles in question, the lead investigators convened to determine the articles’ inclusion statuses. At the conclusion of the full-text review, study authors reviewed the reference lists of included studies to identify any additional studies for inclusion.

After reviewing the full texts of studies, the research team developed a data extraction tool in REDCap (a secure web platform for building and managing online databases and surveys) to extract the following information: study characteristics (ie, author and publication year, study type, study setting, age range of screened children, sample size of screened children, percent female sex of screened children, race and/or ethnicity of screened children, and study aims); screening tool characteristics (ie, average time to complete screener, screening setting, screening method, informant, training required for screening professionals, languages available, appropriate for low-literacy populations [ie, sixth grade reading level or lower], and validation); what SDOH domains the screener measured (per Healthy People 2020 guidelines; 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 with respondents, referrals were offered and/or scheduled, and/or intervention was delivered). Each primary reviewer extracted data from a set of studies that passed the research team’s full-text review, and secondary reviewers confirmed the primary reviewers’ extraction to ensure that the primary reviewer recorded accurate information. The team resolved any discrepancies through discussion and consensus.

The electronic search of databases returned 6274 references (of which 1223 were duplicates), resulting in 5051 studies. In the initial title and abstract screen, the research team deemed 4977 studies irrelevant, leaving 74 full texts to review. A total of 15 studies passed the full screen review, and we identified 2 additional studies from the reference lists of included studies. We retained and abstracted 17 studies. Figure 1 reveals the PRISMA flow diagram.

Table 1 reveals various study characteristics from the 17 studies that span 11 unique screeners. With the exception of 1 study,16 all studies took place in a medical setting. Among the 14 studies in which the ages of screened individuals were reported, the majority (ie, 8 studies) included screening for SDOHs exclusively in young childhood (ages 0 to 5 years).11,16,22 Study samples were primarily evenly divided with respect to biological sex. Among the 13 studies in which the races and/or ethnicities of screened individuals were reported, 10 study samples contained a majority nonwhite sample.11,12,17,18,20,25 

Table 2 depicts SDOH screener characteristics from the 11 unique screeners included in this review. Screening was conducted in a doctor’s or pediatrician’s office for the majority of screeners (ie, 8 screeners), with a parent or caregiver being the primary informant for all screeners. Two screeners included additional information reported by a social worker16 or physician.20 Screeners were completed via a variety of methods, 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 and phone interview.12,27 All screeners were available in English, with 7 screeners also available in Spanish.11,12,17,20,22,27,30 Three screeners had validity and/or reliability assessed in ≥1 study.18,24,29 

With respect to the time frame that respondents were asked to reflect on when answering questions about SDOHs, the majority of screeners (ie, 6 screeners) did not have a clearly defined referent period (eg, past 30 days, past year, or lifetime); the referent periods for other screeners varied by question,18,22,28 and only 2 screeners had a single, clearly defined referent period for all included questions.16,24 Regarding how the SDOH screeners were developed, only 4 screeners reported being informed by practice18,21,24 and/or expert opinion.18,21,23,24 Remaining screeners were solely adaptations of previous tools or did not report how they were developed.

Table 3 reveals the specific SDOH domains assessed in each screener. Because many screeners were used to assess adverse childhood experiences (ACEs) (events that typically occur within the family context), for the purposes of this review, we added an additional domain labeled family context to the Healthy People 2020 domains included in Table 3. The family context domain was assessed in all screeners, and the economic stability domain was assessed in all but 1 screener.20 Common areas examined under the family context domain included violence in the household,11,12,16,20,22,24,30 child abuse and neglect,16,20,23 and mental illness or substance abuse among parents or other household members.11,12,16,21,23,27,30 Although Healthy People 2020 identifies interpersonal violence as an SDOH within the neighborhood and built environment domain, we elected to include interpersonal violence in our newly created family context domain because this SDOH occurs within the family unit. Common areas examined under the economic stability domain included food insufficiency,11,12,16,19,21,30 housing instability,11,12,16,22,25,27,30 and difficulty paying bills, making ends meet, or meeting basic needs.11,12,21,25,27,28,30 Seven screeners assessed the education domain, which included questions assessing parental education11,20,23,25,28,30 and access to child care.11,12,23,25,27,30 Six screeners assessed the health and health care domain, with parent and child health insurance status12,22,25,27,29 being the most common area examined. Seven screeners assessed the neighborhood and built environment,12,21,23,25,27,29 with concerns about the physical conditions of housing being the most common inquiry,12,21,22,25,27,29 followed by violence and safety.12,21,23,27,28 Three screeners assessed social and community context,12,25,27,28 which included questions assessing concerns about immigration status,12,27,28 discrimination,25 religious or organizational affiliation,28 and social support.25,28 Of note, 4 screeners assessed protective factors under the social and community context and family context domains, including whether family members feel close,16 if the child has a relationship with a caring adult,23 religious or organizational affiliation,28 and if parents have social support.25,28 

Table 4 depicts various follow-up procedures from the 17 studies in this review. Authors of only 4 studies reported no follow-up procedures after SDOH screening.18,20,21,27 Authors of 6 studies reported that screening results were discussed with caregivers, and referrals to community resources and outside agencies (eg, referrals to legal or transportation services) were offered and/or scheduled for caregivers but no intervention was delivered.11,17,19,23,24,28 Authors of 3 studies reported that referrals were offered and/or scheduled for caregivers without reporting that screening results were discussed with caregivers and without reporting that an intervention was delivered.22,29,30 Authors of only 3 studies reported that screening results were discussed with caregivers, referrals were offered and/or scheduled, and an intervention was delivered.12,25,26 Interventions came in the form of providers using motivational interviewing to engage caregivers26 and navigators being assigned to caregivers to help caregivers access and understand resources.12,25 

In the present review, we identified 11 unique SDOH screeners. Although we systematically searched databases from their inception dates, all articles that detailed screeners were published in the last 12 years. This growth of SDOH screening within the research literature in the last several years is paralleled by increasing attention to SDOHs within the medical community. Since the early 2000s, the American Academy of Pediatrics and other organizations have encouraged pediatric providers to develop standardized screening tools to assess social and behavioral risk factors that are relevant to their patient populations in an effort to identify and address risks.31,33 More recently, in 2018, North Carolina announced it will soon require Medicaid beneficiaries to undergo SDOH screening as part of overall care management, and more states may soon follow.34 Therefore, it is important to inventory the screening tools currently in use as well as assess their accuracy and impact on patient care. The majority of screeners identified in the present review were either validated, relevant to the priority population, or were accompanied by appropriate follow-up referrals or interventions, but a minority of screeners included all 3 qualities.

A central theme among screeners included in this review is the extent to which screening professionals (eg, primary care providers and social workers) can trust screening results. Only 3 out of the 11 screeners had been tested for reliability and/or validity; thus, we do not know the extent to which most tools accurately measured SDOHs.35 Several screening tool features may impact an informant’s ability to understand screening questions, thereby influencing the tools’ ability to correctly evaluate a child’s SDOHs. These features include the following questions: (1) Is the tool available in an informant’s language of fluency? (2) Is the tool at or below an informant’s reading level? and (3) Is the tool worded in such a way that the reference period for SDOHs is clear? The majority of reviewed screening tools were available in >1 language, and 3 of 7 tools that required informants to read were appropriate for low-literacy populations. However, a minority of screeners included a clear and single reference period for reporting SDOHs (ie, the reference period was not consistent across SDOHs assessed), and even fewer assessed SDOH chronicity or duration. Not only does information on the timing and duration of SDOH experiences guide interventions and referrals, but the reference period can influence the accuracy of informants’ reports; authors of previous research have found that reporting accuracy diminishes as the time between the experience of interest and the report increases.36,38 Additional research is required to identify which SDOH referent periods are the most appropriate for informing interventions and referrals while also simultaneously producing valid responses.

Informants’ ability to understand screening questions is necessary (but not sufficient) to obtain accurate screening results; informants must also answer truthfully. Parents and/or caregivers were the primary informants for all assessed tools; only 2 screeners triangulated information with a physician or social worker report. None included child self-report. Parents and caregivers often hold the most knowledge about their children’s experiences and social context; however, these informants may also be influenced by social desirability bias and fear of intervention with child protective services when answering questions about their children’s SDOHs.39,40 Furthermore, caregivers and children may simply disagree regarding the subjective assessment of the child’s health.41 Triangulating parent and/or caregiver reports with external data sources, however, requires additional resources that may be beyond the scope of many screening settings.

To overcome the barrier of caregiver and/or parent fear or social desirability, many screeners included in this review were developed in conjunction with information provided by community members, experts, and/or practice experience. For example, creators of the Safe Environment for Every Kid (SEEK) Parent Screening Questionnaire (PSQ) not only reviewed the research literature to prioritize amenable risk factors, but they also involved community pediatricians and parents in the development of the SEEK PSQ. On the basis of this method of development, the PSQ began with a statement that conveyed an empathetic tone toward caregivers, highlighted the practice’s concern about all children’s safety, and stated the practice’s willingness to help with any identified issues.18 Future research should conduct SDOH screening in tandem with a social desirability scale to empirically investigate if including empathetic language at the beginning of an SDOH screening tool allays concerns about social desirability bias.42 

Because evidence is currently lacking on which specific SDOH factors have the largest impact on child health, the American Professional Society on the Abuse of Children encourages pediatricians to tailor SDOH screening to their patients’ needs and available community resources.43 The majority of screeners included in this review followed this recommendation. For example, the Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education (WE CARE) screener only screened for SDOHs for which community resources were available.24 A criticism of screening children for ACEs is a lack of appropriate follow-up interventions when screening tools identify ACEs.5 We did not find evidence supporting this critique within studies in which SDOH screening was reported; the vast majority of studies followed screening with immediate referrals and/or interventions to address the identified SDOHs. What typically happens after ACE screening in practice is unknown. However, future research is needed to evaluate the effectiveness of these referrals and interventions in meeting family needs and improving child health and well-being. Moreover, few screeners assessed protective factors; thus, most follow-up interventions were deficit-based rather than strength-based. Given the evidence in support of strength-based interventions,44 future screening tools should incorporate the assessment of more protective factors.

Although we did not restrict our systematic search to clinical settings, all except 1 identified screener took place in either a pediatric clinic or hospital. Alternative settings, specifically educational settings, may be well-equipped to conduct universal SDOH screening. Trauma screening tools for use in educational settings exist and may be applied to select portions of student bodies.45 Universal SDOH screening, however, has not gained the same traction in educational settings that it has in medical settings, despite evidence that SDOHs can hinder optimal educational development and well-being.46,47 

The present review contains limitations. First, SDOH definitions vary. We elected to follow the Healthy People 2020 definition, and doing so may have resulted in excluding articles that other SDOH definitions would have encompassed. Second, because we focused the review on SDOH measures, we did not collect information on outcomes; it is still unknown which SDOH domains impact child health and well-being the most. We believe these limitations, however, are offset by numerous strengths. First, our comprehensive search strategy allowed us to identify the SDOH screening tools that have been the subject of both research and practice. To our knowledge, we are also the first review of tools to assess both the psychometric properties of SDOH screening tools and the follow-up procedures that accompany the tools.

Many of the SDOH screening tools identified in this review included questions about SDOHs that were important to the given population and subsequently addressed identified SDOHs in an informed and appropriate manner. We did find, however, that the extent to which SDOH screening results accurately assess a child’s SDOHs as well as the extent to which the referrals and interventions offered after SDOH screening are effective are points for additional research. Although SDOH screening is increasing in popularity within medical settings, SDOH screening tool developers should consider creating tools for use in other childhood settings.

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; and managed the review team; Dr Austin defined the review scope; participated in the title and abstract review, full-text screen, and data abstraction; and drafted sections of 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 data abstraction; Dr Dotson and Ms Urbaeva participated in full-text screen and data abstraction; Ms Singichetti and Dr Brevard participated in the title and abstract review and full-text screen; Ms Wright conducted the initial literature search and drafted sections of the initial manuscript; 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.

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).

ACE

adverse childhood experience

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

PSQ

Parent Screening Questionnaire

SDOH

social determinant of health

SEEK

Safe Environment for Every Kid

WE CARE

Well Child Care Evaluation Community Resources Advocacy Referral Education

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Competing Interests

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.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data