Introduction
The social conditions under which children grow up influence their development and health outcomes over the life course.1 This includes multiple factors within the household (eg, income, employment, quality of housing, parental substance use, interpersonal violence), the neighbourhood (eg, deprivation, safety, access to transportation, access to health and social resources), the health system (eg, health insurance status, access to services), the education system (eg, access to early childhood education and schooling) and the family’s personal social networks (eg, access to social support). Social interactions and relationships between individuals, groups and organisations are also part of social conditions that contribute to health inequities (eg, structural racism and gender roles).1 2
The impact of adverse social conditions on health has been increasingly studied in recent decades. In this context, various terms for the factors representing adverse social conditions are used in research and policy, such as social factors, social risks and social determinants, which are often used synonymously, lacking a precise definition and which are sometimes confused with other terms, such as ‘social needs’.3 4 Social risks or social determinants typically include areas, such as housing insecurity, food insecurity, transport difficulties, utility needs, interpersonal safety, education, and financial stress which may vary depending on the focus of the study.
Adverse social conditions experienced in childhood contribute to acute and chronic diseases, such as asthma and diabetes,5 6 infectious and cardiovascular diseases7 and have been linked to an increased risk of socioemotional, behavioural and cognitive problems as well as earlier mortality in later life.8–13 Exposures, such as poor housing, food insecurity and financial difficulties are associated with increased rates of hospitalisation, increased emergency department use and delayed medical care.14 15 In addition, socioeconomic conditions and unstable housing also play an important role in the management of certain conditions, such as diabetes, and can be particularly challenging as they can affect a patient’s ability to store and take medication, for example.16
In response to and in recognition of these findings, public health efforts to identify and address social conditions have intensified. In this context, screening is being discussed and investigated as a systematic and useful approach. Healthcare contacts provide a unique opportunity to screen for social conditions in order to identify and address emerging, potentially harmful social problems at an early stage. Early identification can provide the basis for referring children and their families to appropriate social support services. Recent studies suggest that outpatient social conditions screening is associated with increased use of social services which is, in turn, associated with improved health outcomes.17–21 Previous studies have also shown that screening is feasible and acceptable in hospitalised patients.22–24 For example, Colvin et al showed that caregivers of hospitalised paediatric patients had a positive view of the doctor’s role in addressing unmet social needs, particularly those who had previously been assessed by a doctor.22 In addition, Vaz et al demonstrated that screening for social risk factors using a questionnaire is feasible in an inpatient setting and supports the assessment of various social risks.24
Despite these beneficial factors, arguments against screening include limitations in terms of personnel, time and financial resources, as well as differing views on whether it is the healthcare provider’s responsibility at all.25 Health professionals may not feel able to ask about and respond sensitively to social conditions, as knowledge and management of social factors are not necessarily part of medical training. Finally, necessary and helpful interventions are usually not feasible within the healthcare setting, as the resources required would be beyond the scope of clinical care.25–29 This raises concerns that screening for social problems without resolution and referral to appropriate treatment is not only ineffective, but may cause unintended harm to patients and clinicians. It may also be unethical, as once clinicians have identified social issues, they are also required to provide definitive support.26 Besides this, critics also stress that screening must be carried out with ‘caution, humility and empathy’ so as not to inadvertently reinforce discrimination and stigma.4
There have been important reviews on social screening in healthcare providing an overview of the evidence on existing screening approaches.29–32 The present review contributes by including the whole variety of search terms used in the field, such as social risk and social determinants, and by including tools that cover multiple domains rather than focusing on one specific social problem (eg, only on food insecurity).33 In addition, our study differs from others in that we do not focus exclusively on a specific region (eg, the USA) and that we specifically address children and families.30–32
The aim of our study is to identify and describe available screening instruments in outpatient and inpatient healthcare settings that capture social conditions that may have an impact on children’s development, health or well-being. The results of this study will inform the development of a novel social conditions screening tool to be integrated into routine child healthcare pathways in Germany.34 The screening tool has the purpose of identifying social conditions of children and families in healthcare settings in a systematic and comprehensive way to enable healthcare professionals to make early and targeted referrals to social services for support when needed.
Methods and analysis
The proposed systematic review will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement 2020.35 The review will be guided by the PCC (participant, concept, context) framework to inform our review question, search strategy and inclusion and exclusion criteria. This protocol is reported following the PRISMA-P checklist for systematic review protocols.36 The study has been registered with PROSPERO (CRD42023445106).
Eligibility criteria
An overview of our inclusion and exclusion criteria is presented in table 1.
Inclusion and exclusion criteria
Population
For references to be included, they must include children aged 0–18 years who have contact with healthcare providers in inpatient and outpatient settings. We will include references that do not specify the age of the participants but refer to children or adolescents, for example. We will also consider references that focus on various age groups if they include a separate analysis or discussion on children. References involving professionals, parents or caregivers, for example, as a source of information during screening, will also be considered.
Concept
We will consider peer-reviewed articles in which an instrument is developed, described, tested or used to screen children aged 0–18 (or caregivers on behalf of children) for multiple (at least two) social conditions (eg, food insecurity, housing insecurity) in paediatric hospitals or other inpatient and outpatient child healthcare settings. Our review includes a broad set of terms used in the literature to refer to the social conditions that may influence children’s development and health, such as social risks, social problems, social factors or social determinants. In our study, we encompass these terms under the term ‘social conditions’. By this we mean a range of potentially adverse social and structural circumstances, such as financial strain, food and housing insecurity, difficulties in accessing childcare, or adverse individual experiences within the family, such as violence.
Context
The context for this review is paediatric hospitals or other inpatient and outpatient child healthcare settings. Other inpatient settings include rehabilitation centres, psychiatric hospitals or long-term care facilities. Outpatient settings include clinics, emergency rooms or ambulatory surgery centres.
Information sources and search strategy
In developing our search strategy, we sought advice from a librarian at the University of Leipzig. We conducted an initial limited search on PubMed based on initial search terms developed from existing literature.30–32 We reviewed the results at title and abstract level to ensure the sensitivity and specificity of the search strategy and to ensure that important articles already known to the research team were included in the results. We then refined the search strategy for PubMed (Ovid) and adapted this strategy to the PsycInfo (EBSCOhost) and Web of Science Core Collection (Clarivate) databases (see online supplemental file 1). As mentioned above, our search strategy includes several terms that refer to social conditions that affect children’s development, health and well-being, such as social determinants, social problems and social risks. Similarly, we included several terms to describe ‘screening’ and ‘tools’, such as detection, identification, instrument and checklist. As we are only interested in tools capturing multiple domains of social conditions, we did not include search terms for specific problems, such as domestic violence, food insecurity or housing instability. Our search strategy is included in the online supplemental file 1. We will manually search the reference lists of included studies to identify further potentially relevant references. In order to ensure the feasibility of the review, it has been decided to limit the search to a period of 10 years, from 2014 to the present, and to focus on English-language and German-language sources.
Supplemental material
Study selection process
Search results will be uploaded to Covidence.37 In the first phase of the selection process, two reviewers will independently screen titles and abstracts and select studies that meet the inclusion criteria. This step will be followed by a full-text review of these potentially relevant studies. Disagreements during the two phases will be resolved by discussion between the two reviewers to reach consensus or a third reviewer will be consulted. The study selection process will be reported in full in the final systematic review and presented in a PRISMA flowchart, including the results of the search, elimination of duplicates, stages of study selection, reasons for exclusion after full-text reading and the final number of studies included. We will provide a list of all potentially relevant studies that were read in full text but excluded from the review and the reasons for exclusion. We will continually review our eligibility criteria and the focus of the review based on the identified sources and revise the eligibility criteria as necessary, in line with the iterative nature of systematic reviews. Any deviations from the protocol will be transparently documented in the review article.
Data extraction process
We will use a data extraction form developed for this systematic review which includes information on study characteristics (eg, country, setting, study design) and tool characteristics (eg, name and aim of tool, target population, components of the tool). A pilot extraction will be conducted on a random sample of approximately five articles and the form refined as needed. Data extraction will be conducted independently by two reviewers. The reviewers will extract the results as reported in the form of numerical or narrative summaries. Disagreements will be resolved by consensus building or, if necessary, by involving a third reviewer. We will assess the methodological quality of the instruments with the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist.38
Collating, summarising and reporting data
Each study will be categorised by year of publication, country, setting, research design, population and the instrument(s) described. Our search results will be presented in a flowchart to illustrate the decision-making process for the review. We will present the characteristics of the included studies and the evidence found on the different screening instruments in a structured table format. Meta-analyses are not planned as we expect the outcomes of interest to be too heterogeneous across screening tools. The results of our methodological assessment will be presented in tabular form and presented in a narrative format.
Patient and public involvement
In preparing the review protocol, we asked a convenience sample of parents about their priorities, experiences and preferences for screening for social conditions in child healthcare. We will take their feedback into account as we continue our work. Both the interim and final results of our review will be shared with these parents and publications will be made available to them.
Ethics and dissemination
As we will synthesise information from publicly available articles and will not collect personal, sensitive or confidential information from participants, ethical approval is not required. Dissemination activities will consist of reporting results of the systematic review by submitting an article for publication to a scientific journal and presenting results at relevant conferences.
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