Social Determinants of Health: The Impact on Pediatric Health and Well-Being

Case vignette: A 16-year-old Nepali-born English-speaking adolescent presents for a well-child visit and notes concerns for anxiety, depression, and a history of trauma. She resides with her parents who work in hospitality with limited time off, and thus she presented for the initial office visit with a neighbor. Parents were not readily available to discuss treatment recommendations, including medication options. The teen shares a number of challenges that makes coming to appointments difficult. You also notice that the patient currently is not enrolled in insurance, though she appears eligible.

The above vignette highlights various social issues and concerns that impact access to healthcare and overall health/well-being. Social determinants of health (SDOH) and factors centered on mental health are now widely known to impact pediatric health and wellbeing. The Office of Disease Prevention and Health Promotion defines SDOH as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” SDOH can be grouped into five domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.¹

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Dr. Yasmeen Abdul-Karim

Additionally, when considering determinants that impact the mental health of children, it is prudent to consider parental psychosocial factors and adverse childhood experiences (ACEs), such as witnessing interpersonal violence, child abuse, parental substance use, and parental depression.² All these factors have been shown to impact an individual’s mental and physical health not only contemporaneously but also later in life.³

Screening Tool for Pediatric Social Histories

One screening tool to assist with gathering an expanded pediatric social history is called IHELP, developed by Kenyon et al,⁴ with further derivations from Colvin et al.⁵ Utilizing this tool can assist providers with identifying social needs.

The tool begins with a framing statement — “Let me ask you some questions I ask every family” — then proceeds to discuss relevant topics as shared below:

I: Income; Insurance

• Do you have any concerns about making ends meet?
• Do you have any concerns about your child’s health insurance?

H: Hunger, Housing Conditions; Homeless

• Do you have any concerns about having enough food?
• Have you ever been worried whether your food would run out before you got money to buy more?
• Within the past year has the food you bought ever not lasted, and you didn’t have money to get more?
• Do you have any concerns about poor housing conditions like mice, mold, or cockroaches?
• Do you have any concerns about being evicted or not being able to pay the rent?
• Do you have any concerns about not being able to pay your mortgage?

E: Education; Ensuring Safety (Violence)

• Do you have any concerns about your child’s educational needs?
• [DO NOT ASK IN FRONT OF CHILD 3 OR OLDER OR IN FRONT OF OTHER PARTNER] “From speaking to families, I have learned that violence in the home is common and now I ask all families about violence in the home. Do you have any concerns about violence in your home?”