Tuesday, September 15, 2015

The Great Divide: Examining Social Determinants of Health

By: Joann Schulte  DO, MPH; Editorial Board Member  
       And they lived happily ever after.  Surely you've heard that phrase ending fairy tales or rags to riches stories.  The plot is basically poor boy or girl pulls himself or herself up by the bootstraps with minimal help from anybody else. That myth has endured ever since Horatio Alger started penning his stories in the 1890s.  The reality is that most people who make themselves a success have help along the way from parents, teachers or somebody who cared and took an interest.  Of course,  children who face adversity have dreams, but often have barriers that Horatio Alger just didn't mention.
     One factor that gets short shrift in such stories is how the hero or heroine started out. Specifics such as dealing with hunger or  having to worry about apartment infestations may not be described in detail in a hard luck story, but these issues are common in reality.  Basics like food insecurity, poor housing or a stressed out single parent are among the social determinants of health (SDH) that can crush a child's dreams early on.  The toxic stress model suggests that social determinants of health often disrupt normal physiological processes, get "under a child's skin" and put a child's future and dreams at risk.
       Pediatricians often try to help individual children who go hungry or live in rat infested housing.  One patient at a time is good, but doesn't fix a community.  Recently  innovative programs called Medical - Legal Partnerships have shown some success in addressing SDH on a  broader community scale.
      Research by Lovegrove,et al. (doi:10.1542/peds.2015-2092), published this month in Pediatrics, documents some successes achieved in Ohio.  That's where the Division of General and Community Pediatrics at Cincinnati Children's Hospital Medical Centers has paired with the Legal Aid Society of greater Cincinnati.  The partnership is between pediatricians and attorneys who have experience helping those trying to overcome their poverty status..
      The pediatricians, who provide care for 15,000 children, did an anonymous survey of parents asking what unaddressed needs their children had.   The survey found that 29 % of parents reported living in poor housing with conditions such as cockroaches or mold.  One in five parents reported financial problems limiting their abilities to buy medication for themselves.  Thirty percent of children lived in household where food insecurity was a problem and 15% of families with infants had to stretch their allotted formula to last long enough to get their next allotment.
      Working together, the physicians and attorneys who comprise  the Cincinnati Child Health Law Partnership (Child HeLP) have identified and improved a cluster of substandard housing  areas where problems included pest infestations, broken windows and water leaks.  They also worked  to provide sufficient formula through donations to food banks that helped more than 1,500 families feed their infants.
       The Cincinnati program and others like it often use Maslow's hierarchy of needs   to assess common needs.   The pyramid assesses human needs, starting at a physiological base with food and shelter and progressing to self actualization (see Figure).  The programs then implement community interventions that benefit multiple children and their families with these needs.  The article by Longrove et al. provide a good overview of a process that can link clinical and community resources in programs that can intervene in economic, environmental and psychosocial areas.  That's a good way to reshuffle at least part of the deck that is often stacked against children from poor families.  A better start to the story is more likely to produce a happy ending.

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