# Health Disparities and Social Determinants Across the Lifespan

## Introduction

**Health disparities** are preventable differences in health outcomes and their determinants between population groups. The **social determinants of health (SDOH)** -- the conditions in which people are born, grow, live, work, and age -- profoundly influence health trajectories from infancy through old age. Med-peds physicians encounter disparities at every stage of life and are uniquely positioned to address upstream factors that shape downstream outcomes for both children and adults.

## Framework for Social Determinants of Health

### Healthy People 2030 Domains

**Economic stability**: Poverty, employment, food security, housing stability. **Education access and quality**: Literacy, language, early childhood education, higher education. **Healthcare access and quality**: Insurance coverage, provider availability, health literacy. **Neighborhood and built environment**: Housing quality, transportation, environmental exposures, safety. **Social and community context**: Social cohesion, discrimination, incarceration, civic participation.

### Life Course Perspective

Exposures during **critical and sensitive periods** (prenatal, early childhood, adolescence) have lasting effects on adult health. **Adverse childhood experiences (ACEs)** are strongly associated with chronic disease, mental illness, and premature mortality in adulthood. **Cumulative disadvantage**: Social determinants compound over the lifespan, widening disparities with age. **Intergenerational transmission**: Poverty, trauma, and poor health in one generation affect the next.

![Social determinants of health framework across the lifespan](illustration-sdoh-lifespan-framework.jpg)

## Disparities Across the Age Spectrum

### Perinatal and Infant Health

**Black infant mortality** is 2.3 times higher than White infant mortality in the U.S. **Preterm birth** rates are highest among Black and Native American women, driven by structural racism, chronic stress, and inadequate prenatal care. **Maternal mortality**: Black women are 3-4 times more likely to die from pregnancy-related causes. **Breastfeeding disparities**: Lower initiation and duration rates among Black and low-income women, influenced by workplace policies, cultural support, and hospital practices.

### Childhood and Adolescence

**Food insecurity** affects 1 in 7 U.S. children, contributing to obesity, developmental delays, and poor academic performance. **Lead exposure**: Disproportionately affects children in older housing in low-income communities; irreversible neurodevelopmental effects. **Asthma**: Higher prevalence and morbidity in Black and Puerto Rican children; linked to housing quality, air pollution, and access to specialty care. **Mental health**: Immigrant and refugee children face unique stressors; LGBTQ+ youth have higher rates of depression, suicidality, and homelessness. **Insurance gaps**: Uninsured children have less access to preventive care and more emergency department utilization.

### Adult Health

**Diabetes**: Prevalence 2-3 times higher in Black, Hispanic, and Native American adults compared to White adults. **Cardiovascular disease**: Disparities in hypertension control, access to cardiac catheterization, and outcomes post-MI. **Cancer**: Later stage at diagnosis and higher mortality among Black patients for multiple cancer types. **Mental health**: Stigma, cultural barriers, and provider shortages limit access in underserved communities. **Incarceration**: 2.3 million incarcerated individuals face disrupted healthcare, chronic disease exacerbation, and reentry challenges.

### Geriatric Health

**Alzheimer disease**: Disproportionately affects Black and Hispanic older adults; underdiagnosed and undertreated. **Polypharmacy risks**: Greater in lower-income seniors with fragmented care. **Social isolation**: A major risk factor for cognitive decline, depression, and mortality in older adults. **End-of-life care**: Racial and ethnic minorities are less likely to receive hospice and more likely to receive aggressive end-of-life interventions.

## Screening and Intervention

### Screening for SDOH

| Tool | Population | Domains Covered | Setting |
|------|-----------|----------------|---------|
| PRAPARE | Adults | Employment, housing, education, social support, stress | Primary care |
| AHC-HRSN | Adults and children | Housing, food, transportation, utilities, safety | CMS Accountable Health Communities |
| WE CARE | Pediatric | Education, employment, childcare, food, housing, household heat | Pediatric primary care |
| SEEK | Pediatric | Parental depression, substance use, DV, food insecurity, stress | Pediatric primary care |
| Hunger Vital Sign | All ages | Food insecurity (2 questions) | Any clinical setting |

**Validated screening tools**: PRAPARE, AHC-HRSN, WE CARE, SEEK (pediatric-specific) Integrate screening into routine clinical workflows (intake forms, annual visits) Screen for food insecurity (Hunger Vital Sign: 2-question screen), housing instability, transportation barriers, interpersonal violence, and utility needs. Document SDOH using **ICD-10 Z codes** to capture social risk factors in the medical record.

### Clinical Interventions

**Community health workers**: Bridge gaps between clinical care and social services. **Medical-legal partnerships**: Embed legal services in healthcare settings to address housing, benefits, immigration. **Integrated behavioral health**: Co-located mental health services improve access, particularly in primary care. **Patient navigation**: Trained navigators help patients access resources, keep appointments, and manage chronic disease.

### Policy and Advocacy

Medicaid expansion improves insurance coverage and reduces disparities in access. **WIC, SNAP, and housing assistance programs** directly address food and housing insecurity. Paid family leave policies improve maternal and infant health outcomes. Addressing **structural racism** through policy change, institutional accountability, and community investment.

![Community-level interventions addressing social determinants of health](illustration-sdoh-community-interventions.jpg)

## Implicit Bias and Structural Racism

**Implicit bias**: Unconscious attitudes that affect clinical decision-making; contributes to disparities in pain management, referral patterns, and communication. **Structural racism**: Policies and systems that perpetuate racial inequity in education, housing, employment, and healthcare. Medical education must include training in recognizing and mitigating bias. Diversifying the healthcare workforce improves patient-provider concordance and outcomes.

![Impact of implicit bias on clinical decision-making pathway](illustration-implicit-bias-clinical-decisions.jpg)

## Clinical Pearls

Social determinants account for an estimated 30-55% of health outcomes, far exceeding the contribution of clinical care alone. Adverse childhood experiences create a biological and behavioral bridge between childhood adversity and adult chronic disease. Screening for SDOH should be as routine as screening for depression or substance use; validated tools exist for all age groups. Addressing health disparities requires action at individual, institutional, community, and policy levels. Med-peds physicians are uniquely positioned to witness and intervene on the life course effects of social determinants.

## References

1. Braveman P, Gottlieb L. The social determinants of health: It's time to consider the causes of the causes. *Public Health Rep*. 2014;129(Suppl 2):19-31.
2. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The ACE Study. *Am J Prev Med*. 1998;14(4):245-258.
3. National Academies of Sciences, Engineering, and Medicine. *Integrating Social Care into the Delivery of Health Care*. National Academies Press; 2019.
4. Trent M, Dooley DG, Douge J, et al. The impact of racism on child and adolescent health. *Pediatrics*. 2019;144(2):e20191765.