Residency · Residency · Medicine Pediatrics
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.
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.
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.
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
- 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.
- 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.
- National Academies of Sciences, Engineering, and Medicine. Integrating Social Care into the Delivery of Health Care. National Academies Press; 2019.
- Trent M, Dooley DG, Douge J, et al. The impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765.