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Fast Facts

A brief refresher with useful tables, figures, and research summaries

Community and Societal Pediatrics

According to the American Academy of Pediatrics (AAP), community pediatrics is “the practice of promoting and integrating the positive social, cultural, and environmental influences on children’s health as well as addressing potential negative effects that deter optimal child health and development within a community.” This approach to well child and preventive care promotes the health and well-being of children in the context of their families and communities and recognizes the importance of social determinants of health. Pediatricians are also charged with addressing determinants of child health at the community and societal level through advocacy, action, and reform.

This section addresses the following topics related to the practice of community pediatrics:

Routine Well Child Care
Social Determinants of Health
Adverse Childhood Experiences
Screening for Social Determinants of Health
Mitigating Effects of Adverse Childhood Experiences
Advocacy
Mitigating Structural Racism

Routine Well Child Care

Routine well child care is a central feature of pediatric practice and provides the opportunity to:

address parental concerns
provide routine surveillance of growth and development
conduct age-appropriate, evidence-based screening
provide anticipatory guidance
administer immunizations

The well child visit is also an opportunity to become acquainted with a child and family and begin a partnership that can extend over time. Every pediatric patient (except for a few emancipated minors) exists within a family context, and every family exists within a community and a larger societal context. Each family — biologic, foster, or adopted; nuclear or multigenerational — is different, and each has strengths and weaknesses. Acute and chronic health conditions and associated outcomes are influenced by factors that range from the child’s community-level determinants of health to immediate family and genetic factors. Routine care and prevention provide opportunities to act at each of these levels of influence.

Social Determinants of Health

Evidence indicates that social, environmental, and behavioral factors influence 50% to 60% of health outcomes, whereas genetic factors influence 30% and the health care system affects 10% to 20%.

[Image] — **Determinants of Health and Their Contribution to Premature Death**

Social determinants of health (SDH) have a significant effect on health outcomes. The World Health Organization (WHO) defines SDH as “the conditions in which people are born, grow, live, work and age.”

The domains of SDH can be categorized as follows:

economic stability
education access and quality
health care access and quality
neighborhood and physical environment
social and community context

The following graphic provides examples of SDHs within each domain.

Social Determinants of Health

Adverse Childhood Experiences

Social determinants can have an impact on health even after the conditions have been resolved. Traumatic events in childhood (e.g., abuse and neglect) or adverse childhood experiences (ACEs) are a subset of SDH.

Examples of Adverse Childhood Experiences

experiencing violence, abuse, or neglect
witnessing violence in the home or community
having a family member attempt or die by suicide
having a family member with substance use problems
having a family member with mental health problems
experiencing instability due to parental separation or incarceration of household members

The Kaiser Permanente Adverse Childhood Experiences (ACE) study examined the association between ACEs and later health outcomes in 17,000 participants. The results indicated that as the number of traumatic events in childhood increases, so does the risk for adult morbidity and mortality (a dose-response effect). Negative health outcomes associated with ACEs include: alcoholism and alcohol abuse, chronic obstructive pulmonary disease, depression, fetal death, diminished health-related quality of life, illicit drug use, ischemic heart disease, liver disease, poor work performance, financial stress, risk for intimate partner violence, multiple sexual partners, sexually transmitted diseases (STIs), smoking, suicide attempts, unintended pregnancies, early initiation of smoking, early initiation of sexual activity, adolescent pregnancy, risk for sexual violence, and poor academic achievement.

Screening for Social Determinants of Health

In pediatrics, understanding the patient’s social context is essential before the clinician can address the patient’s needs. Historically, social context was only discussed if the clinician asked, and with wide variation in how this information was assessed. This inconsistency can introduce bias. For example, a clinician may only ask families with obvious discord about substance use, even though any family can be affected.

Universal screening is a method to counter this bias. We can integrate a standardized screening for social determinants into well visits as we do for anemia, autism, and sexually transmitted infections (STIs). Many screening tools exist (see the AAP Tool Finder for a database of screening tools). The following factors affect decisions about which tools to use in your practice:

the goals of screening in your setting (e.g., referral to resources, better understanding of social context, identifying needs)
the format used for delivering the screen (e.g., on paper or electronic form, self-administered or administered by staff)
who will respond to positive results (e.g., the physician, nurse, medical assistant, community health worker, or another entity)

Mitigating Effects of Adverse Childhood Experiences

Adverse health outcomes related to SDH and ACEs are not immutable. Preventing ACEs can lead to significant reduction in chronic disease outcomes in adulthood, as demonstrated in the following graphic.

Although the community and government are responsible for interventions to address adverse conditions (e.g., improving access to affordable housing, a living wage, equal educational opportunities), health care providers can address social determinants in the clinical setting in the following ways:

Referral to resources: The resources that exist in a community are widely variable and may include food banks, housing shelters, domestic violence advocacy, adult education, legal aid societies, and vocational training. Patients may be aware of some services, but with an ever-changing landscape, they may not be aware of all services that could be helpful. The following resources can help identify local services in your community:

call 2-1-1 or visit 211.org
online search engine for free or reduced-cost services: Aunt Bertha
the Children’s Advocacy Project: Cap4Kids

However, clinician involvement should not end at a referral to such services. Families often have barriers to accessing resources. As with any medical problem, once a need is identified, it should be added to the list of concerns, tracked, followed up, and management plans modified as needed. The AAP has created a Toolkit for Pediatricians to Address Food Insecurity.

Modifying clinical practice: Practice and treatment-plan modifications can sometimes address an identified need (e.g., transportation difficulties). In the clinical setting, consider the following modifications:

follow-up by phone or telehealth instead of an in-person visit
follow-up with a visiting nurse
scheduling an office visit around known transportation assistance (e.g., bus or friend)

Partnering with patients: Regardless of whether resources exist or clinical modifications can be made, understanding a family’s social context is an opportunity to partner with them. Partnering can sometimes help modify the differential diagnosis. Sometimes we are called to sit with the discomfort of not being able to do anything.

“ Slowly, I have come to see that asking, listening, and accepting are a profound form of doing.” —Vincent Felitti, MD, principal investigator of the ACE Study

Advocacy

To advocate means to offer public support for or recommend a cause or policy. Pediatricians have engaged in advocacy efforts since the beginning of the profession.

“It is not enough, however, to work at the individual bedside in the hospital. In the near or dim future, the pediatrician is to sit in and control school boards, health departments, and legislatures. He is the legitimate advisor to the judge and the jury, and a seat for the physician in the councils of the republic is what the people have a right to demand.” —Dr. Abraham Jacobi, founder of American pediatrics

Advocacy takes us beyond the bedside, outside of the hospital or clinic walls, to call for change on a community, state, or federal level. When we see a need, we feel the call to respond! The following are some examples of ways in which pediatricians engage in advocacy:

In the community, pediatricians advocate for fluoridated water, school-based health centers, and safe places to play.
At the state level, pediatricians advocate for distracted-driving laws, expanded child insurance coverage, assault weapons bans, and evidence-based immunization requirements.
At the federal level, pediatricians advocate to protect immigrant children, to improve children’s access to health care, for gun violence prevention, and to put children first in federal spending decisions.

Mitigating Structural Racism

Structural racism refers to the ways in which society fosters racial discrimination through mutually reinforcing systems of housing, education, employment, earning, benefits, credit, media, health care, and criminal justice, which in turn reinforces discriminatory beliefs, values, and distribution of resources. Although the medical community strives to provide apolitical and equitable care to all, research has shown that medicine is not immune to the underlying systems, laws, and policies currently in place. Rather than maintaining the status quo and ignoring these biases and disparities, clinicians must recognize and respect the ethnic and racial diversity of our country, on both a systemic and personal level. Physicians carry a powerful voice and can participate in defining the structures that shape our health. Aaron and Stanford recommend the following ways to do so:

Amplify the voices for change of patients and providers and protect these people from punishment or retaliation.
Bring social causes of disease into the exam room, name them, discuss them with patients, and cite them in the medical record where pertinent.
Be creative at integrating social factors into the care plan.
Form alliances across fields and across identity groups to build a large collective voice to better address the social factors and laws contributing to modern disease.

Research

Landmark clinical trials and other important studies

Research

Screening for Adverse Childhood Experiences in Children: A Systematic Review

Loveday S et al. Pediatrics 2022.

This systematic review examined whether screening for ACEs in children leads to increased identification of ACEs, referrals to services, uptake of services, and improved mental health outcomes for children and parents. Screening for ACEs increased identification of adversity and possibly referrals to services.

The Effect of Multiple Adverse Childhood Experiences on Health: A Systematic Review and Meta-Analysis

Hughes K et al. Lancet Public Health 2017.

After the original Adverse Childhood Experiences (ACEs) Study, a growing body of research has examined these events. This meta-analysis synthesizes the results.

Adverse Childhood Experiences: Translating Knowledge into Identification of Children at Risk for Poor Outcomes

Marie-Mitchell A and O’Connor TG. Acad Pediatr 2013.

The original ACEs study showed the relation between childhood adversity and adult health. This study showed that ACEs can be screened for in childhood and that they are related to childhood-onset outcomes.