Social Determinants of Child Health Up Odds of Injury

Several social determinants of child health (SDoCH) were associated with an increased risk for pediatric injury in Manitoba and can be used to inform prevention efforts, new research suggested.

The indicators include living in a rural area, being in protective care, being born to a teen mother, having a parent involved in the justice system, and family receipt of income assistance, according to a retrospective case-control study.

Trauma-informed care training that includes these SDoCH “is essential in understanding the context behind pediatric injuries and delivering comprehensive, compassionate support to children and their caregivers” in hospital and outpatient settings, study author Rae Spiwak, PhD, assistant professor and research scientist in the department of surgery at the University of Manitoba’s Max Rady College of Medicine in Winnipeg, told Medscape Medical News.

The data were published on June 4 in JAMA Network Open.

Rurality and Risk

Researchers analyzed social and clinical administrative datasets from the Manitoba Centre for Health Policy Population Data Repository to examine the association between SDoCH and traumatic injury among children aged 17 years or younger who were hospitalized with physical injuries between 2002 and 2019.

A total of 9853 cases were matched with 49,442 uninjured control cases for a total sample of 59,295. Among cases, the mean age at the time of injury was 9.8 years, 64.5% of those injured were male, 47.6% lived in a rural area, and 36.9% lived in a low-income neighborhood.

Fourteen SDoCH were measured during the child’s lifespan, from birth to the date of injury, including low income, rural status, receipt of income assistance, parent justice system involvement, parent with less than a high school education, immigrant parent, high residential mobility, being born to a teen mother, child in protective care, child mental health disorder, maternal axis I or axis II mental disorder, and maternal physical disorder.

Multivariate logistic regression analysis showed that living in a rural area was associated with the highest odds of traumatic physical injury (adjusted odds ratio [aOR], 6.62), followed by living in protective care (aOR, 1.43), being born to a teen mother (aOR, 1.34), and having a parent involved in the criminal justice system (aOR, 1.27) or receiving income assistance (aOR, 1.13).

The researchers used a Haddon matrix to plot the SDoCH that placed children at the greatest odds of sustaining a physical traumatic injury on a timeline of preinjury, injury, and post-injury and to identify potential points for interventions and prevention.

The Haddon matrix “is based on the premise that injuries result from harmful interactions between the individual, the agent, and the physical and socioeconomic environments,” the authors explained. They used the matrix in previous work to organize strategies for pediatric burn injury interventions, and based on the current study results, they will expand the framework for all-cause pediatric injury.

Team Approach

“Healthcare is a team sport, and to provide the best care, there needs to be interplay between all involved,” said Spiwak. The study’s findings can help pediatricians and primary care providers incorporate risk screening into routine checkups, she suggested. “Knowing that factors such as rural living can help clinicians identify children and families who may benefit from early intervention and support, providers can ensure that parents and families are provided with education, such as safe practices around large farm equipment and all-terrain vehicle use.

“Emergency medicine providers can integrate these findings into injury prevention strategies when managing pediatric trauma cases,” she continued. “If certain social determinants are known risk factors, clinicians could refer social workers to engage with families during or after ED [emergency department] visits — not just treating the immediate injury, but also helping address root causes and prevent future injury.”

An example is Manitoba’s ED violence intervention program for youth, which has been shown to reduce traumatic injury recidivism, Spiwak noted. “A similar program focused on nonviolent injury could be a useful application of this work.”

Commenting on the findings, Pramod Puligandla, MD, told Medscape Medical News that the key messages “should resonate with all pediatric caregivers.” Puligandla, who was not involved in the study, is a professor and director of Pediatric Surgery at McGill University Medical School and director of the Extracorporeal Life Support Program at Montreal Children’s Hospital in Montreal.

“With injury being the most frequent cause of pediatric morbidity and mortality, identifying populations at risk for injury through an analysis of SDoCH is important to institute intervention and prevent injury,” he said. “Indeed, SDoCH are important upstream targets to reduce morbidity and mortality, as well as narrow or close gaps in equity.”

“These efforts not only need to be initiated in the in-hospital setting but likely most importantly, in the prehospital setting, where injury may be prevented,” he said. “The Haddon Matrix analysis used by the authors identifies potential interventions through the life cycle of these vulnerable populations in both settings. Targeted interventions should also address structural racism, as well as explicit and implicit bias.”

How translatable the findings are to other populations or geographic regions is unclear, Puligandla noted. “The study focuses on children in Manitoba. The authors highlight the overrepresentation of Indigenous populations within many of the SDoCH they evaluated.” For example, the estimated Indigenous population in Manitoba is 18%, and in Saskatchewan, 17%. These are much higher percentages than in Ontario and Quebec (< 3%) or British Columbia and Alberta (< 6%). “Each province or territory likely needs to do its own assessment to target the at-risk populations within their respective regions,” said Puligandla. 

This work was supported by the Canadian Institutes of Health Research. Spiwak and Puligandla reported having no relevant financial relationships.

Kate Johnson is a Montreal-based freelance medical journalist who has been writing for more than 30 years about all areas of medicine.