Table 4.

Case 3: Rachel and Macy - social determinants of health and structural racism.

Birth & Family Medical Histories	Birth History: Macy's mother, Renee, worked part-time while going to school to become a nursing assistant. She did not realize she was pregnant until 10 weeks due to a history of irregular periods but was not able to establish prenatal care until the second trimester (16 weeks) because of appointment availability and her work schedule. Renee later developed gestational diabetes and pregnancy-induced hypertension.
	Family Medical History: Mother: Renee had a history of obesity since childhood. Maternal Grandmother: Rachel has a history of obesity and tobacco use. Rachel has been divorced for more than 10 years – after enduring years of fear and uncertainty related to her husband's substance abuse disorder. For years afterward, she and her children, including Renee, lived “hand-to-mouth” despite her working as Program Coordinator of a youth literacy program. Rachel is discouraged. She feels Macy's health and Renee's death are due to being under constant stress, not to mention the lack of access to fresh affordable food and produce. There are no grocery stores in her neighborhood – only overpriced corner stores that sell mostly alcohol and cigarettes. The closest grocery story is a 30-minute bus ride away.
Assessment	Macy is a 9-month-old female with elevated weight-for-length with multiple negative social determinants of health
Actionable Steps	1) Medical Assessment: Screen every patient with obesity for SDOH
	2) Screen parents and caregivers for depression
	3) Take steps to deliver trauma informed care and address structural racism
Additional History & Discharge Plan	•SDOH screening reveals that Rachel has concerns about unreliable transportation and fluctuating food insecurity
	•Edinburgh Postnatal Depression Scale [53] reveals that Rachel is experiencing signs of depression, specifically guilt, anxiety, sadness and feeling overwhelmed. Upon discussion of her screening results Rachel explains her depression is aggravated by grief, family and social stressors, including racism. Rachel is overworked and feeling depressed. She tends to feed Macy anytime she cries and will continue to offer the bottle despite signs of satiety. She feels like she is unable to bond with Macy due to stress.
	•Based on the SDOH and depression screens, the clinic social worker meets with Rachel prior to discharge to help her identify resources and schedule transportation for Macy's 12-month well visit using her insurance.
Follow-up	•At Macy's 12-month visit, weight gain continues. However, she is reaching her developmental milestones. Rachel reports that she used the recommendations from the social worker to identify a Primary Care Mobile Health Unit and nonprofit counseling center that are a short bus ride from her home. Volunteers at the nonprofit provide up to 4 hours/week of free babysitting, which Rachel uses when she needs to run errands or go to counseling. The Center also has a weekly farmer's market with fresh produce.
	•Overall, Rachel's mood is improved. She feels less overwhelmed and better able to respond to Macy. You praise Rachel's progress and encourage her to keep up with counseling appointments. The clinic social worker also meets with Rachel and is heartened by the progress she sees in both Rachel and Macy. She helps schedule transportation for the 15-month well visit.