Abstract
This cross-sectional study uses data from the 2017 National Survey of Children’s Health to assess whether social challenges increase with higher medical condition complexity among US children.
Health is strongly influenced by both medical conditions and social determinants of health (SDH). The degree to which challenges in one affect the frequency or magnitude of challenges in the other is not fully understood. Children with medical complexity may be at especially high risk for related social complexity.1,2 If so, then children with medical complexity may be even more vulnerable than their underlying illness might suggest owing to enhanced risk for SDH challenges. A comprehensive medical-social approach to pediatric complex care may be warranted—one not currently seen in traditional health care practices. To better understand this potential need, we compared the prevalence and types of SDH challenges across children by level of medical complexity.
Methods
We performed a retrospective, cross-sectional study of 21 599 responses representing 73.4 million children aged 0 to 17 years. Data were taken from the 2017 National Survey of Children’s Health, which is funded and directed by the Maternal and Child Health Bureau of the Health Resources and Services Administration.3 The screening items of children with special health care needs (CSHCN) were used to categorize children into 3 groups.4 Children without special health care needs had none of the following attributes: (1) chronic mental or physical health problems; (2) chronic functional limitations; or (3) the need for therapies, chronic medications, or any health care needs greater than healthy peers. Children with special health care needs were then categorized as having lower medical complexity if they had neither chronic functional limitations nor greater health care needs than their peers. Children with special health care needs with either of those 2 attributes were categorized as having higher medical complexity. Waiver of ethical review for the study and informed consent was granted by the institutional review board of Boston Children’s Hospital because the research did not meet criteria for human subjects research.
The data analysis was performed between January 1 and December 31, 2017. With the use of the Healthy People 2020 framework,5 SDH challenges identified from the survey were organized by (1) neighborhood characteristics, (2) parent or household characteristics, and (3) adverse childhood experiences. The rates of SDH challenges were adjusted by age, sex, and race or ethnicity and compared across groups using design-adjusted logistic regression. Because of the large sample size, the threshold for statistical significance was 2-sided P < .01. All analyses were performed with SAS software, version 9.4 (SAS Institute Inc).
Results
In the study cohort of 73 424 383 children, 37 542 467 (51.1%) were boys and 35 881 916 (48.9%) were girls; 51.0% were non-Hispanic white, 24.9% Hispanic, 13.4% non-Hispanic black, and 10.7% another race/ethnicity. Among children in the cohort, 81.8% had no special health care needs, 15.6% were CSHCN with lower medical complexity, and 2.6% were CSHCN with higher medical complexity (Table). The percentages of children experiencing challenges in the following domains increased with medical complexity (no special health care needs vs CSHCN with higher medical complexity): (1) neighborhood: rundown housing (11.6% vs 16.9%) and vandalism 6.5% vs 12.2%; (2) parent/household: single-parent household (15.9% vs 19.9%), primary parent has fair or poor physical health (5.6% vs 22.4%), primary parent has fair or poor mental health (3.5% vs 18.7%), and income less than 200% of the federal poverty level (37.2% vs 51%); and (3) adverse childhood experiences: parent divorce (21.7% vs 29.3%), parent incarceration (6.1% vs 18.2%), child abuse (2.9% vs 6.5%), and food insecurity (5.5% vs 13.6%) (Figure). All differences were statistically significant (P < .001).
Table. Demographic Characteristics of the Study Population by Complexity of Special Health Care Needs.
| Characteristic | No. (%) | |||
|---|---|---|---|---|
| All children | Special health care needs | |||
| None | Lower complexity | Higher complexity | ||
| Overall | 73 424 383 (100) | 60 096 885 (81.8) | 11 417 083 (15.6) | 1 910 415 (2.6) |
| Age, y | ||||
| 0-1 | 7 699 922 (10.5) | 7 324 816 (12.2) | 342 720 (3.0) | 32 386 (1.7) |
| 2-4 | 12 084 849 (16.5) | 10 655 129 (17.7) | 1 241 489 (10.9) | 188 231 (9.9) |
| 5-12 | 32 926 710 (44.8) | 26 302 300 (43.8) | 5 661 967 (49.6) | 962 442 (50.4) |
| 13-17 | 20 712 902 (28.2) | 15 814 640 (26.3) | 4 170 907 (36.5) | 727 356 (38.1) |
| Sex | ||||
| Male | 37 542 467 (51.1) | 29 803 477 (49.6) | 6 487 287 (56.8) | 1 251 703 (65.5) |
| Female | 35 881 916 (48.9) | 30 293 408 (50.4) | 4 929 796 (43.2) | 658 712 (34.5) |
| Race/ethnicity | ||||
| Non-Hispanic white | 37 415 487 (51.0) | 30 794 035 (51.2) | 5 695 824 (49.9) | 925 627 (48.5) |
| Non-Hispanic black | 9 841 673 (13.4) | 7 238 651 (12.0) | 2 185 677 (19.1) | 417 345 (21.8) |
| Hispanic | 18 309 354 (24.9) | 15 358 772 (25.6) | 2 535 935 (22.2) | 414 647 (21.7) |
| Othera | 7 857 869 (10.7) | 6 705 426 (11.2) | 999 647 (8.8) | 152 796 (8.0) |
Other race/ethnicity included Asian, American Indian, and Pacific Islander.
Figure. Social Determinants of Health in Children by Complexity of Special Health Care Needs.
Shown are the percentages of children with each social determinant of health measured from the 2017 National Survey of Children’s Health.
Discussion
In the present study, SDH challenges were prevalent and associated with medical complexity. This association suggests that more attention with respect to SDH challenges is needed, especially for children with medical complexity. Because of the problems reflected by many of the SDH challenges, implementation of not only individual-level but also community-level social solutions is probably needed. Otherwise, efforts expended on SDH may remain predominately focused on helping children and families endure these problems rather than helping society solve them. A limitation of the present study is that it could not assess causal associations between SDH challenges and medical complexity. More research is needed to understand when and how medical complexity and SDH challenges develop and influence each other. Population-based, longitudinal surveys should consider items that clarify the onset of both special health care needs and SDH challenges to help unravel these temporal relationships.
References
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