Lizzie Wortley, ST7 paediatrics

It can be really easy to get frustrated when working.  We know that even when seeing ten wheezers a day, they all have different stories and we have different responses to them.  But it’s hard to feel like even your best holistic care isn’t having a particularly effective long-term impact.  That’s why we think social paediatrics has a role in all our work.  But it’s not a speciality that has well defined borders, and that makes it hard for us to hold onto and “practice”.  It is both the science of medicine and the art of healing not bundled neatly together, but pulled apart, broken down, in order to rebuild it around an individual and their needs.  

Defined by the International Society of Social Paediatrics as “a focus on the child, in illness and in health, within the context of their society, environment, school and family”(1), others see it as personalised public health.  

Because it can be intangible, in this series of articles about the wider determinants of health there will be some debate.  How on earth do you study the impact of “everything else” on health outcomes?  In many different and complex ways!  Answers on a postcard! (seriously, if you would like to write about any of this – get in touch!)

Again, because we are discussing all elements of a life, some of it’s not an easy read – sometimes because it relates to your own personal experiences; sometimes because it’s hard to believe in the reality of other people’s lives.  Some of it may initially feel preposterous; some of it will go against what you understood from all your years of studying at medical school or reading the paper.  Some of it may seem a bit too “Guardian”.  Some of it will seem to conflict with the principles of autonomy we know from medical ethics (we will discuss this more later).  

Let’s be open: There is no denying that it is hard to find the language and correct terms to navigate complex, emotional and sensitive subjects.  No one gets it perfect all the time.  As Brené Brown says: “I’m here to get it right, not be right”.  We’re all learning.  The point of these pieces is to open up an important conversation and improve our understanding, reduce our confusion and frustration when it all seems overwhelming, and make us all a bit more empathic with each other and our patients.  

So why do we care about “social paediatrics”?

We slog our guts out working hard to try and make people better and improve their lives.

We do QI projects that try to fix the “system”.

We really, really want children and young people to have a better time of it.

And actually, for all our efforts in the medical system, it’s not the quality of our care that has the biggest impact.  It’s what’s happening in and around the child. This can be genetic or environmental.  And the increase in epi-genetic studies in the last 15-20 years shows how the “environment” influences the way genes are transcribed – so environment influences everything (2).  

Environment means something different to everyone.  It can be hard to pin down.  In this context I mean from the cellular fluid, up to the political system someone is raised in.  It goes from the intra-uterine “environment” up to the early years funding policy of the local area where someone lives.  Or as a colleague of a colleague puts it “The world that they inhabit”.   

And this impacts everything – from the way your cellular and neurological pathways develop, your genes are transcribed, and your future emotional response to stress (both psychological and physiological).  It impacts the likelihood you will attend healthcare settings, how sick you will be when you do, and the availability of healthcare in your area.  With this in mind, attributing percentages of causes to any one outcome is really hard, but we know that across the social gradients, long-term conditions, morbidity and mortality are dramatically different (3).

For example, poor mental wellbeing is up to 4 times worse in young people from lowest income households. (4)  Whether or not you think that may make superficial sense (one may assume there are more stressors in a lower income household) and think that can be treated, the reality is that poor mental health impacts on your ability to form relationships, engage at school and concentrate.  But all three of those things are vital to gain qualifications, get a job and maintain that employment.  And it is through employment and education that we expect people to “pull themselves up by the bootstraps”.  

Add into the mix what a lot of suggestions to improve mental health are (particularly “social prescriptions”) and you start to see a much more complex picture emerging.   Where you live (shared bedrooms, green space access, fast food density, quiet environment) impacts on your ability to have a healthy diet, regularly exercise, sleep well, be “mindful” and practice gratitude.  When you’re a young person, you cannot control your environment or remove external stressors.

So what does that mean for our practice?

We have other pieces on Adverse Childhood Experiences and the First 1000 days coming up which explain in more detail how these biochemical pathways are formed and their impact on outcomes.  There’s no easy answer, but in understanding interactions and influences we can try and “manage” patients and their families more effectively and realistically. Here’s a starting point.

Hang On, I still need something more tangible than “Environment”

Researchers have used modelling to best describe what they mean by environment and its impact on outcomes.  Here’s an example of one. 

The reason I like this is because it separates the parents from their parenting behaviours and their own actions.  E.g. eating chocolate when the children are asleep, or drinking when out with friends, the parent is separate from their relationship with their child.  

This, for me, makes it relatable to the way I live my life, and therefore easier to relate it for the way the people around me may live theirs.  

That statement may seem incredibly ego centric and “anti” social paediatrics.  However, I would argue that it’s only in really understanding our privilege and experiences, and how these may compare, differ and match the people around us and our patients’ families that we can really practice the holistic medicine that starts to tackle the other drivers for the health outcomes of the person in front of us.  

And that’s why we’re starting to have more pieces on the wider determinants of health – to help us all see how our different life experiences impact on our outcomes and what we can control through choice, and what we can’t, and what that means for autonomy.

We hope you enjoy reading and learning as much as we have enjoyed starting this conversation.  

If you’d like to write something for us then we are interested in to hear from you.  If you’re interested in a “wider determinant of health” and want to help others understand it, get in touch @paediatricFOAM or paediatricfoam@gmail.com

References:

1.        Spencer N, Colomer C, Alperstein G, Bouvier P, Colomer J, Duperrex O, et al. Social paediatrics. J Epidemiol Community Health. 2005;59(2):106–8. 

2.        Halfon N, Hochstein M. Life Course Health Development: An Integrated Framework for Developing Health, Policy, and Research. Milbank Q. 2002;80(3):433–79. 

3.        Marmot M, Bell R. Fair society, healthy lives (Full report). Public Health [Internet]. 2012;126(SUPPL.1):S4–10.

4.        Pearce A, Dundas R, Whitehead M, Taylor-Robinson D. Pathways to inequalities in child health. Arch Dis Child. 2019;104(10):998–1003. 

Written Sept 2020