SYMPOSIUM: SOCIAL PAEDIATRICS
The social determinants
of child health
Nick Spencer
Abstract
Social determinants of health have long been recognised but their
importance is often overlooked. Globally social determinants are
responsible for most childhood illness and death. In the UK, conditions
which constitute a large part of paediatric practice are socially
patterned. Social determinants exert their influence on child health
through a complex inter-relationship of more distal social factors
such as income and education with more proximal factors such as
health behaviours.
The pathways by which the social determinants exert their influence
operate over time and across generations. Socially related risk and
protective factors cluster in different social groups and accumulate
over time. Social determinants are profoundly influenced by social
and political decisions which are beyond the control of parents and in-
dividual paediatricians. Societies can protect children against the
adverse effects of social disadvantage. National paediatric societies
have a key role in promoting policies which protect children. This
brief review summarises the impact of social determinants on chil-
dren’s health in the UK and considers the role of paediatricians in
reducing the health inequities generated by these determinants.
Keywords advocacy; social determinants of health; social protection
Introduction
Social factors have long been known to influence the growth,
health and development of children. As far back as the mid-19th
century social reformers were identifying the impact of poor
housing, inadequate nutrition and other socially-related factors
on children. Their studies helped to promote the social changes
which eventually led, in today’s rich nations, to the major im-
provements in living conditions, nutrition and healthcare which
have enabled vast improvements in child survival and the health
status of child populations. The same deprivation of basic ne-
cessities for a healthy life which was responsible for high child
mortality and morbidity in rich nations in the 19th century
continues to blight the lives of millions of children in low and
middle income countries.
Despite this evidence for the historical and global importance
of social determinants of child health (SDCH), they have tended
to be overshadowed by the advances in understanding of disease
processes and medical treatments. Renewed interest in the role of
social factors and health behaviours in the aetiology off disease
culminated in the publication in 2008 of the WHO Commission
on Social Determinants of Health report which definitively re-
Nick Spencer MPhil FRCPCH (Hon) FRCPE DCH is Emeritus Professor at
Warwick Medical School, University of Warwick, Coventry, UK.
Conflict of interest: none declared.
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established the critical role of social determinants in population
health and in the health of children globally.
Professor Sir Michael Marmot, who chaired the WHO Com-
mission, has published a series of country-level reviews of social
determinants. The UK review, Fairer Society, Healthy Lives,
while acknowledging the improvements in health of the UK’s
children, shows that, despite being one of the wealthiest coun-
tries in the world, the UK has high levels of relative child poverty
compared with other rich nations and wide child health
inequities.
Definition and relevance
SDCH refers to a range of societal and environmental factors that
impact on the health of individual children and child pop-
ulations. Marmot characterises SDCH as “causes of causes”; in
other words, they usually act as distal factors influencing more
proximal factors in causal pathways to health outcomes.
Although they may be obvious in individual children, they are
most commonly identified in child populations as health in-
equities, inequalities that are unfair, unjust, avoidable and un-
necessary and that systematically burden populations rendered
vulnerable by underlying social structures, and political, eco-
nomic, and legal systems. Inequities are responsible for sub-
stantial mortality and morbidity among children in both poor and
rich nations. Table 1 shows the impact of social inequity on a
range of child health outcomes among UK children aged 11 years.
The health outcomes shown in the table are relatively common
and represent a significant proportion of paediatric activity. The
role played by SDCH in their aetiology should be of concern to
paediatricians.
Epidemiology
In child populations, the epidemiology of SDCH focuses on the
social patterning of exposure to risk and protective factors and of
health outcomes. Predictor variables which represent social
patterning are known as equity stratifiers. The stratifier used in
Table 1 is equalised household income; however, there are many
others which can be used such as parental education and various
classifications of parental occupational status and many epide-
miologists recommend using more than one equity stratifier to
illustrate SDCH.
The impact of an equity stratifier on risk exposure or health
outcome can be represented in various ways. Frequency or point
prevalence, with or without confidence intervals around the
estimate, by social group in a child population is the simplest
way to express the influence of SDCH. The Population Attrib-
utable Fraction (PAF) (see Table 1) expresses point prevalence
as the proportion of the outcome occurring in a child population
that is attributable to social inequity. The approach used in
Table 1 takes the most advantaged group (in this case, the
highest income quintile) as the reference in order to fully
represent the impact of social inequity on the outcomes and to
illustrate what could be achieved given optimal social
conditions.
Relative risk (RR) or odds ratio (OR) with confidence intervals
for an outcome by social group are commonly used to show social
patterning and can be expressed as unadjusted or adjusted i.e.
accounting for potential confounding variables in multivariate
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 SYMPOSIUM: SOCIAL PAEDIATRICS

It is important to note that not all adverse health outcomes

Proportion of child health outcomes at 11 years of age show a social gradient. For example, autism and type 1 diabetes
attributable to social inequity in the UK (based on mellitus do not show a social gradient indicating that the aetio-
analysis of Millennium Cohort Study using equivalised logical factors are not socially-related.
household income quintiles as equity stratifier)
Child health outcome Percentage reduction if all Mechanisms and pathways
children had same outcome There is no direct causal relationship between social determinants
as the highest income quintile and child health outcomes. They exert their effects through
(%) (population attributable mediating socially-related risk and protective exposures such as
fractions) health-related behaviours and environmental conditions e
‘causes of causes’ acting over the course of individual lives. Risk
Disability/Limiting long-standing illness:
exposures tend to cluster among those at the lower end of the
Limited a lot 38.5%
social spectrum and their impact can also accumulate over time.
Limited a little 20.1%
Low cumulative household income from birth to 10e11 years was
Limitation due to learning 46.7%
associated with the highest risk of activity limiting chronic illness
difficulties
in children participating in the US National Longitudinal Survey of
Limitation due to mobility 39.8%
YoutheChildren.
problems
Socially patterned health outcomes are the biological expres-
ADHD 39%
sion of social determinants e in other words, the social trans-
SDQ Score >90th centile 64%
lated into the biological. This process has been characterised as
Sleep limiting wheeze/asthma 59.5%
social circumstances getting “under the skin”, also known as
in last 12 months
embodiment. In explaining social inequities in low birth weight,
Table 1 Krieger and Davey Smith use the concept of embodiment as
follows:

“Low birth weight as an embodied expression of social

analysis. The most socially disadvantaged group can be compared
inequality reflects socially patterned exposures (during and
with the rest or each sub-group with the most advantaged. The
prior to pregnancy) to such factors as maternal malnutrition,
latter is useful in demonstrating the presence of social gradients in
toxic substances (e.g. lead), smoking, infections, domestic
child health outcomes. Figure 1 shows the social gradients in the
violence, racial discrimination, economic adversity in neigh-
same health outcomes as shown in Table 1.
bourhoods, and inadequate medical and dental care.”
All four conditions show social gradients such that risk tends
to increase in stepwise fashion as the level of household income
In a similar way, brain development in early childhood re-
decreases. The steepest social gradient is for high Strengths and
flects exposure to risk and protective factors in the child’s home
Difficulties Questionnaire (SDQ) scores but all conditions show a
environment.
similar trend. Social gradients give an insight into the mecha-
Social determinants can be considered as distal variables
nisms by which social factors impact on health and inequities
exerting influence through more proximal risk factors. The
develop and are perpetuated. The mechanisms and pathways by
complexity of these relationships can best be understood as
which child health inequities are generated are more fully dis-
pathways from distal through proximal variables to the outcome
cussed in the next section; it is suffice to say here that social
of interest. Pathways enable biologically plausible temporal re-
gradients support the hypothesis that socially-related risk expo-
lationships over the life course to be taken into account. For
sures, acting cumulatively over time, result in increasing inci-
children, the life course does not start at birth but fetal life and
dence/prevalence of certain outcomes as living circumstances
intergenerational influences also need to be considered. Using
become more disadvantaged.

ADHD High SDQ Severe limiting illness Sleep-limiting wheeze

6 8 5 5
4 4
Odds ratio

Odds ratio

Odds ratio

Odds ratio

6
4 3 3
4
2 2
2
2 1 1

0 0 0
0
Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5 Q1 Q2 Q3 Q4 Q5
Equivalised income quintile Equivalised income quintile Equivalised income quintile Equivalised income quintile

Figure 1 Health outcomes at 11 years showing social gradients (most advantaged quintile, Q1 ¼ reference) (Spencer unpublished).

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Please cite this article in press as: Spencer N, The social determinants of child health, Paediatrics and Child Health (2018), https://doi.org/
10.1016/j.paed.2018.01.001
 SYMPOSIUM: SOCIAL PAEDIATRICS

these concepts, the mechanisms by which social inequities and
social gradients are generated and maintained can be explored.
The prerequisites for constructing scientifically plausible,
comprehensive, explanatory pathways for social inequities in
child health are shown in Box1.
A simplified explanatory pathway diagram for child health
and well-being, shown in Figure 2, incorporates the essential
elements listed in Box 1.
The equity stratifiers in Figure 2 are socio-economic status
(SES) of origin of both parents influencing the family SES at the
child’s birth. The temporal relationships in the pathway are
plausible and the pathway incorporates a life course perspective
which is intergenerational. The links between the social and the
biological are shown in pathway from SES to the child’s birth-
weight which impacts on health and well-being directly as well
as indirectly through education as lower birthweight is associ-
ated with reduced cognitive function. The pathway allows for the
Prerequisites for explanatory pathways for social in-
equities in child health
C Equity stratifiers (distal variables) that have an empirically proven
relationship with proximal risk factors that are, in turn, known to
be associated with the outcome of interest
C Biologically plausible temporal relationships between variables
included in the pathway
C Incorporate a life course perspective including intergenerational
influences
C Incorporate scientifically plausible links between the social and
the biological
C Incorporate clustering and accumulation of socially related risk
and protective exposures
Box 1
clustering and accumulation of socially related risk and protec-
tive exposures. All the pathways shown have been empirically
proven.
Social inequities in child health can only be understood as
occurring as a result of complex relationships among socially
related risk and protective exposures acting over time and across
generations as Figure 2 illustrates.
Impact of social disadvantage in infancy and childhood
across the life course
In addition to the direct impact on child health, there is extensive
evidence that social disadvantage in infancy and childhood ex-
erts an independent effect on health in adolescence and adult-
hood. Social disadvantage pre-conception and in pregnancy is
associated with high risk of preterm birth and intra-uterine
growth retardation (IUGR) both of which have been shown to
independently affect adolescent and adult health. The latent ef-
fects of fetal programming associated with IUGR increase the risk
in later life of coronary heart disease and other conditions such
as non-insulin dependent diabetes mellitus. Birthweight is also
inversely proportional to cognitive development. Very preterm
infants born before 32 weeks gestation are highly vulnerable in
early infancy but also have increased morbidity into later life.
Infants born before 32 weeks in a Swedish study were four times
as likely to be receiving assistance for disability in their 20s as
infants born at normal gestational age.
Chronic illness in childhood, which is strongly socially
patterned, has been shown to be associated with an increased
risk of disability in adulthood in a Norwegian study. Mental
health problems in early childhood are associated with adoles-
cent and adult psychiatric problems particularly anxiety and
depression.

Social determinants and the structure of societies

The preceding sections outlined how SDCH influence health at
Mother’s SES of origin Father’s SES of origin the individual level. Understanding pathways at the individual
level is important but they need to be considered within a soci-
etal context. Many of the factors that make up the socio-
Family SES economic status (SES) of individuals are actually societal not
individual attributes. Illiteracy of a mother in a low income
country does not arise because of her individual failings but as a
Birth weight
direct consequence of the failure of the society in which she lives
to provide universal educational opportunities. Similarly, in rich
Health Psycho-social nations, the worker taking home wages below the poverty level
behaviours environment
cannot suddenly make an individual decision to increase his or
her pay; pay levels depend on the wider labour market beyond
Education the individual’s control.
Nutrition and
diet Figure 3 sets the individual level model represented in
Figure 2 within societal factors which impact on the pathway by
which social determinants influence health and well-being of
Environmental
individual children. The figure also seeks to represent the
exposures changing societal influences over time.
The influence of societal level factors can be seen in the
marked economic and social policy differences between coun-
Child health and wellbeing tries which have a powerful impact on population health. Among
low income countries, some, such as Cuba and Kerala State in
Figure 2 Pathways to child health and well-being (Spencer e India, have achieved very high levels of female literacy compared
unpublished). with many other countries with comparable levels of national

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Please cite this article in press as: Spencer N, The social determinants of child health, Paediatrics and Child Health (2018), https://doi.org/
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 SYMPOSIUM: SOCIAL PAEDIATRICS
Mother’s SES of origin Father’s SES of origin
Family SES
Birth weight
Health
behaviours
Environment,
Nutrition and Education
transport and
diet
food policies
Environmental
exposures
Child health and wellbeing
Figure 3 Mapping societal level factors on individual level pathways. Source: Spencer (unpublished).
income. Equally, in rich nations, differences in child poverty
levels, arising as a direct result of economic and social policy,
have a profound impact on child health and well-being.
Accessibility and affordability of healthcare and medical in-
terventions are also societal level responsibilities which cannot
be provided by individual households. Conditions such as acute
diarrhoea and acute respiratory infection for which simple cheap
effective treatments are well established are still responsible
globally for millions of child deaths, in large part due to lack of
healthcare access. Poor children in countries without universal
healthcare are at double jeopardy from adverse social de-
terminants e increased risk of disease and absence of healthcare.
Even in some rich nations, poor children face financial and other
barriers to healthcare.
The relevance of social determinants to paediatric
practice
Paediatricians, along with other medical professionals, primarily
work with individual children and their families. Our training and
experience is directed towards diagnosing and managing medical
conditions in individual patients and only limited emphasis is
given to how health is generated at societal and population level.
Understanding the importance of social determinants and their
role in child health requires a focus at both individual and popu-
lation level. Equally, as SDCH exert their influence as distal rather
than proximal causes of conditions affecting children, they may
remain ‘unseen’ by the paediatrician. In addition, SDCH are pro-
foundly influenced by social and political decisions which are
beyond the control of individual paediatricians.
Given these circumstances, it is unsurprising that many pae-
diatricians either feel powerless to influence SDCH or choose to
focus only on managing the immediate clinical problem. How-
ever, social determinants impinge on their daily work. As shown
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Fiscal policy,
Psycho-social universal and
environment Social targeted
networks service
and capital, health,
local factors
education,
social
provision
Individual Societal
level level
above, many of the common conditions that present in clinics
and hospital wards are strongly influenced by social factors and
recognition and acknowledgement of this influence allows the
practitioner to manage the clinical situation more sensitively and
effectively. For example, families with low financial resources
may struggle with frequent hospital visits and be unable to follow
treatment regimens which incur added expense. Approaches that
practitioners can take to provide responsive services sensitive to
social context are listed in Practice Points below and Dr Singh’s
companion paper in this issue presents a comprehensive account
of what individual practitioners can do to address the impact of
social determinants in their work and in their localities.
Political action and advocacy on social determinants by doc-
tors is not new. There is a long and honourable tradition of
medical intervention on behalf of individuals and communities.
Given that national policies are the main drivers of the societal
conditions which affect children’s health, while action and
advocacy at the individual level is important, national level
advocacy is needed to inform policy makers of the impact on
child health of social determinants and to convince them of the
need for policies which protect children from the adverse effects
of social disadvantage. In the UK, there is a particularly pressing
need for paediatricians to take political action on behalf of poor
children and their families.
In response to increasing inequality in society and the impact
of austerity policies on the most vulnerable and socially disad-
vantaged families, the Royal College of Paediatrics and Child
Health (RCPCH) has become increasingly vocal in urging gov-
ernment and decision-makers to reverse austerity policies which
remove social protection from disadvantaged children. In May
2017, the RCPCH published a survey of College members on the
impact of poverty on child health in the UK which concluded that
“It is clear that the impacts of poverty on children’s health are
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 SYMPOSIUM: SOCIAL PAEDIATRICS
being felt on the frontline, and that things appear to be getting
worse.”
In a recent press release in response to a new report on child
poverty in the UK, the College made a clear demand for change in
current UK government policy:
“The RCPCH has long called for the cap on welfare spending to
be withdrawn and for the government to ensure that a suffi-
cient social safety net is in place so that the risks of rising living
costs e such as child care, inflation and rent costs e are not
transferred from the Treasury to families on low incomes who
are struggling to provide for their children. And finally, the
Office for Budget responsibility should disclose the impact of
each budget on child poverty and inequality in the report it
publishes alongside the Chancellor’s annual statement.”
In the UK, disabled children and adults have been adversely
affected by benefit and service reductions resulting from policies
designed to reduce government expenditure. Advocacy by pae-
diatricians and their organisations is most powerful when it gives
voice to those directly affected by policy decisions. In its report,
Disability Matters in the UK 2016, the RCPCH presents the views
and comments of families with children with disabilities on their
experience of service and benefit provision in a period of aus-
terity. The report highlights the impact of policy on the lives of
these children and their families and demonstrates how policy
directly affects the services and care that paediatricians can offer.
These publications and the public stance of the RCPCH shows
that if paediatricians are to promote the health of children, they have
to become more than just providers of treatment and care during
illness but advocates for children in order to protect them from
forces beyond the control of the individual child and family which
may damage their health and threaten their wellbeing. Advocacy for
children is often limited to representing the child against its parents
in child protection cases. However, as the College demonstrates,
advocacy can be a much broader concept. This broader concept of
advocacy can equally be applied to specific clinical and public
health issues in which SDCH play a significant role.
The example of asthma
The Pediatric Department at the Cincinnati Children’s Hospital
Medical Center in the USA, having noted a high level of asthma
admissions from the poor areas of the city, studied the distribu-
tion of asthma admissions in Ohio County, which includes the
city, by neighbourhood social characteristics. They found that
admission rates varied 88-fold across neighbourhoods with 15
neighbourhoods having no admissions in the study period. Based
on this study, a programme of intervention, jointly with local
government and the community, to reduce environmental risk in
those areas with poor housing environments was instituted and
asthma admission rates were reduced.
The example of childhood obesity
Childhood obesity and overweight has emerged in recent years as
a significant public health issue associated with subsequent
health problems in later childhood, adolescence and into adult-
hood. In the UK, one in five children are overweight or obese
when starting school rising to one in three at the end of primary
school. Obesity and overweight are strongly socially patterned.
PAEDIATRICS AND CHILD HEALTH --:-
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Twice as many children are overweight or obese in the most
disadvantaged 10% of the child population as in the most
advantaged 10%. The policy response to childhood and adult
obesity has tended to focus on individual behaviour. Advice on
nutrition and exercise is frequently presented as a simple choice
with minimal recognition of the commercial pressures on con-
sumption and the financial and other constraints on the choices
poorer families are able to make. Although obesity affects in-
dividuals it is driven by obesogenic forces in society. Modifica-
tion of the obesogenic environment combined with evidence-
based advice on nutrition and exercise is essential if the
obesity epidemic is to be reversed. Advocacy needs to confront
the huge financial interests which benefit from over-
consumption of sugar and sweetened drinks. Legislation and
regulation by government are necessary to limit the power of
these vested interests; paediatricians and paediatric organisa-
tions can advocate for effective legislative measures rather than
depending on voluntary agreements with the food industry to
reduce sugar in its products and to limit marketing of obesogenic
foods and drinks to children. The RCPCH is a member of the
Obesity Health Alliance which brings together 40 organisations
to campaign for legislative change.
Conclusion
SDCH have a profound impact on the health of UK children ac-
counting for a high proportion of many common adverse child
health outcomes. Social determinants exert their influence
through complex pathways and are mediated by health behav-
iours and environmental factors. Reducing the adverse effects of
social determinants on the health of children requires action at
the national political level but paediatricians can contribute to
promoting social protection through both individual action and
through their national societies. A
FURTHER READING
Beck AF, Moncrief T, Huang B, et al. Inequalities in childhood asthma
admission rates and underlying community characteristics in one
US county. J Pediatr 2013; 163: 574e80.
Beck AF, Simmons JM, Sauers HF, et al. Connecting at-risk inpatient
asthmatics to a community-based program to reduce home envi-
ronmental risks: care system redesign using quality improvement
methods. Hosp Pediatrics October 2013; 3: 326e34.
Chen E, Martin AD, Mathews KA. Trajectories of socioeconomic status
across children’s lifetime predict health. Pediatrics 2007; 120:
e297e303.
Galobardes B, Davey-Smith G, Lynch J. Systematic review of the in-
fluence of childhood socioeconomic circumstances on risk for car-
diovascular disease in adulthood. Ann Epidemiol 2006; 16: 91e104.
Krieger N, Davey Smith G. “Bodies count,” and body counts: social
epidemiology and embodying inequality. Epidemiol Rev 2004; 26:
92e103.
Marrmot, M. Fairer society, healthy lives. London: UCL, Institute of
Health Equity. http://www.instituteofhealthequity.org/resources-
reports/fair-society-healthy-lives-the-marmot-review (accessed 25
July 2017).
Obesity Health Alliance. http://obesityhealthalliance.org.uk/ (accessed
26 July 2017).
5 Ó 2018 Elsevier Ltd. All rights reserved.
 SYMPOSIUM: SOCIAL PAEDIATRICS
Royal College of Paediatrics and Child Health. Disability matters in
Britain. 2016. London: Royal College of Paediatrics and Child
Health, http://www.rcpch.ac.uk/system/files/protected/education/
RCPCH%20DM%20iPDF%20Inclusion%20Report_2016_IF_R8.
pdf (accessed 25 July 2017).
Royal College of Paediatrics and Child Health. Poverty and child
health: views from the frontline. May 2017. London: Royal College
of Paediatrics and Child Health, http://wwwrcpch.ac.uk/system/
files/protected/education/RCPCH%20DM%20iPDF%20Inclusion
%20Report_2016_IF_R8.pdf (accessed 25 July 2017).
WHO Commission on Social Determinants of Health. Closing the gap
in a generation: health equity through action on social determinants
of health. Final report. Geneva: World Health Organisation; 2008.
Practice points
Childhood asthma
Advocacy might concentrate on the following issues:
C the evidence linking asthma to poor social conditions
C the evidence linking residence in poor areas and proximity
to heavy traffic
C the evidence linking asthma to overcrowding, poor housing
conditions, damp and passive smoking
C collecting and collating local data using equity stratifiers
C lobbying national and local government to modify children’s
environments by improving housing conditions
C forming healthy alliances with local and nationally and
professional groups to influence housing policy locally and
nationally
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C promote community participation and community diagnosis
locally which can identify from the perspective of commu-
nity residents the main drivers of asthma among local
children
Childhood obesity
C collecting and collating national and local data using equity
stratifiers
C mapping fast-food outlets locally by area social
characteristics
C lobbying national government to reduce advertising of
obesogenic products to children
C working to ban the sale of sweetened drinks in hospital and
in schools
Responsive services
C accessible, flexible and relevant services ‘free at the time of
use’
C locally provided services of high quality minimizing the
financial burden imposed by the need to travel to specialist
services
C services which respect parental skills and treat parents as
genuine partners in the care of their children e particularly
important in relation to children with disabilities as shown
by parental responses to the RCPCH Disability Matters
report
C services which recognize the special problems of caring for
children in poverty and modify case management and
treatment regimens accordingly
C services which promote non-discriminatory practice
respecting socio-cultural differences
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