Evidence on Social Determinants of Health, Health Equity Lacking in Guideline on Mild TBI Among Children
Nathan Cook, PhD, Grant Iverson, PhD, and colleagues reviewed the evidence underlying the CDC Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children and found pronounced knowledge gaps about how social determinants of health and health equity factors relate to managing this injury.
- This analysis determined the extent to which social determinants of health and health equity variables were considered during the development of the CDC Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury (mTBI) Among Children
- 67.5% of 37 studies reviewed either did not address social determinants of health at all or mentioned one in only a descriptive or demographic fashion
- Only 22% of studies examined a health equity variable in depth, only three studies examined race and/or ethnicity, and no study examined culture/acculturation or language as contributors to health inequity
- Healthcare providers treating children with mTBI are encouraged to carefully consider how social determinants of health and health equity variables might be relevant during clinical assessment, patient/family education, and treatment or rehabilitation
In 2018, the Centers for Disease Control and Prevention published in JAMA Pediatrics the first U.S. guideline for management of mild traumatic brain injury (mTBI) among children. The multidisciplinary guideline includes 19 sets of recommendations based on a massive systematic review of 75 articles.
Nathan E. Cook, PhD, a neuropsychologist in the Sports Concussion Program at Mass General for Children and the Department of Physical Medicine and Rehabilitation at Spaulding Rehabilitation Hospital, Grant L. Iverson, PhD, a neuropsychologist–investigator in Physical Medicine and Rehabilitation at Spaulding, and colleagues leveraged that work to review evidence on the relevance of social determinants of health (SDoH) and health equity to pediatric mTBI. Their report appears in the Journal of Neurotrauma.
Methods
The reviewers collected the studies cited in the guideline to support recommendations on diagnosis, short-term prognosis (within one year of injury), longer-term prognosis, and treatment/rehabilitation of pediatric mTBI. From 37 papers (n=15,887 patients), they extracted details on:
- Five SDoH domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context
- Five health equity variables: race, ethnicity, culture/acculturation, socioeconomic status, and language
Social Determinants of Health
The results of the content analysis for SDoH were:
- 5% of studies either did not address an SDoH domain at all or mentioned one in only descriptive or demographic fashion
- The most common domains addressed in an inferential or intentional manner were Social and Community Context (27% of studies) and Economic Stability (13.5%)
- SDoH domains were mentioned mainly about prognosis: no study addressing diagnosis, and only one addressing treatment, considered SDoH in an inferential or primary fashion
- No studies examined Neighborhood and Built Environment, even though it relates to crime, violence, and accessibility of biking and walking
Health Equity
The results of the content analysis for health equity were:
- 22% of studies examined a health equity variable in depth, usually by investigating socioeconomic status as a predictor or modifier of outcome
- 32% of studies mentioned at least one health equity factor but only as a demographic category
- Only three studies examined race and/or ethnicity, and no study examined culture/acculturation or language
Relevance of Social Considerations to the Care Plan
Clinicians treating children with mTBI should carefully consider whether the patient and family:
- Have access to fitness facilities and equipment or safe outdoor spaces for exercise-based rehabilitation
- Can read at the level of the educational materials typically provided
- Need a medical interpreter or educational materials in their primary language
- Need help identifying specialty clinics, obtaining a referral, and dealing with their health insurance company
- Are comfortable and knowledgeable about communicating with school personnel for accommodations during recovery