Dr. Karen Kwaning (she/her/hers) is a resident physician in Internal Medicine and Pediatrics at the Brigham and Women’s Hospital and the Boston Combined Residency Program at Boston Children’s Hospital. She is interested in health disparities research, school health, and adolescent mental health. – Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
During my continuity clinic, I met Tony (not his real name), a timid 19-year-old presenting for his first adult annual physical exam. He had not had a well adolescent visit with a primary care doctor for several years. During our brief time together, I took time to address his concerns and explore his lifestyle habits and mental health.
I learned that Tony grew up in a family who had immigrated from the Dominican Republic and was low income. He had often struggled to concentrate in school, and this intensified after he started college to pursue a business degree (he aspired to open his own car body shop). His inability to concentrate heightened his feelings of anxiety and depression. And in college, he constantly ordered fast food.
However, upon reviewing his growth chart, I realized he had lost 20 pounds in the past 4 months since his last urgent care appointment at our clinic and was severely underweight despite a fast-food diet and limited physical activity.
My mind whirled with concerns of anxiety, depression, and undiagnosed attention deficit hyperactivity disorder (ADHD) that could explain his mental health and school performance. Furthermore, after discussing his story with my clinic preceptor, we added hormonal or even malignancy-related causes to the list of diagnoses that could explain his acute weight loss. The fact that Tony had not seen a primary care physician for annual visits during this transition into adulthood heightened my concerns about being able to efficiently address these chronic and acute health issues under the time constraints of a primary care visit.
Many aspects of Tony’s life, including his socioeconomic background and racial-ethnic identity, may have made his transition to adult care more difficult. In a review article being early released this week in Pediatrics entitled, “Social and Structural Drivers of Health and Transition to Adult Care,” Katherine Bailey at the University of Toronto and colleagues from 11 Canadian institutions investigate the social and structural drivers of health associated with outcomes for youth, especially those from socioeconomically marginalized groups, transitioning to adult care (10.1542/peds.2023-062275).
The authors conduct an excellent review of how social drivers (eg, insurance) and demographic characteristics (eg, gender, race, and ethnicity) are associated with transition to adult healthcare outcomes (eg, transition planning and preparation). As I read that “Hispanic youth were less likely to have a follow-up appointment compared to White youth” and “youth with lower household income were more likely to experience a delay in care, less disease knowledge and successful transfer to a new medical home,” I reflect on how these associations may explain some of the ailments of the young adults whom I care for, like Tony.
Strikingly, the authors highlight that “no studies explored the effect of structural discrimination on transition outcomes, such as racism, sexism, homophobia, transphobia, and ableism.” I suspect this is because there is still very little published on the downstream impact of structural discrimination, and I believe this scoping review serves as a call to action to investigate further the impact of structural drivers of health on the transition to adult health care for youth. The authors write, “future research and advocacy should use an intersectional health equity lens, which involves understanding how race, gender, social class, and other characteristics intersect to create unique forms of discrimination and oppression that impact transition outcomes.”
I found this to be a thought-provoking article and one that I recommend to those who care for adolescents and young adults, so that we can consider ways that we can facilitate the transition to adult care, particularly for those who face socioeconomic and other structural challenges.
