Community Pediatrics: Navigating the Intersection of Medicine, Public Health, and Social Determinants of Children’s Health

Environmental and social factors contribute significantly to the health and well-being of children in the contexts of families, schools, and communities. Over the past decade, the Institute of Medicine recognized and quantified the effects of external factors on early brain development and the health of children in 2 seminal reports, Neurons to Neighborhoods¹ in 2000 and Children’s Health, the Nation’s Wealth² in 2004. As understanding of the mechanisms and impact of biological, behavioral, cultural, social, and physical environments on healthy development deepens and expands, the long-standing role of pediatricians in promoting the physical, mental, and social health and well-being of all children must also evolve.³ The field of pediatrics must address the problems facing children in the 21st century by influencing these critical determinants of child health and well-being.⁴ To do so, pediatricians must successfully merge their traditional clinical skills with public health, population-based approaches to practice, and advocacy.

The American Academy of Pediatrics (AAP) offers a definition of community pediatrics to remind all pediatricians, pediatric medical subspecialists, and pediatric surgical specialists alike of the profound importance of the community dimension in pediatric practice. Community pediatrics is the practice of promoting and integrating the positive social, cultural, and environmental influences on children’s health as well as addressing potential negative effects that deter optimal child health and development within a community. Community pediatrics includes all of the following:

• A perspective that expands the pediatrician’s focus from one child to the well-being of all children in the community;

• A recognition that family, educational, social, cultural, spiritual, economic, environmental, and political forces affect the health and functioning of children;

• A synthesis of clinical practice and public health principles to promote the health of all children within the context of the family, school, and community⁵; and

• A commitment to collaborate with community partners to advocate for and provide quality services equitably for all children.^6,7 

Participating in community activities to improve the health and welfare of all children is considered an integral part of the professional role and ethical obligation of all pediatricians. For many pediatricians, efforts to promote the health of children have been directed at attending to the needs of particular children in a practice setting, on an individual basis, and providing them with a medical home⁸ in concert with pediatricians’ own community interests and commitments. Increasingly, however, the major threats to the healthy development of America’s children stem from problems that cannot be addressed adequately by the practice model alone.⁹ These problems include infant mortality; preventable infectious diseases; dental caries; sedentary lifestyles; chronic health care needs; obesity, metabolic syndrome, and other historically adult-onset chronic diseases; high levels of intentional and unintentional injuries; exposure to violence in all forms; risks of neurodevelopmental disabilities and illnesses from exposure to environmental tobacco smoke, lead, and other environmental hazards; substance abuse; mental health conditions; poor school readiness¹⁰; family dysfunction; sexual health, unwanted pregnancies, and sexually transmitted diseases; relatively low rates of breastfeeding; social, medical, behavioral, economic, and environmental effects of disasters¹¹; and inequitable access to medical homes¹² and basic material resources and poverty.¹³ Whether the pediatrician is communicating with patients and families or with a community, it is critical to remember that this must be done in a culturally and linguistically effective manner to be successful. On the part of pediatricians, culturally effective communication includes behaviors and attitudes that are appropriate to care for patients and families with a wide variety of cultural attributes.

In the past decade, increasing attention has been paid toward recognizing the social determinants of children’s physical, mental, and behavioral health. Briefly, social determinants are the economic and social conditions that shape the health of individuals and communities. In 2005, the World Health Organization established a Commission on the Social Determinants of Health to examine the evidence of the effects of social determinants on health outcomes, specifically for the purpose of promoting health equity globally. With the description of the life course health development model¹⁴ and the recognition of the life course health development perspective by agencies serving children and families, including the US Maternal and Child Health Bureau, the effects of poor social and economic factors in childhood on the quality of adult health have become increasingly clear. For example, authors of studies have examined the link between childhood obesity and cardiovascular disease in adulthood, lack of adequate calcium and vitamin D intake in childhood on adult osteoporosis, and childhood maltreatment and family dysfunction on adult mental and physical health problems.^13,15,16 

Childhood obesity, dental caries, asthma, and early mental health issues are prevalent in today’s child population and interact reciprocally with family dysfunction or school stress. Pediatricians must have the knowledge, skills, and willingness to address these issues in addition to more traditional clinical solutions. An integral approach to doing so incorporates interdisciplinary practice. As former AAP president Robert Haggerty, MD, reminded us in 1995, “we must become partners with others, or we will become increasingly irrelevant to the health of children.”¹⁷ Pediatricians should recognize that health care is merely 1 influential component of overall health and well-being for children and families, and children often move through other systems, such as education, child welfare, mental health/social services, and juvenile justice. Interdisciplinary communication and coordination are crucial for successfully addressing all factors that contribute to a child’s health and well-being.

The physical environment is an important part of a community. Health hazards from toxic environmental exposures (such as mold, heavy metals, and fluorocarbons) are routinely recognized and brought to the attention of pediatricians. Less consideration has been given to the potential for adverse effects on health from “built environments,” such as poor-quality housing, lack of access to opportunities for safe gross motor play, inadequate transportation, especially for children with limited mobility, and lack of coordinated community planning, although awareness has grown over the past decade of the effects of the built environment on the childhood obesity epidemic.¹⁸ Accessible housing and transportation options that meet the needs of all children and families, including those with mobility, sensory, and health impairments, to travel safely and making all community and leisure environments accessible to all children, especially those with special needs, has the potential to decrease the risk of obesity and metabolic syndrome.

Because the design of a child’s physical environment can cause or prevent illness or injury, a high-quality environment is essential for children to achieve optimal health and development. Community planning and building and land-use policies can either undermine or promote safety, health, and optimal development while simultaneously preserving future resources. Children in low-income families are more likely to be exposed to structural hazards in the home and are more likely to have diseases such as lead poisoning and asthma. Although environmental risks are more prevalent in low-income families, children from any income level may be exposed. For all children, examining the quality of a child’s physical environment is crucial when assessing children’s health. Pediatrician advocates are needed to speak out for children’s needs in the physical environment.

One could argue that pediatricians have always been a part of the public health system. As trusted sources of information for parents and front-line providers of preventive health care for children, pediatricians have fulfilled the role of addressing the needs of populations of children, whether they are in an early education and child care setting, school, or local community. Pediatricians often contribute to the public health system by recognizing and reporting illnesses, hazards, and trends to public health departments.

Because of this responsibility, pediatricians should know where to get accurate information regarding the latest public and school health issues facing children in their communities, as well as how to communicate this information effectively either individually to families or to groups in public forums or through the media. The Institute of Medicine has recently provided a framework for primary care and public health professions to work together.¹⁹ Pediatricians should partner with local health departments and school districts and child welfare agencies to be aware of programs for children and families that address certain needs, such as injury prevention, child maltreatment prevention, lead poisoning, environmental tobacco smoke control, breastfeeding promotion, overweight/obesity prevention, asthma, perinatal care, trauma, child abuse prevention, and disaster preparedness.^20,–23 One example of a pediatric/public health approach would be to ensure that children’s issues are addressed in disaster planning/response.

The passage of the Patient Protection and Affordable Care Act in 2010 was a milestone in health care in the United States that could not have been achieved without advocacy on multiple levels by many groups of people, including pediatricians. Pediatricians have always advocated on behalf of the nation’s youngest citizens, whether on the individual level for necessary services or more widely at the community, state, or federal level in legislative avenues. Because children do not have a voice in government, others must speak up on behalf of the nation’s most vulnerable population of citizens.

In recent years, pediatric medical education has promoted the formal training of residents in legislative advocacy. The AAP Community Pediatrics Training Initiative has developed advocacy training modules for use in pediatric residency training programs and is supporting individual programs to implement advocacy rotations in their curricula. Statewide collaboratives, such as in California and more recently in New Jersey, have been established to serve as networks for residency programs to share advocacy curricula and support implementation of new curricular experiences in legislative advocacy. These efforts are in direct response to the recognition that, to influence policies and laws affecting children and families, pediatricians need specialized skill sets to be effective advocates on multiple levels.

With the passage of the 2010 Patient Protection and Affordable Care Act, pediatric leadership and advocacy will be crucial to ensure some just reward for the activities described in this policy statement. To counter the growing financial and productivity pressures on practicing pediatricians, some recognition of the importance of addressing the social determinants of children’s health will be necessary in the financing models for accountable care organizations.²⁴ 

With the shifting epidemiology of problems facing children and growing recognition that social determinants play a major role in children’s health, pediatricians must have a second “bag of tools” in addition to the clinical “doctor’s bag” that addresses more traditional agents of childhood disease. This second bag of tools includes skills such as being able to function in an interdisciplinary fashion; partnering with public health and child welfare entities; recognizing root sources of health and pathology from children’s social, economic, physical, and educational environments; and advocating on multiple levels. The following recommendations offer guidelines for pediatricians to optimize their effectiveness as clinical practitioners and advocates in the community. To accomplish these recommendations, payment and financing systems must be appropriately aligned and recognize clinicians who provide population-based prevention.²⁵ 

1. Pediatricians should use community data (epidemiologic, demographic, and economic) to increase their understanding of the effects that social determinants have on child health outcomes.

2. Pediatricians should work together with public health departments, school districts,^21,–23 child welfare agencies, community and children’s hospitals, and colleagues in related professions to identify and decrease barriers to the health and well-being of children in the communities they serve.^26,27 In addition, pediatricians should have access to information about community programs and resources that could affect the health and well-being of the children in their community.

3. Pediatricians should routinely, and in a culturally effective manner, promote preventive health strategies for common childhood issues (ie, immunization, injury prevention, oral health, sexual health, nutrition, obesity prevention, breastfeeding, positive parenting, and abuse and neglect) in both individual well-child visits as well as on a population level within a community. Pediatricians can play an important role in coordinating and focusing new and existing services to realize maximum benefit for all children.^28,29 

4. Pediatricians and other members of the community should interact with and advocate to improve all settings and organizations in which children spend time (eg, early education and child care facilities, schools, school-based health centers, family support and resource centers, youth programs, recreation venues, and transportation systems). Together with families, schools and community resources should be considered as primary assets in promoting children’s health, safety, and development.

5. Pediatricians should advocate for universal access to health care in a medical home and for the social, economic, educational, and environmental resources essential for every child’s healthy development, including those in foster care who may have no other natural advocates.

6. Pediatricians should be able to interface with the media and be able to be trusted sources of information for parents and the general public about public health issues pertaining to children, such as vaccine safety and emergency/disaster/crisis medical issues.

7. Pediatric medical education (both undergraduate and graduate) should include specific curricula on community and public health topics pertaining to child health, including social determinants of health, how to identify and access community resources, school health, health care systems and financing, and child advocacy, including interactions with the public child welfare system and legislative advocacy skills.

8. Continuing medical education programs should consider and periodically review basic community pediatric competencies to be included in maintenance of certification efforts for pediatricians.³⁰ Maintenance of certification and quality improvement activities should include options to address child health issues in community settings.

9. AAP chapters and their members should provide leadership for further understanding of community pediatrics and encourage participation in creative, community-based, integrated models such as those supported through the Community Access to Child Health program and the Healthy Tomorrows Partnership for Children program.

10. The AAP is committed to continued recognition and provision of leadership and support to pediatricians to develop and exercise advocacy skills at the local, state, and national levels to ensure that children have access to care, to resources, and to conditions that promote healthy development. This includes support for the following:

    • Federal and state programs that reduce the burden of debt on medical students in pediatric primary care and pediatric medical subspecialty and surgical specialty fellowships, including but not limited to the National Health Service Corps.

    • Incorporation into the curricula for residency programs and for young physicians’ discussion of different strategies for engaging in community activities no matter the practice setting.

    • Expectation of community engagement as an explicit part of comprehensive clinical payment models currently under development, including the patient-centered medical home and accountable care organizations.

11. The AAP is committed to continuing to strategically address the lack of payment for the work pediatricians do in the community, which addresses social determinants of health and population-based health issues, much of which is currently uncompensated. Not only should these services be recognized as a crucial part of child health, but also, payment for these services should be at a reasonable and fair level so that pediatricians can afford to pursue these activities in their communities.

By caring for children in the context of their families and communities, pediatricians play an important role in promoting the health and well-being of the nation’s youngest citizens. Pediatricians who work with schools, early education and child care programs, community agencies and organizations, and local public health departments and child welfare agencies equip themselves to be effective child advocates in the community. Pediatricians can also play a crucial role in public health by communicating important facts about issues facing children’s health; ensuring children’s issues are addressed in disaster planning and response efforts¹¹; and advocating at the local, state, and federal legislative levels for universal access for all children to high-quality medical homes and for social policies that promote equal opportunities for the development of children, families, and communities. The recommendations in this policy statement are meant to provide a framework for guiding the development of relevant curricula in pediatric medical education and supporting the practice of high-quality and effective pediatric care.

Peter A. Gorski, MD, MPA

Alice A. Kuo, MD, PhD

Deise C. Granado-Villar, MD, MPH, Chairperson

Benjamin A. Gitterman, MD, Vice Chairperson

Jeffrey M. Brown, MD, MPH

Lance A. Chilton, MD

William H. Cotton, MD

Thresia B. Gambon, MD

Peter A. Gorski, MD, MPA

Colleen A. Kraft, MD

Alice A. Kuo, MD, PhD

Gonzalo J. Paz-Soldan, MD

Barbara Zind, MD

Benjamin Hoffman, MD – Chairperson, Indian Health Special Interest Group

Melissa A. Briggs, MD – Section on Medical Students, Residents, and Fellowship Trainees

Frances J. Dunston, MD, MPH

Charles R. Feild, MD, MPH – Chairperson, Prevention and Public Health Special Interest Group

M. Edward Ivancic, MD – Chairperson, Rural Health Special Interest Group

David M. Keller, MD – Chairperson, Community Pediatrics Education and Training Special Interest Group

Regina M. Shaefer, MPH