Shabih Manzar, MD

Abstract

Social determinants of health (SDoH) are the non-medical factors, the conditions in which people are born, grow, work, live, and age, that influence the health outcomes. SDoH includes financial condition, food insecurity, transport facility, physical activity, stress, social connections, housing stability, depression, tobacco, and alcohol use. SDoH among pregnant women has been shown to affect neonatal outcomes. With electronic health records (EHR), SDoH is readily accessible for analysis. By utilizing the Epic® (EHR system), based on the electronically generated color-code (green 0, yellow 1, and red 2), we evaluated the SDoH. We noted a lack of physical activity as a significant SDoH concern among pregnant women. Public health measures should be taken to improve physical activity in our community.

Introduction 

As defined by World Health Organization, social determinants of health (SDoH) are the non-medical factors that influence health outcomes. (1) SDoH could include the conditions in which people are born, grow, work, live, and age. It includes financial condition, food insecurity, transport facility, physical activity, stress, social connections, housing stability, depression, tobacco, and alcohol use. In recent years, there has been increased recognition and appreciation of the impact of SDoH on an individual’s health. By virtue of increased need for access to healthcare and the detrimental effect on the pregnancy outcome, pregnant women are vulnerable to SDoH. 

Previous studies have shown the effect of SDoH and adverse maternal and birth outcomes. Amjad et al. (2), in their meta-analysis, evaluated SDoH and found race and rural residence as predictors of preterm birth (PTB) while low maternal socio-economic status and illiteracy as risk factors for maternal mortality and low birth weight infants. Maness and Buhi (3) in their systematic review of seventeen studies, reported poverty and family structure as the most important SDoH in pregnancy. However, the role of some important SDoH, like the quality of housing, access to healthy foods, access to healthcare services, employment status, were not reported. Therefore, there is a gap in research regarding a comprehensive look at SDoH among pregnant women. With electronic health records (EHR), SDoH is readily accessible for analysis. By utilizing the Epic (EHR system) (4), based on the electronically generated color-code (green 0, yellow 1, and red 2), we evaluated the SDoH among pregnant women. 

Methods 

The information about social determinants of health (SDoH) is built in the electronic health records (Epic) of all patients, including pregnant women. SDoH assessment consists of a questionnaire on ten factors: 

1. Financial Resource Strain 
2. Food Insecurity 
3. Transport Needs 
4. Physical Activity 
5. Stress 
6. Social connections 
7. Housing stability 
8. Depression 
9. Tobacco use 
10. Alcohol use 

An IRB approval was obtained. On admission to the labor unit of the hospital, all pregnant women completed the SDoH questionnaire (Appendix 1) assisted by the nurse assigned to the patient. When these questionnaires are completed, a color-coded wheel is generated by the electronic record system (Appendix 2). The principal investigator collected the data on the MS excel sheet (Appendix 3) 

Results 

Out of 35 women, 30 women completed the questionnaire (85% response rate). Physical inactivity was noted to be of highest concern (29%), followed by social support (17%), tobacco use (13%), housing and transport (11%) each, stress (9%), food insecurity (7%) and financial instability (3%). Interestingly alcohol use and depression were zero percent (See Figure 1). 

[Figure 1: Distribution of Social Determinants of Health among Pregnant women]

Discussion 

Community health assessment is an integral part of public health wellbeing. Looking at different aspects of social determinants of health (SDoH) provides an idea about which aspect needs the most attention. Our study noted lack of physical activity as one of the major concerns among pregnant women admitted to our hospital. Our finding of high-stress levels among the participant was in line with the earlier report. (5) One important factor in SDoH is housing instability. We found a high proportion of housing problems among our cohort. DiTosto et al. (6) have shown that housing instability and homelessness during pregnancy were significantly associated with preterm birth, low birth weight neonates, neonatal intensive care unit admission, and delivery complications. 

We also noted a high number of social concerns. It has been shown earlier those pregnant women with high psychosocial vulnerability face a higher risk of preterm birth. (7,8) We did not find depression a concern among our participants, which was very interesting. It would be interesting to look at the post-partum depression rate among the same cohort in a follow-up study. Although medication abuse has been reported among pregnant women in earlier reports (8), we did not find alcohol use a significant problem among the study participants. 

In conclusion, low physical activity is a high concern problem among pregnant women. Public health initiatives should be started on advocating physical activity. Based on our findings, community involvement with other important public health stakeholders should be an urgent need. 

[READ ARTICLE APPENDICES, STARTING ON PAGE 4]

References:

1. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
2. Amjad S, MacDonald I, Chambers T, et al. Social determinants of health and adverse maternal and birth outcomes in adolescent pregnancies: A systematic review and meta- analysis. Paediatr Perinat Epidemiol. 2019;33(1):88-99. doi:10.1111/ppe.12529
3. Maness SB, Buhi ER. Associations Between Social Determinants of Health and Pregnancy Among Young People: A Systematic Review of Research Published During the Past 25 Years. Public Health Rep. 2016; 131(1):86-99. doi:10.1177/003335491613100115
4. https://www.epic.com/
5. Moradi G, Zokaeii M, Goodarzi E, Khazaei Z. Maternal risk factors for low birth weight infants: A nested case-control study of rural areas in Kurdistan (western of Iran). J Prev Med Hyg. 2021;62(2): E399-E406. Published 2021 Jul 30. doi:10.15167/2421-4248/jpmh2021.62.2.1635
6. DiTosto JD, Holder K, Soyemi E, Beestrum M, Yee LM. Housing instability and adverse perinatal outcomes: a systematic review. Am J Obstet Gynecol MFM. 2021;3(6):100477. doi: 10.1016/j.ajogmf.2021.100477
7. Pedersen JF, Kallesøe SB, Langergaard S, Overgaard C. Interventions to reduce preterm birth in pregnant women with psychosocial vulnerability factors-A systematic review. Midwifery. 2021; 100:103018. doi: 10.1016/j.midw.2021.103018
8. Givens M, Teal EN, Patel V, Manuck TA. Preterm birth among pregnant women living in areas with high social vulnerability. Am J Obstet Gynecol MFM. 2021;3(5):100414. doi:10.1016/j.ajogmf.2021.100414

Author contribution: Dr. Manzar conceptualized the study and wrote the draft.

Acknowledgment: I want to thank the nursing staff who helped collect data.

Funding and financial support: None

Disclosures: The author has no disclosures or conflicts of interest