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Cover page of the Journal of Health Sciences

 Table of Contents  
Year : 2020  |  Volume : 13  |  Issue : 2  |  Page : 169-170

Why it is imperative to understand the psychosocial determinants of health while treating childhood asthma?

1 Department of Paediatrics, Rajah Muthiah Medical College and Hospital, Chidambaram, Tamil Nadu, India
2 Department of Anatomy, Jawaharlal Insitute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission05-Feb-2020
Date of Acceptance16-Apr-2020
Date of Web Publication23-Jun-2020

Correspondence Address:
Dr. V Dinesh Kumar
Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kleuhsj.kleuhsj_37_20

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How to cite this article:
Prabha M S, Kumar V D. Why it is imperative to understand the psychosocial determinants of health while treating childhood asthma?. Indian J Health Sci Biomed Res 2020;13:169-70

How to cite this URL:
Prabha M S, Kumar V D. Why it is imperative to understand the psychosocial determinants of health while treating childhood asthma?. Indian J Health Sci Biomed Res [serial online] 2020 [cited 2021 Dec 1];13:169-70. Available from: https://www.ijournalhs.org/text.asp?2020/13/2/169/287419


The social determinants of health is a carpet term which encompasses all nonmedical factors influencing the outcomes of health-care management, namely economic status, quality of living place, transportation, presence of pets, and even the “psychological feel” of having disease.[1] While developed countries eye at developing 'precision public health strategies' in order to perform risk assessment at individual level [2], we often fail to gauge the social determinants of health while planning intervention for individual cases. In a survey conducted among 1000 practitioners, 4 out of 5 felt that it is imperative to address the social determinants with the same weightage as medical needs. However, those who had recognized the importance were not confident enough in tapping the same during patient encounters.[3] Keeping this factor in mind, we introspected upon the following rhetoric: “will screening for psychosocial determinants offer additional opportunities for upstream prevention in cases of childhood asthma?” We have chosen childhood asthma as a candidate disease for discussing about social determinants because it demands a significant proportion of out-of-pocket expenditure and is characterized by airway inflammation and socio-environmental factors triggering it.

The social determinants related inquiries made by the pediatricians while interviewing the children with asthma can be synthesized into a conceptual framework. The framework includes (1) child-level determinants such as vaccinations, past viral illnesses, and history regarding allergens; (2) family-level determinants such as economic status, education level, family history of asthma, and household quality; and (3) environmental determinants such as risk of indoor allergens, tobacco smoke, farms, and pets in vicinity.[4] We feel that apart from these external risk factors, it is necessary to address the “perceived dimension” of the disease by the child in order to tailor the holistic plan of care. In other words, the terminology “whole-person” model of care should include the set of influential factors which could possibly induce stress in the child and thereby aggravate the disease.

A recent school-based study, involving teenagers suffering from asthma, demonstrated a correlation between asthma severity and lower quality of life scores.[5] Furthermore, those with significant depressive symptoms reported a lower controller usage compared to those who had a lesser severity of depressive symptoms. Even though the usage of controller or “feel of being diseased” cannot be completely attributed to the etiology of depression, the association could not be easily ignored. Similarly, the feel of living in a “disadvantaged neighborhood” can also induce stress in children with asthma.[4] The plausible mechanism for this clinical conundrum could be the impact of chronic stress in hypothalamus–pituitary–adrenal (HPA) pathway and vice versa.[6] Another study conducted among Brazilian middle school students also showed a strong association between perceived feel of violence, such as feeling unsafe at school, physical aggression, and being bullied, and self-report of asthma symptoms.[7] A study of high-risk birth cohort found that maternal stress and depression were significantly associated with recurrent wheeze in children suggesting the strong involvement of HPA axis at any age in manifestation of asthma.[8]

Literature search on this topic yields handful conceptual frameworks which are constituted by the interconnected elements operating at various levels of social influence.[9] However, these models which are postulated entirely from Western countries cannot be extrapolated to India where the social gradient is broad and health inequalities are prominent. For example, in the latest study, Morgenlanderet al.[10] found that most of the pediatric residents were screening at least seven social determinants in their continuity clinics. We posit that a conceptual framework entirely based on Indian social determinants of health should be developed in the future, especially for diseases such as asthma. This should include a battery of psychosocial indicators matched to our societal factors including feeling of being isolated, experience of violence/physical aggression, sleeping problems, chances of abuse, feeling neglected, academic difficulties, and strained relationship between parents. As an initial measure, pediatric departments shall start dedicated multidisciplinary resident clinics where social determinants of health are documented in a systematic manner. Social determinants could thus be promoted as an upstream factor in pediatric clinics.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Garg A, Jack B, Zuckerman B. Addressing the social determinants of health within the patient-centred medical home: lessons from paediatrics. JAMA 2013;309:2001-2.  Back to cited text no. 1
Khoury MJ, Iademarco MF, Riley WT. Precision Public Health for the Era of Precision Medicine. Am J Prev Med 2016;50:398-401.  Back to cited text no. 2
Fenton M. Health care's blind side: the overlooked connection between social needs and good health. The Robert Wood Johnson Foundation; 2011. Available from: http://www.rwjf.org/en/library/research/2011/12/health-care-s-blind-side.html. [Last accessed on 2020 Jan 31].  Back to cited text no. 3
Kinghorn B, Fretts AM, O'Leary RA, Karr CJ, Rosenfeld M, Best LG. Socioeconomic and environmental risk factors for paediatric asthma in an american Indian Community. Acad Pediatr 2019;19:631-7.  Back to cited text no. 4
Shankar M, Fagnano M, Blaakman SW, Rhee H, Halterman JS. Depressive symptoms among urban adolescents with asthma: A focus for providers. Acad Pediatr 2019;19:608-14.  Back to cited text no. 5
Priftis KN, Chrousos GP. Neuroimmunomodulation in asthma: focus on the hypothalamic-pituitary-adrenal axis. Introduction. Neuroimmunomodulation 2009;16:263-4.  Back to cited text no. 6
Ribeiro-Silva RC, Malta DC, Rodrigues LC, Ramos DO, Fiaccone RL, Machado DB, et al. Social, environmental and behavioral determinants of asthma symptoms in brazilian middle school students-A National School Health Survey (Pense 2012). Int J Environ Res Public Health 2018; 15:2904.   Back to cited text no. 7
Ramratnam SK, Visness CM, Jaffee KF, Bloomberg GR, Kattan M, Sandel MT, et al. Relationships among maternal stress and depression, type 2 responses, and recurrent wheezing at age 3 years in low-income urban families. Am J Respir Crit Care Med 2017;195:674-81.  Back to cited text no. 8
Lucyk K, McLaren L. Taking stock of the social determinants of health: A scoping review. PLoS One 2017;12:e0177306.  Back to cited text no. 9
Morgenlander MA, Tyrrell H, Garfunkel LC, Serwint JR, Steiner MJ, Schilling S. Screening for social determinants of health in pediatric resident continuity clinic. Acad Pediatr 2019;19:868-74.  Back to cited text no. 10


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