Natalie J. Tedford

Trauma remains a leading cause of preventable childhood mortality and disability worldwide, with over 95% of pediatric injury-related deaths occurring in low- and middle-income countries (LMICs). Social drivers of health (SDH) – including socioeconomic status, insurance coverage, and community infrastructure – strongly influence these outcomes but remain underexplored in sub-Saharan Africa. To examine the association between selected SDH factors and morbidity and mortality among injured children presenting to a tertiary referral hospital in Northern Tanzania. This secondary analysis utilized data from a prospective pediatric injury registry at Kilimanjaro Christian Medical Center (KCMC) from November 2020 to January 2024. Children under 18 years presenting with acute injuries were enrolled. SDH variables included residence type, payment method, insurance status, household composition, food security, and transfer status. Outcomes were in-hospital mortality and morbidity, defined using the Glasgow Outcome Scale – Extended Peds (GOS-E Peds). Multivariable logistic regression and modified Poisson regression models were used to identify independent predictors of mortality and morbidity. A total of 877 children were included (median age 7 years, 63% males). Mortality rate was 7.0%, while 38.8% experienced poor morbidity outcomes (GOS-E Peds ≥3). In multivariable analysis, lack of health insurance (adjusted OR=2.4, 95%CI 1.1—5.3) and transfer by ambulance to KCMC (adjusted OR=3.8, 95%CI 1.5—9.4) were associated with higher odds of mortality. Older age (adjusted PR = 1.05, 95%CI 1.02—1.09) predicted greater morbidity, while non-ambulance transfer was protective (adjusted PR = 0.74, 95%CI 0.56—0.97). Food insecurity remained an independent correlate of poor outcomes. Social and economic inequities, particularly inter-facility ambulance transfer, lower MUAC, and food security, were independently associated with adverse pediatric injury outcomes. Food insecurity and lack of insurance remained cross-cutting vulnerabilities. Integrating SDH surveillance into trauma care systems and addressing access barriers may reduce injury-related morbidity and mortality in LMICs.

Background: Trauma is a leading cause of death and disability in children globally, with social determinants of health (SDH) affecting health outcomes. Limited data is available on the influence of SDH on outcomes in injured children in low- and middle-income countries (LMICs). Objective: To explore the relationship of SDH factors with morbidity and mortality in pediatric trauma patients at a referral hospital in an LMIC. Methods: This cross-sectional study utilized a prospective pediatric trauma registry at a tertiary hospital in northern Tanzania. It enrolled children under the age of 18 who presented with acute injuries. SDH factors included community type, payment method, insurance status, household composition, daily nutrition, and transfer status. Morbidity was assessed using the Glasgow Outcome Scale Extended Peds (GOS-E Peds). The primary outcomes were mortality and morbidity. Chi-square analysis, logistic regression, and modified Poisson regression modeling were employed to analyze associations between SDH burden and patient-specific outcomes. Results: From November 2020 to January 2024, 877 patients were enrolled, resulting in a mortality rate of 7.0% and 38.8% experiencing poor morbidity outcomes (GOS-E Peds ≥3). Older patients, uninsured patients, those living outside of Moshi Urban, those transferred by ambulance to KCMC, and those sustaining burn injuries had higher odds of mortality in univariable analysis. In adjusted Poisson regression, older patients demonstrated higher odds of morbidity, while those transferred without an ambulance to KCMC showed lower odds of morbidity. Food insecurity emerged as a significant factor influencing survival and poor outcomes, as illustrated in a Sankey diagram (Figure 1) that depicts the pathways to good (GOS-E Peds ≤2) and poor (GOS-E Peds ≥3) outcomes. Conclusions: Several SDH factors, including insurance status and food insecurity, were associated with increased mortality and morbidity. These findings underscore the need for SDH monitoring and targeted interventions to address disparities in pediatric trauma outcomes in LMICs.

We aimed to explore the healthcare team members’ (HTMs) views on social determinants of health (SDH) screening and referral processes in a pediatric emergency department (PED). We conducted a cross-sectional, mixed-methods study to explore PED HTMs’ views on social care practices at a quaternary-level children’s hospital. The survey was created using a goal identification framework. The survey gathered quantitative and qualitative data by assessing SDH screening practices, comfort and personal habits in screening, prioritization of SDH domains, workflows to perform screening, and perceived barriers to screening. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed using thematic analysis and multiple reviewers to identify themes in free-text responses. There were 63 HTMs (48% response rate, Table 1), all of whom reported SDH screening efforts should continue in the PED (Fig. 1), yet 36% were unaware of the current SDH screening processes. Participants reported a median comfort level rate of 47.5 out of 100 when asking SDH-related questions (Fig. 1), and the highest reported barriers were “lack of knowledge/skill on resources” (77.3%), “lack of time” (68%), and “patient volume” (59%) (Fig. 2). Regarding the screening process, approximately half of the respondents suggested improvements in “integration of screening” and “variability of screening” (Fig. 4). This explorative analysis demonstrated that HTMs support continuing screening and referring patients for SDH-related needs. In addition, HTM survey respondents suggested improvements in screening and referral processes, opportunities for HTM training, and screening support to address social needs and ultimately improve patient health outcomes.