On the importance of social determinants of health: A second look at scabies and failure to thrive in an immigrant female infant.

What is known about this subject in regard to women and their families?

Scabies disproportionately affects children in tropical, low- and middle-income countries, and women are frequently the primary caretakers for their children.

In endemic settings, lack of diagnosis and effective treatment for scabies leads to financial burden on the household and negatively affects health-related quality of life.

What is new from this article as messages for women and their families?

This article calls on dermatologists to use a social determinants of health lens to understand skin health in children and their families.

Dermatologic presentations can be a reflection of adverse social determinants of health influencing the health and well-being of women and their families.

Dermatologists should adjust their patient-centered care plan to account for social needs and refer women and their families to community resources to assist with social needs.

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Dear Editors,

A 15-month-old female patient was admitted for a rash and failure to thrive, weighing 14 pounds (0.1 weight-for-age percentile) for the past 6 months. Seven months prior, the patient had arrived in the United States after traveling with her family from Guatemala. Since then, her diet had consisted solely of atole made with water, oatmeal, and sugar. She and her sibling also had experienced an itchy rash for the past year. In Guatemala, a topical cream containing clotrimazole, gentamicin, and a steroid was used without improvement. In the United States, the rash was correctly diagnosed as scabies, and permethrin 5% cream was applied as spot treatment to itchy lesions on the patient and her sibling.

This appears to be a straightforward case of an infant with failure to thrive and scabies. Yet, if the assessment ended here, there would be a missed opportunity to understand the impact of social determinants on this infant's health (Table 1). Social determinants of health are the conditions in which we are born, live, learn, work, play, and age that affect health and well-being. First, overcrowding is a major risk factor for scabies infestation. The journey from Guatemala to the United States would have involved prolonged periods in cramped spaces and, upon arrival, the family likely lived in close quarters, such as a shared apartment or shelter.

Table 1

Social determinants of health: Categories and examples

Categories	Examples
Economic stability	EmploymentExpensesIncomeDebt
Neighborhood and physical environment	HousingTransportationSafetyWalkability
Education	LanguageLiteracyEarly childhood educationHigher education
Food	Access to nutritious food
Health care system	Health insuranceHealth literacyAccess to a primary care providerQuality of health care
Community and social context	Support systemsSocial integrationDiscriminationRacism

These are examples of several social determinants of health, and those discussed in this case letter are italicized. Informed by the Kaiser Family Foundation (https://files.kff.org/attachment/issue-brief-beyond-health-care).

Second, the patient's diet of atole suggests food insecurity, common for immigrants in the United States (Kersey et al., 2007). The patient's failure to thrive was attributed to nutritional deficiency and poor caloric intake. Chronic scabies infestation may have played a role, owing to increased metabolic activity from scratching and poor appetite. During the 4-day hospitalization, the patient gained 1 pound, and she continued to gain weight after discharge with nutritional drink supplementation and intake of solid food with high fat and high protein, enabled by referrals to food banks and enrollment in the Special Supplemental Nutrition Program for Women, Infants and Children.

Third, patients with limited English proficiency are more likely to have low health literacy (Leyva et al., 2005), medication-related adverse events (Wilson et al., 2005), and poor understanding of medical situations (Wilson et al., 2005). The patient's mother stated that Spanish was her preferred language, and a Spanish phone interpreter was used for all conversations. Yet, two teach-back cycles with dermatology were required for treatment counseling, even after the primary team's counseling. This may reflect low health literacy or that many Guatemalans in the United States are Mayan and may speak little to no Spanish, with the Guatemalan Mayan languages Mam, K'iche’ and Q'anjob'al representing some of the most common languages spoken in immigration court (U.S. Department of Justice, 2017). The insufficient supply of Mayan-language interpreters means that Spanish is often used to communicate.

Dermatologists are increasingly recognizing the importance of social determinants of health in clinical care (Elpern, 2019). Understanding patients’ social needs is important for informing the differential diagnosis of a clinical presentation, formulating a patient-centered care plan, and providing assistance through social work and community resource referrals (Table 2). Asking about social determinants of health is not only important for all of these reasons, but also to help build and foster empathy for our patients, especially those whose lives differ from our own.

Table 2

Assistance with social needs of dermatologic patients in the United States

Social need	Assistance
HomelessnessHousing instability	• Local shelters: https://www.homelessshelterdirectory.org/• U.S. Department of Housing and Urban Development Homelessness Assistance Programs by state: https://www.hudexchange.info/homelessness-assistance/• Local nonprofit organizations connecting clients to housing resources, supporting clients to secure stable housing and attain economic stability, providing legal and financial assistance for tenants at risk for eviction
Transportation barriers	• Discounted public transportation• Medicaid transportation reimbursement• Some health care systems are partnering with ride-share companies
Food insecurity	• Local food banks: https://www.feedingamerica.org/find-your-local-foodbank• Supplemental Nutrition and Assistance Program: https://www.fns.usda.gov/snap/state-directory• Special Supplemental Nutrition Program for Women, Infants, and Children: https://www.fns.usda.gov/contacts?f%5B1%5D=program%3A32• Meals on Wheels for seniors (age requirement varies by program and area): https://www.mealsonwheelsamerica.org/
Lack of health insurance	• Eligibility office or online enrollment for Medicaid or state/local government subsidized health insurance (e.g. Healthy SF, MassHealth Limited). Six states (CA, IL, MA, NY, OR, WA) and Washington, DC, use state-only funds to cover income-eligible children regardless of immigration status. In 2020, Illinois expanded health benefits to cover individuals age ≥65 years regardless of immigration status.
Limited English language proficiency	• Referral to a dermatologist who speaks the patient's preferred language. Someone with bilingual certification is ideal.• Use of a qualified professional interpreter (live or on-demand video/phone). Live interpreters are ideal but typically need to be scheduled in advance of the clinic appointment.

Referral organizations and resources vary by state and county. Recommend compiling a handout that summarizes the resources offered by an organization and the intended beneficiaries. This is an example of a handout for San Francisco residents: https://healthadvocates.ucsf.edu/health-advocates-resource-flowsheets-0. The California Social Resource Database organizes resources by county: https://www.caliresources.org/.

Funding

None.

Study approval

N/A

Conflicts of interest

None.