Social Determinants of Health and Symptomatic Recovery from Pediatric Concussion

Social determinants of health (SDoH) are the non-medical factors that influence an individual's health and well-being. This study aimed to examine the relationships between SDoH and post-concussion symptom severity in Canadian children. We conducted a secondary analysis of data collected through Advancing Concussion Assessment in Pediatrics (A-CAP), a prospective longitudinal cohort study. Children aged 8-16 years with concussion (n = 633) or orthopedic injury (OI; n = 334) were recruited from five Canadian pediatric emergency departments. Post-concussion symptoms were rated by children and parents using the Health and Behavior Inventory. Linear mixed-effects models assessed the associations of SDoH (i.e., race, household income, parental education, insurance status, neighborhood deprivation) and their interactions with time with post-concussion symptom severity. The cumulative impact of all SDoH was assessed with negative binomial generalized linear models at 3 months post-injury. In the linear mixed-effects models, race and education were significant predictors of both child-reported, race: F(5, 1390.37) = 2.27, p = 0.05; education: F(3, 1155.55) = 3.14, p = 0.03, and parent-reported somatic symptoms, race: F(5, 2562.35) = 2.93, p = 0.01; education: F(3, 787.22) = 3.28, p = 0.02. Joint tests of race, F(15, 804.38) = 2.12, p = 0.008, and neighborhood deprivation, F(3, 379.12) = 2.74, p = 0.04, and their interactions with time variables were statistically significant for parent-reported somatic symptoms. In the negative binomial generalized linear models, SDoH cumulatively contributed to the prediction of symptoms at 3 months post-injury over and above injury type (concussion vs. OI) and known prognostic factors (5P risk score) for child-reported cognitive, F(17, 1154.75) = 1.94, p = 0.012, and somatic, F(17, 322.81 = 2.11, p = 0.007, symptoms and parent-reported somatic symptoms, F(17, 327.15) = 1.93, p = 0.015. In summary, individual SDoH had small associations with symptoms after concussion in Canadian children, but the cumulative effects of multiple SDoH are likely an important factor in post-concussion symptom severity.