ANALYSIS OF PEDIATRIC HOSPITALIZATIONS ACCORDING TO THE SOCIAL DETERMINANTS OF HEALTHABSTRACT
Objective: to analyze pediatric hospitalizations according to the social determinants of health.
Method: this is an exploratory, descriptive, and observational study conducted between May and October 2024 with 100 children hospitalized in a medium-complexity pediatric unit of a regional hospital in the interior of Piauí, Brazil. Data were obtained through structured interviews with caregivers and by analyzing medical records, including sociodemographic, economic, and clinical-epidemiological variables. The social determinants of health were analyzed according to the Dahlgren and Whitehead model, using descriptive statistics.
Results: a predominance of children under five years of age (51%), male (67%), mixed-race (64%), and attending school or daycare (65%) was observed, indicating biological and social vulnerability in early childhood and suggesting greater exposure to common infections. Low parental education was observed at the intermediate level (37% of mothers and 36% of fathers with completed high school education), as well as informal occupations (housewife 45%; farmer 22%; bricklayer 19%) and family income below two minimum monthly salaries (54%), revealing living conditions which limit access to continuous care. Territorially, 83% resided in the Cerrado macro-region, marked by a lower supply of services. Hospitalizations were concentrated in September (34%), a period of drought and worsening of respiratory diseases, with fever (15%) and pneumonia (25%) as the main causes, reflecting the interaction between biological, socioeconomic and environmental factors.
Conclusion: pediatric hospitalizations reflect the influence of the social determinants of health in multiple dimensions, highlighting the interaction of biological, socioeconomic, geographic and political factors in determining health outcomes.
DESCRIPTORS:
Child health; Hospitalization; Health profile; Social determinants of health; Health inequalities
RESUMO
Objetivo: analisar as hospitalizações pediátricas segundo os determinantes sociais da saúde.
Método: estudo exploratório, descritivo e observacional, realizado entre maio e outubro de 2024, com 100 crianças internadas em unidade pediátrica de média complexidade de um hospital regional do interior do Piauí, Brasil. Os dados foram obtidos por entrevistas estruturadas com os responsáveis e por análise de prontuários, contemplando variáveis sociodemográficas, econômicas e clínico-epidemiológicas. Os determinantes sociais da saúde foram analisados segundo o modelo de Dahlgren e Whitehead, por meio de estatística descritiva.
Resultados: verificou-se predomínio de crianças menores de cinco anos (51%), do sexo masculino (67%), pardas (64%), e que frequentavam escola ou creche (65%), indicando vulnerabilidade biológica e social na primeira infância e sugerindo maior exposição a infecções comuns. No nível intermediário, observaram-se baixa escolaridade parental (37% das mães e 36% dos pais com ensino médio completo), ocupações informais (dona de casa 45%; lavrador 22%; pedreiro 19%) e renda familiar inferior a dois salários-mínimos (54%), revelando condições de vida que limitam o acesso a cuidados contínuos. Territorialmente, 83% residiam na macrorregião Cerrado, marcada por menor oferta de serviços. As hospitalizações concentraram-se em setembro (34%), período de seca e piora das doenças respiratórias, com febre (15%) e pneumonia (25%) como principais causas, refletindo a interação entre fatores biológicos, socioeconômicos e ambientais.
Conclusão: as hospitalizações pediátricas refletem a influência dos determinantes sociais da saúde em múltiplas dimensões, evidenciando a interação de fatores biológicos, socioeconômicos, geográficos e políticos na determinação dos resultados de saúde.
DESCRITORES:
Saúde da criança; Hospitalização; Perfil de saúde; Determinantes sociais da saúde; Desigualdades de saúde
RESUMEN
Objetivo: analizar las hospitalizaciones pediátricas según los determinantes sociales de la salud.
Método: se realizó un estudio exploratorio, descriptivo y observacional entre mayo y octubre de 2024 con 100 niños hospitalizados en una unidad pediátrica de mediana complejidad de un hospital regional del interior de Piauí, Brasil. Los datos se obtuvieron mediante entrevistas estructuradas con cuidadores y análisis de historias clínicas, incluyendo variables sociodemográficas, económicas y clínico-epidemiológicas. Los determinantes sociales de la salud se analizaron según el modelo de Dahlgren y Whitehead, utilizando estadística descriptiva.
Resultados: se observó un predominio de niños menores de cinco años (51%), varones (67%), mestizos (64%) y que asistían a la escuela o guardería (65%), lo que indica vulnerabilidad biológica y social en la primera infancia y sugiere una mayor exposición a infecciones comunes. En el nivel intermedio, se observó baja escolaridad parental (37% de madres y 36% de padres con educación secundaria completa), ocupaciones informales (ama de casa 45%; agricultor 22%; albañil 19%) e ingresos familiares inferiores a dos salarios mínimos (54%), lo que revela condiciones de vida que limitan el acceso a la atención continua. Territorialmente, el 83% residía en la macrorregión del Cerrado, caracterizada por una menor oferta de servicios. Las hospitalizaciones se concentraron en septiembre (34%), período de sequía y agravamiento de enfermedades respiratorias, con fiebre (15%) y neumonía (25%) como principales causas, lo que refleja la interacción entre factores biológicos, socioeconómicos y ambientales.
Conclusión: las hospitalizaciones pediátricas reflejan la influencia de los determinantes sociales de la salud en múltiples dimensiones, destacando la interacción de factores biológicos, socioeconómicos, geográficos y políticos en la determinación de los resultados en salud.
DESCRIPTORES:
Salud infantil; Hospitalización; Perfil de salud; Determinantes sociales de la salud; Desigualdades en salud
INTRODUCTION
Childhood is a crucial stage in the life cycle marked by biological, emotional, and psychological transformations1. Health conditions play a determining role in growth and development during this period, with repercussions that can extend throughout life2. Despite advances in child care, pediatric hospitalizations still unequivocally reflect social inequalities3 and the persistent weaknesses of health systems4.
In the current context in which demographic and epidemiological transitions coexist with the persistence of infectious diseases and the emergence of chronic conditions in childhood5, understanding the determinants of hospitalizations goes beyond health analysis, as it requires consideration of political, socioeconomic, cultural, and environmental factors6. For example, children in vulnerable situations are more exposed to environmental risks, failures in care continuity, and unequal access to effective healthcare and services, resulting in a higher frequency of avoidable hospitalizations and adverse clinical outcomes4.
In this context, the Dahlgren and Whitehead (1991) model stands out as one of the most robust frameworks for understanding the Social Determinants of Health (SDH). The model illustrates the integrated influence of multiple strata on the health-disease process represented in concentric layers: biological factors, lifestyles and behaviors, social support networks, living and working conditions; and externally, public policies, economic structures, and cultural aspects. This perspective demonstrates that health does not solely result from individual characteristics, but from experiences and opportunities unequally distributed across territory and time7.
Applied to child health, this conceptual framework allows us to understand how the social and economic contexts that affect adults also impact the well-being of children, shaping the environments in which they develop, given their greater vulnerability to socioeconomic inequalities6. From this perspective, the United Nations Children’s Fund (UNICEF) broadened this understanding by proposing the Childhood Health and Social Disorders Model, which positions the child at the center of three interdependent spheres: their world (biological, emotional, and relational factors); the world around them (health services, school, family, community, protection, and social support); and the world in general (macroeconomic policies, legislation, and structural conditions of inequality)8.
With its application, it is possible to understand that childhood illness is an essentially social phenomenon whose etiology transcends the child’s body and stems from the interactions between proximal and distal determinants, encompassing everything from biological and behavioral aspects to the family, community, and structural context, all influenced by social, economic, and health policies6-7.
In the meantime, it is essential to distinguish SDH from the Social Determination of Health, as these concepts are related but have distinct theoretical foundations. While the SDH focus on measurable social factors which influence health status, the Social Determination of Health understands the health-disease process as a product of social organization forms, economic relations, and power structures. Thus, the assessment of the SDH guides interventions and policies aimed at reducing vulnerabilities and promoting equity in child health9.
The SDH, defined as the conditions in which people are born, grow, live, work, and age7, are responsible for 30% to 55% of health outcomes10. International evidence shows that social factors such as skin color, low socioeconomic status11, maternal education12 and parental occupation10 are associated with increased childhood hospitalizations. This relationship is particularly evident in low- and middle-income countries3 and in regions marked by historical inequalities, such as Northeast Brazil13.
Considering that the proper approach to the social determinants of health is fundamental to improving health indicators and reducing inequalities in the long term10; that these factors are still little explored in research in hospital services11; and that understanding their influences on pediatric hospitalizations constitutes an essential basis for supporting more equitable and intersectoral public policies capable of articulating preventive and health promotion actions in the territory, the following research question was established: what are the social determinants of health that influence pediatric hospitalizations in a regional hospital located in a municipality in the interior of Piauí?
Given this scenario, the present study aims to analyze pediatric hospitalizations according to the social determinants of health, seeking to contribute to the scientific debate and to strengthening strategies for child healthcare in social vulnerability contexts.
METHOD
This is an exploratory, descriptive, and observational study prepared according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE®) checklist14, and conducted in the pediatric ward of a medium-complexity regional hospital located in a municipality in the interior of the state of Piauí, Brazil, between the months of May and October 2024. The sector is divided into surgical and clinical pediatrics with, respectively, three and eight hospital beds. According to information collected in the service, care is offered 24 hours a day, for children aged between 30 days and 11 years, 11 months and 29 days, who are accompanied by a multidisciplinary team composed of doctors, nurses, nutritionists and psychologists, among other professionals. The service receives children from several surrounding cities, with various health problems.
The participants were selected by non-probabilistic convenience sampling. Children in the aforementioned age range, hospitalized for at least 24 hours in the pediatric unit, were included. Cases with illegible or incomplete medical records that made it impossible to obtain clinical data were excluded.
The study objective, data collection procedures, and the estimated time were explained to the caregivers and, when possible, to the children themselves who were able to consent, especially preschool-aged children. In these cases, adapted language and concrete examples were used to promote understanding and autonomous decision-making regarding participation.
Data collection took place during the daytime, after institutional consent and ethical approval. A previously trained research assistant, with no direct involvement in the care of the children, conducted the data collection stages. An informational meeting was initially held with the nursing management and shift coordinators to detail inclusion criteria, instruments, and informed consent procedures.
The data collection process began with a semi-structured interview applied to the legal guardian (mother, father, or primary caregiver), using a form adapted from a previous study15, which covered sociodemographic and economic data (age, sex, ethnicity, education level of the child and parents, parental occupation, number of residents, family income, and origin). Clinical-epidemiological information (such as reason and month of hospitalization, medical diagnosis, comorbidities, need for ventilatory support, and length of stay) was extracted from medical records with the authorization of the guardians and, when pertinent, the assent of the child. The minimum monthly salary in 2024 was R$1,412.00 and the average value of the Bolsa Família benefit was R$685.61, used as parameters to contextualize the socioeconomic conditions of the families.
The data collection forms were organized and then entered into a Microsoft Excel 2010 spreadsheet (double entry for later validation). The spreadsheet was subsequently imported into the Statistical Package for Social Sciences for Windows (SPSS) (2009) version 20.0 software to generate the results. The variables were expressed as absolute and relative frequencies.
With the data in hand, a representation of the way the SDH act on the health outcomes of hospitalized children was developed, which enabled a graphic visualization of its structural dimension. The Dahlgren and Whitehead model was followed based on three references - in its classic7 and updated8,16 versions. The diagram illustrates the layered arrangement of the determinants: proximal, related to individual characteristics (age, sex, ethnicity and school attendance); intermediate, referring to family, community and social networks (parental education, occupation, number of residents, income and origin); and distal, associated with socioeconomic, cultural, environmental and political conditions.
The study complied with Resolutions No. 466/2012 and No. 580/2018 of the National Health Council. The participation of guardians was conditional upon signing the Informed Consent Form, and the Informed Assent Form was presented to eligible children. All participants were identified by alphanumeric codes to preserve anonymity. No artificial intelligence was used to conduct this research.
RESULTS
A total of 100 children admitted to the pediatric unit of a medium-sized hospital located in the interior of Piauí, Brazil, were evaluated. The analysis was based on the Dahlgren and Whitehead model (Figure 1), and highlights the articulated influence of the social determinants of health (SDH) at multiple levels (individual, family, community, and structural) on the profile of pediatric hospitalizations.
Illustration of the action mode of the social determinants of health on the health outcomes of hospitalized children. Piauí, Brazil, 2024. (n=100).
At the proximal level (the child’s world), referring to individual and behavioral characteristics, there was a predominance of children under five years of age (51%), male (67%), and self-declared mixed-race (64%) by their guardians. These findings reinforce the biological and social vulnerability associated with early childhood. Most attended school or daycare (65%), which, although representing a positive indicator of social inclusion, also increases exposure to common infections at this age (Table 1).
Distribution of the social determinants of proximal health among the children participating in the study. Piauí, Brazil, 2024. (n=100).
The low educational attainment of parents stood out at the intermediate level (the world around them) relating to family and socioeconomic conditions, being concentrated in complete secondary education (37% of mothers and 36% of fathers), as well as the predominance of informal and low-income occupations, such as housewives (45%), farmers (22%) and construction workers (19%) (Table 2). Family income below two minimum monthly salaries in more than half of households (54%) and dependence on income transfer programs (33%) reflect structural vulnerabilities which compromise access to essential goods and services, such as adequate food, safe housing and transportation to health units. These conditions place these families in the intermediate and outer layers of the Dahlgren and Whitehead model, highlighting how living and working conditions indirectly determine the risk of child hospitalization.
The concentration of children in the Cerrado macro-region (83%), especially in the Vale dos Rios Piauí and Itaueira territory (44%), with the most distant municipality located 633 km from the health service (average 152 km), represents territorial inequalities typical of inland regions marked by lower availability of specialized services and geographical barriers to access to continuous care. At the distal level (world in general), which expresses the accumulated effects of living conditions on health outcomes, a higher number of hospitalizations was observed in September (34%), coinciding with the period of drought and low air humidity in the region (Table 2). These spatio-temporal inequalities constitute structural components of the social determinants of health (SDH), which interact non-linearly with family and community factors.
The main clinical cause of pediatric hospitalizations included fever (15%), with the most frequent diagnosis being lower respiratory tract infection/pneumonia (25%). Most hospitalized children did not have comorbidities (76%). It was also observed that most patients did not require ventilatory support (96%) and remained hospitalized for up to 10 days (92%) (Table 3).
Figure 1 summarizes the way social determinants of health (SDH) act on pediatric hospitalizations, demonstrating how individual factors (age, sex, skin color), family factors (parents’ education and occupation), community factors (income and housing conditions), and structural factors (public policies and organization of services) are dynamically interrelated. This interrelation shows that child health not only results from biological vulnerability, but also from the mutual influence between social and economic contexts that shape the daily lives of families. It is observed that the interactions between the layers occur non-linearly and cumulatively with continuous feedback loops (Δt), in which vulnerabilities at one level can exacerbate disadvantages at other levels.
DISCUSSION
The analysis of pediatric hospitalizations shows that childhood illness expresses a social and historical process of inequality in which the social determinants of health (SDH) are not only articulated as explanatory variables, but also as products of specific forms of economic, political, and territorial organization. Understanding these hospitalizations from the perspective of the social determinants of health implies shifting the focus from the simple association between risk factors and clinical outcomes to the analysis of how living conditions, parental occupation, and family income are socially produced and unequally distributed conditioning opportunities and risks from childhood onwards.
The results reinforce the complex and multifactorial nature of childhood hospitalization, marked by a simultaneous interaction of proximal determinants (age, sex, ethnicity, and education of the child), intermediate determinants (education and occupation of parents, income, number of residents in the household, and origin), and distal determinants (political context), which act integratedly in shaping health trajectories7,17.
From this perspective, the Dahlgren and Whitehead model offers a useful framework for understanding these layers of vulnerability, but its interpretation must transcend the descriptive character, highlighting the interconnections between micro and macrostructural levels that shape children’s health. The innermost layers (age, sex, and skin color) extend beyond the biological field and reflect the social hierarchy of children’s bodies, granting certain groups less access to resources and protection6.
Children under five years of age were the most hospitalized, a group with greater immunological susceptibility to respiratory infections, corroborating the predominance of pneumonia as the main diagnosis and fever as a recurring reason for hospitalization18,19. These findings are consistent with national data, which indicate that acute respiratory infections account for 20% of child hospitalizations, with bacterial pneumonias responsible for more than half of the cases20. However, the interpretation of these results must transcend the biological aspect and recognize that low educational levels, insufficient income, precarious housing (intermediate SDH) and restricted access to health (distal SDH) constitute interdependent factors which increase infant morbidity and mortality21.
Another relevant aspect refers to school attendance: most children attended school or daycare, spaces considered essential for learning and socialization, but which also represent environments of exposure to infectious agents22. Classrooms, generally equipped with natural or mixed mechanical ventilation, are often poorly ventilated and have high CO2 concentrations, which favors the permanence and transmissibility of pathogens23. Structural interventions, such as adequate mechanical ventilation, can significantly reduce the risk of infection, reinforcing the importance of public policies and school infrastructure (distal SDH) in protecting children’s health24.
The predominance of hospitalizations in males stood out among the proximal determinants. Literature indicates greater biological vulnerability of boys to illnesses such as pneumonia, diarrhea, and hemorrhages25. A Spanish study on the incidence of hospitalizations and in-hospital mortality showed that 53% of hospitalizations for community-acquired pneumonia occurred among boys26. However, there is no consensus, and sociocultural factors, such as the perception that boys are “stronger” and therefore exposed to greater risks, may also influence illness patterns27-28.
Regarding skin color, another proximal SDH, a predominance of brown children was revealed, which is a finding consistent with population data29. Although demographically expected, it is essential to recognize the interaction between ethnicity, socioeconomic origin, and SDH, as this convergence amplifies vulnerabilities among ethnic minorities11,30. This fact was evidenced in a study conducted in the United States of America (USA) during the Covid-19 pandemic, which showed a higher frequency of hospitalizations, emergency room visits, and delays in well-child visits among non-white children30.
Racial inequalities in Brazil are marked by historical legacies of exclusion; this reproduces inequities which manifest themselves both in material conditions, such as housing, health, and education, and in symbolic and cultural dimensions3. Addressing these disparities requires public policies sensitive to racial complexity and based on critical approaches, at the risk of perpetuating inequalities17.
The precarious living and working conditions of families at the intermediate level, with a predominance of informal occupations, low parental education, and family income below two minimum monthly salaries, reflects an unequal development model which concentrates income and restricts rights. This context compromises preventive care and timely access to healthcare6,12. The socioeconomic status of parents as an intermediate SDH therefore strongly influences the risk of child hospitalization: families with low income, precarious housing, and unstable jobs are more vulnerable to preventable illnesses3,21. These factors structure a cycle of vulnerability in which childcare is not only limited by the scarcity of these material resources, but also by the absence of effective social protection and support policies10.
The territory where children live and are cared for is also among the intermediate SDH, and additionally imposes itself as a symbolic and material space of inequality. The concentration of hospitalizations in the Cerrado macro-region, especially in the Vale dos Rios Piauí and Itaueira territory, expresses the geopolitical dimension of the social determinants of health: extensive areas (26,514.40 km2, distributed among 19 municipalities)31 with low service density constitute structural barriers that perpetuate historical regional inequalities. Unequal access to care thus results from the way the State organizes and distributes resources, maintaining dependence on long journeys and compromising comprehensive care32.
Distances greater than 80 km impact public health and families33, as observed in the region studied, where municipalities are located an average of 152 km from the pediatric hospital unit, highlighting the concentration of service provision and the role of geography as an intermediate SDH. These barriers reveal that hospitalization does not only result from clinical conditions, but also from the unequal distribution of services in the territory3. A study conducted in Pakistan that included 416 children investigated the relationship between the distance from children’s homes and morbidity from acute infections, and confirmed that the distance to health units increases morbidity from respiratory infections and diarrhea, reinforcing the need for structural reforms to expand access in remote regions32.
In addition, the concentration of hospitalizations in September suggests the influence of climatic seasonality on childhood illness. Piauí faces high temperatures and critical relative air humidity (<30%)34 during this period, constituting conditions which are associated with exposure to air pollution - both environmental, resulting from intentional fires to prepare the soil, and domestic related to the use of wood stoves due to a lack of resources to purchase cooking gas. These factors compromise immune responses and increase susceptibility to respiratory infections4. Given this scenario, it becomes essential to strengthen the infrastructure and environmental policies aimed at mitigating the risks to children’s health associated with climate variations, especially during extreme temperature and humidity events34 which tend to accentuate pre-existing socioeconomic inequalities.
The most frequent causes of hospitalization therefore not only reflect biological vulnerabilities, but also material living conditions, such as unhealthy housing, poor sanitation, and exposure to environmental and domestic pollutants. These problems are sensitive to primary healthcare, and highlight gaps in the effectiveness of public policies for child care. The predominance of cases without comorbidities and with short hospital stays indicates that a large proportion of these hospitalizations could be avoided through intersectoral preventive actions21.
The social determinants of health (SDH) thus act in an interdependent manner, requiring integrated, equitable, and contextualized approaches16. Limitations include the fact that the data were only obtained from one hospital institution and were partly based on clinical records, which are subject to gaps and inconsistencies. Information on post-discharge follow-up was also not included, which restricts understanding of the medium- and long-term effects of the SDH. Furthermore, the figure representing the action mode of the SDH on health outcomes still requires validation. Despite these limitations, the study offers novel evidence for the context of Piauí. However, it is recommended that new multicenter studies with expanded variables, such as school year and seasonality, be conducted to generate more robust and applicable findings.
Implications for professional and nursing practice
In practical terms, the study shows that pediatric hospitalizations cannot be solely understood from an individual clinical perspective, but result from the interaction between biological, family, socioeconomic, territorial, and environmental factors, as illustrated by the Social Determinants of Health (SDH) of the Dahlgren and Whitehead model. Understanding the influence of these determinants on children’s health outcomes and social conditions is essential to strengthening equity and improving health outcomes. The prevalence of low family education, informal work, and insufficient income indicates that care should go beyond a biomedical approach, considering the lifestyles and material contexts of families. From a healthcare perspective, this reinforces the importance of preventive and intersectoral strategies, strengthening primary healthcare, and improving environmental and housing conditions, as these are essential pillars for promoting children’s health. The findings offer important support for public policies and clinical practice, guiding evidence-based interventions focused on equity, comprehensiveness, and quality of pediatric care.
CONCLUSION
The analysis showed that pediatric hospitalizations are intrinsically related to the social determinants of health, which interact in a complex, interrelated, and multifactorial way, encompassing proximal dimensions (age under five years, male sex, brown skin color, school attendance), intermediate dimensions (parents’ education: completed high school, mother’s occupation: housewife, father’s occupation: farmer, four residents in the household, family income less than two minimum monthly salaries, and origin: Vale dos Rios Piauí and Itaueira), and distal dimensions (political context).
It was found that biological, socioeconomic, geographic, and contextual factors influence health outcomes, resulting in a characteristic epidemiological pattern of pediatric hospitalizations marked by fever, pneumonia, absence of comorbidities, low need for ventilatory support, and short hospital stay. However, it was not possible to determine which social determinants of health have the greatest weight on these results.
These findings reinforce the idea that childhood hospitalization cannot be solely explained by biological determinants, but must be understood from the interdependence between individual, family, social, and structural factors. Thus, the need for public policies and care practices which incorporate the perspective of the social determinants of health in planning pediatric care is highlighted, with an emphasis on preventive, intersectoral, and equitable actions.
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NOTES
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ORIGIN OF THE ARTICLE
This article was developed from the research “Analysis of the socioeconomic and clinical-epidemiological profile of pediatric hospitalizations in a regional hospital in Piauí”.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Research Ethics Committee of the Federal University of Piauí, opinion. no. 6.795.919/2024, CAAE: 79320624.9.0000.5660.
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TRANSLATED BY
Christopher J. Quinn.
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DATA AVAILABILITY
The dataset that supports the results of this study is not publicly available.
Edited by
The dataset that supports the results of this study is not publicly available.
Legend: CHS: Complete High School Education; ** < 2: household income below two Brazilian minimum wages. Source - Research data, 2024. Figure adapted