Health inequalities tool 2 - Develop clinical skills for talking to families

Many paediatricians may find it difficult to raise questions about poverty with families. We give some tips to make this subject more approachable.
Icons of three people with speech bubble; background with repeated icon of family

If we stop thinking about smoking, housing, food, and air quality as “wider determinants” of health – and start considering them “core determinants” – then it doesn’t just become easier to ask about them, it becomes imperative. 

Don’t shy away from it. If an adult had a consultation with a GP about a cough, and they weren’t asked about whether they smoked, they would probably leave feeling a little “short-changed”. If we aren’t asking families about things which may impact on their children’s health, we are short-changing the children themselves. However, pick your timing carefully – parents can feel alienated if we are perceived as jumping in with two feet to ask about smoking when they are stressed about an acutely unwell child with pneumonia.

Don’t try and guess who might be struggling. Ask everyone the same suite of questions and tell every parent that you ask these routinely. Children and young people in families in relative deprivation can live in affluent council wards. Families who do not fall below the poverty line may still be struggling to get by. They may in fact be ineligible for certain resources, such as Free School Meals, that might otherwise have made their financial situation easier. It is also impossible to judge a child or young person’s social situation by their appearance – some parents go to great lengths to ensure their children are immaculately dressed when they interact with healthcare professionals. The WHAM Project (The Wellbeing & Health Action Movement) have developed a suite of tools to help clinicians identify families living in poverty.   

Explain why you are asking the questions, and don’t make the parent feel like you are judging them, or skirting around the problem – rather, just acknowledge the problems but don’t insist on being a hero – just offer your help. Let people know they aren’t alone in experiencing problems.

Examples of sentences we use to approach conversations in our respiratory clinic:

Good nutrition is really important for child development, and fresh fruit is really important too… it can be tricky to get children to eat fruit - what is Max’s diet like? Lots of parents tell us that fruit is often really expensive at the moment – has that been your experience?

As you can imagine, if Max breathes air that has pollution in it from traffic it can irritate their airways – do you live near a main road or have to walk down one to get to school? Similarly, the air someone breathes indoors can cause problems too sometimes – are there any issues with damp, dust, or mould as these are really common and are known to cause problems? What is your current living arrangement? Do let us know if we can be of any help writing a letter to the landlord to speed up getting better – we end up doing that with a lot of our patients.

Max seems a little anxious at the moment – this can make children have tummy pains and chest problems – is there anything stressful happening at school or at home? Children are pretty good at spotting when adults are worried about things – sometimes it’s worth just having a think if there is something stressing you out that they might pick up on – if there is, and we can help, just let us know.

What do children and young people think?  

Children, young people and parents/carers from RCPCH &Us suggested: 

  • Talk to children and young people as well as parents/carers and giving each other space to speak separately. Each one will have a different piece of the puzzle to share, but might not want to talk openly with everyone in the same place. Share the RCPCH emoji cards or grounding activity with children and young people, parents or carers before you start the conversation so that they have a tool to use if they start to feel upset 
  • Learn about the help that is available locally so that you can signpost well – there is nothing worse than being given information about a charity or service that is closed or that you are not able to help you. You might have services that are doing social prescribing for children and young people that can help 
  • When you start talking to children, young people and families, let them know that you are there to help on more things than just medical things because you can help to link them up to other services.  Sometimes we think that we can only talk to you about medicines or what hurts, but don’t realise that sometimes our housing might be affecting our health 
  • Remember that sometimes children and young people are providing care to their parents and families by being emotionally responsible or sorting out bills and decisions, so they might need help in accessing food banks on behalf of their parents and carers 
  • Link up with schools, youth workers, charity staff and social workers so that together you can help our wellbeing that is impacted by living in poverty. They might also be the best people to talk with us about what is happening, but we need you to all work together 
  • Work with other teams and services to create information that links us to local or national support services that we can see in the waiting area, that is included in clinic letters, is giving out to us in appointments and use postcards or health diaries to find out what we want to talk about with you. 
The toolkit authors explain more in our podcast

Dr Ian Sinha and Dr Alice Lee, who are based at Alder Hey Hospital and work in its Lab to Life centre, spoke with Dr Helen Stewart, RCPCH Officer for Health Improvement for this podcast released in December 2022.

They discussed why paediatricians have a role in addressing health inequalities and provided advice on how to talk with families in a way that's approacable and meaningful.

Listen to the 25-minute episode on your podcast player, or here: 


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