The social deteminants of health: the role of the healthcare practitioner

This blog has kindly been shared with us by our partner, Medbridge Education. We acknowledge the original author, Breanna Lathrop who presents a course on Assessing and Addressing Social Determinants of Health for Medbridge Education.

Afterwards, we've provided some comment and response to some of the points made in the article, to show how it is still very relevant from a UK (and worldwide) context.

The Social Determinants of Health: The Role of the Healthcare Practitioner

A few months ago, I met a new patient.

His energy was contagious, and his personality was too big for the exam room. Recently released from prison, he had a vision for a new start at life. He had a family thrilled to welcome him home and plans for a new career.

His blood pressure hovered just below hypertensive urgency, and he had never been on medication for cholesterol despite his high risk for heart disease. We discussed a treatment plan, and at his follow-up visit a few weeks later, his blood pressure was already showing significant improvement.

A few weeks later, his sister called to thank us for providing care to him—and to let us know he had died from a stroke. His visions and hope for the future had come to an abrupt end.

While his death certificate gives the cause of his death as “cerebral vascular accident,” that is only part of the truth. His causes of death were racism, mass incarceration, poverty, and inadequate housing. Social determinants of health impacted his life expectancy long before he set foot in my clinic.

A Necessary Realignment for Healthcare

The healthcare system is currently engaging in a much-needed realignment focusing on health equity, and social determinants of health (SDOH) is becoming a more mainstream conversation.

Healthcare providers have long known that living environment has an impact on health. Social determinants of health are the conditions in which people are born, live, work, grow, and age, which affect health and quality of life as well as the wider forces and systems that shape daily life, including policies, social norms, and political systems.1 They include factors such as education, employment, socioeconomic status, and housing, as well as larger systems of oppression, including racism and classism.

SDOH are not simply risk factors for poor health outcomes, but directly correlate to health status and mortality.2 The chronic stress of experiencing racism, poverty, housing instability, and food insecurity creates chronic stress in the body, which leads to maladaptive coping mechanisms, structural changes, and DNA degradation.3, 4 This results in increased chronic disease burden and shorter life expectancies.

In Atlanta, the zip code in which I work has a life expectancy 24 years less than a neighborhood just 20 minutes to the north. This gap in life expectancy between neighborhoods within the same city exists throughout the U.S., from 30 years in Chicago to 15 years in Seattle.5

These numbers are staggering, suggesting that if a healthcare system does not address social determinants of health, its influence on health outcomes and longevity is limited. In fact, in the U.S., only 10 percent of premature deaths can be prevented by medical care alone.6 Yet, the healthcare system is already overwhelmed and costly. How do we, as healthcare providers and administrators, begin to address social determinants of health?

A Framework for Healthcare Systems

In MedBridge’s white paper on addressing social determinants of health, we outline a framework for healthcare systems desiring to better address SDOH.

First, we can’t fix what we don’t fully understand. Healthcare systems can establish an organizational culture and evaluation process to identify and eliminate health disparities. This starts by educating all members of the healthcare team about SDOH. Other critical strategies include implicit bias training and providing healthcare providers with the time and tools needed to practice empathy and perspective-taking.7 Healthcare systems must also develop monitoring systems by which they can identify disparities in treatment access, screening rates, satisfaction, and outcomes across race, ethnicity, zip code, and socioeconomic status. Finally, healthcare systems need both qualitative and quantitative approaches to soliciting patient and community feedback about health and social needs, as well as healthcare preferences.

Next, healthcare systems need to identify and respond to the social needs of individual patients. Screening for social determinants of health allows healthcare providers to identify the social needs of their patients and allows healthcare systems to better understand their service communities. Healthcare providers can use validated screening tools to ask patients about social determinants of health, such as the Social Needs Screening tool or the PRAPARE tool. Screening should prioritize trust building, normalize discussions about social needs, and be incorporated into holistic care.8 Information gathered can be used to connect patients to resources to support needs such as housing, childcare, mold removal, job placement, and financial support. Patient navigators, community health workers, case managers, certified peer specialists, and social workers can help bridge these connections between meeting traditional healthcare needs and addressing SDOH.

What You Can Do as a Healthcare Practitioner?

Meeting the social needs of patients is not equivalent to addressing SDOH.9

Healthcare practitioners can and must collaborate cross-sector to facilitate policy, systemic, and social change. SDOH interventions in the areas of housing, nutrition, income support, and care management have been consistently linked to improved health outcomes.10

Healthcare practitioners can collaborate with employers, farmers, business owners, housing specialists, lawyers, public policy makers, social planners, and community leaders to create sustainable and compressive strategies to address SDOH in the community. Healthcare practitioners can also use their knowledge, experience, and stories to advocate for policy change at local, state, national, and systemic levels, promoting health equity to decrease health disparities.

As a healthcare provider, I often think about how I can deliver high quality, evidence-based care to my patients. In part, this involves staying up to date on guidelines, collaborating with and learning from my peers, and fulfilling CME. Yet this is only part of the work.

Providing equitable care and improving patient outcomes also means identifying my implicit biases—and implementing strategies to reduce their impact. It means increasing my ability to talk about SDOH in a trauma-sensitive and empowering way. It means increasing my knowledge of community resources and forming new partnerships. It means examining my decisions and behaviors outside of the healthcare system, which impact the wellbeing of my community. It’s an ongoing process of learning and growth, which at times can feel frustrating and overwhelming. However, this work is necessary to be the type of provider my patients deserve.

References:

1. World Health Organization. (2021). Social Determinants of Health. Retrieved from https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
2. Braveman, P. & Gottlieb, L. (2014). The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 129(suppl. 2), 19–31.
3. Steptoe, A. & Marmot, M. (2002). The role of psychobiological pathways in socio-economic inequalities in cardiovascular disease risk. European Heart Journal, 23(1), 15.
4. Geronimus, A., Pearson, J., Linnenbringer, E., Schulz, A., Reyes, A., Epel, E., & Lin, J., et al. (2015). Race/ethnicity, poverty, urban stressors and telomere length in a Detroit community-based sample. Journal of Health and Social Behavior, 56(2), 199–224.
5. NYU Langone Health. (2021). City health dashboard. Retrieved from https://www.cityhealthdashboard.com
6. Schroeder, S. (2007). We can do better—improving the health of the American people. New England Journal of Medicine, 357, 1221–1228.
7. Van Ryn, M., Burgess, D., Dovidio, J., Phelan, S., Saha, S., Malat, J., & Griffin, J., et al. (2011). The impact of racism on clinical cognition, behavior, and clinical decision making. Du Bois Review, 8(1), 199–218.
8. Garg, A., Boynton-Jarrett, R., & Dworkin, P. (2016). Avoiding the unintended consequences of screening for social determinants of health. JAMA, 316(8), 813–814.
9. Castrucci, B. & Aurebach, J. (2019). Meeting individual social needs falls short of addressing social determinants of health. Health Affairs Blog. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20190115.234942/full/
10. Taylor, L. A., Tan, A. X., Coyle, C. E., Ndumele, C., Rogan, E., Canavan, M., & Curry, L. A., et al. (2016). Leveraging the social determinants of health: what works? PLoS One, 11(18), E0160217.

Allied Health and Therapy Network comments and discussion:

1) In Atlanta, the zip code in which I work has a life expectancy 24 years less than a neighborhood just 20 minutes to the north.

• Mortality inequality is not limited to a US context: Although there was a reduction in the UK in mortality inequality between those who live in more or less advantaged areas between 2001 and 2010, the gap still exists. Even more worrying is that the gap widened again between 2010 and 2016. Across all age groups, except 5-19 and 80+ years old, the 2016 data showed strong clinically significant differences in mortality rates between those living in low deprivation and high deprivation areas; all between 1.5 - 2.0 times more per 1000 people (Banks et. al., 2021).
• You can look at this link to give you an idea of what this means in reality: Map of healthy life expectancy at birth - The Health Foundation. The map shows the average life expectancy of men and women across different areas of the UK. Soberingly, there is up to a 20-year average gap between some of these areas!

2) Healthcare systems must also develop monitoring systems by which they can identify disparities in treatment access, screening rates, satisfaction, and outcomes across race, ethnicity, zip code, and socioeconomic status. Finally, healthcare systems need both qualitative and quantitative approaches to soliciting patient and community feedback about health and social needs, as well as healthcare preferences.

• We think this highlights that all healthcare, psychology and educational professionals need to consider their CPD carefully. Being a member of our professions brings us into contact with many diverse groups of people from many different backgrounds. CPD must be more than attending courses on, reading about and seeking supervision about, clinical approaches and interventions. We should also be continually thinking of ways to improve our service, improve accessibility and inclusivity and informing ourselves about the factors that often prevent some people from accessing our support and how we can be proactive in reaching those clients.
• No matter whether we work as part of a large organisation or as a sole trader, this is still relevant and can be achieved.

3) Patient navigators, community health workers, case managers, certified peer specialists, and social workers can help bridge these connections between meeting traditional healthcare needs and addressing SDOH.

Healthcare practitioners can and must collaborate cross-sector to facilitate policy, systemic, and social change.

• This rings really true with what we are trying to achieve with the Allied Health and Therapy Network and it's why we opened the membership to social workers. We should be asking ourselves frequently whether us providing our service as a standalone practitioner, without the involvement of other professionals from different sectors, is enough.

Healthcare practitioners can also use their knowledge, experience, and stories to advocate for policy change at local, state, national, and systemic levels, promoting health equity to decrease health disparities.

Providing equitable care and improving patient outcomes also means identifying my implicit biases—and implementing strategies to reduce their impact.

• Politics is scary and it opens a can of worms. We debated whether to comment onnthis as we're not in the game of politics and we recognise our members will have many different political affiliations. However, we agree that all of the professional groups the Allied Health and Therapy Network is open to are in a powerful position to identify the social challenges that some of our client groups encounter. We do think it can be easy to get caught up in political jargon and rhetoric, especially around election time. But in our opinion, maybe this is one of the biases we need to identify and just be aware of so that it doesn't influence the way in which we think about all the other things we should be doing to try and engage more with clients from all walks of society so we can do what we trained to do - support people who need our support.

References:

1. Banks, J., Cattan, S., Kraftman, L. & Krutikova, S. (2021). Mortality inequality in England over the past 20 years. Fiscal Studies The Journal of Applied Public Economics, 42(1), 47-77