What are the Top Common Social Determinants of Health?

The following excerpt comes from an August 9, 2017, article by Sara Heath on Patient Engagement HIT.


The social determinants of health are the factors that affect health outside of the four walls of the hospital. Housing, social services, geographical location, and education are some of the most common social determinants of health.

These factors have a significant impact on the current healthcare landscape. As more healthcare organizations deliver value-based healthcare, they are developing strategies to drive wellness care.

Organizations are catering to patient needs outside of the hospital with the goal of keeping patients healthy in the long-run. Patients who have better health support in their daily lives may be less likely to fall ill and require an expensive medical intervention.

But what are the specific social determinants of health? Which examples are most common? And how can healthcare organizations and community partners act on these determinants?

Socioeconomic factors can encompass several different social determinants of health. Poverty can limit access to healthy food, safe neighborhoods, and good schools, among other things. Most prominently, poverty affects housing.

Although individuals can lose reliable housing for a number of reasons – trauma, violence, mental illness, addiction, or another chronic health issue – poverty remains a notable factor driving homelessness.

Hospitals treating a large homeless patient population can forge partnerships with housing departments to help drive housing in the community. Housing development partners can help place individuals who are homeless in houses and offer support that will help individuals maintain that housing.

“Access to safe, quality, affordable housing – and the supports necessary to maintain that housing – constitute one of the most basic and powerful social determinants of health,” wrote the Corporation for Supportive Housing (CSH) in a 2014 white paper.

“Supportive Housing, an evidence-based practice that combines permanent affordable housing with comprehensive and flexible support services, is increasingly recognized as a cost-effective health intervention for homeless and other extremely vulnerable populations,” CSH wrote.

Expanding housing development can also help ensure that living conditions are safe, free of asbestos, lead paint, or other environmental factors that can impair health.

Housing support can also account for other poverty-driven determinants of health, CSH said.

“Furthermore, supportive housing developments often attract or directly bring critical services to resource-barren neighborhoods,” wrote CSH. “Many supportive housing developments are increasingly featuring on-site or direct linkages to gym facilities, after-school programs, recreational spaces, food pantries, recovery support groups and full-service health clinics that benefit the larger community.”

There are countless different social support and public service gaps that are significant social determinants of health, according to Healthy People 2020, a public health organization developed as a part of the Affordable Care Act.

Issues such as race disparities, lack of social support groups, weak culture of health equity, and limited public services are all drivers of adverse health events.

Populations rely on community partners that will advocate for health equity. Examples of partners include the housing department working with homeless patients or health navigators helping a population’s surplus of single mothers.

Social support also includes efforts toward desegregation, which in turn may ensure certain races are not targeted disproportionately for the social determinants of health. One example is black patients living in poverty-ridden areas at a higher rate than their white patient counterparts.

Support for the public good means ensuring public services meet all patient needs. For instance, neighborhoods that are filled with trash need more support from public sanitation departments.

Public safety is also integral and requires the partnership of safety officers, such as fire departments and police. Police specifically can work to reduce drug issues, crime, and incidents of violence. Public safety officers can also help funnel patients out of negative lifestyles by reducing safety issues.
To learn more, read the full article.

Pediatric Grand Rounds Focus on Diabetes

The following is cross-posted from the Med School Watercooler of the University of South Alabama College of Medicine.

Dr. Anne-Marie Kaulfers, associate professor of pediatrics at the University of South Alabama College of Medicine and a pediatric endocrinologist with USA Physicians Group, will present “Update on Diabetes and Pre-Diabetes/Obesity” for August’s pediatric grand rounds.

The event will take place Friday, Aug. 18, at 8 a.m. in the conference room on the first floor of the Strada Patient Care Center.

Dr. Kaulfers will explain the difference in labs regarding Type 1 and Type 2 diabetes. She will also discuss new technologies that will soon be available for patients with diabetes and the new guidelines for obesity and pre-diabetes.

The event is open to faculty, staff, and students at USA. A light breakfast, coffee, and beverages will be provided. For additional information, contact Katie Catlin at kncatlin@health.southalabama.edu.

The Strada Patient Care Center is located at 1601 Center St. in Mobile.

Working with Communities to Improve Health

The following excerpt comes from an article that first appeared May 1, 2017, on the NIMHD website under NIMHD Community Health and Population Sciences Feature Articles


Improving health is not always a matter of prescribing the right medicine. Sometimes the environment needs to change. Many Americans live in neighborhoods that lack safe walking routes, grocery stores, and health facilities.

“Are there places for kids to play? Are there good farmers markets or grocery stores?” asks Irene Dankwa-Mullan, M.D., M.P.H., formerly of NIMHD and now deputy chief health officer of IBM Watson Health. Such features help people in a neighborhood live healthier lives. Along with NIMHD director Eliseo Pérez-Stable, Dr. Dankwa-Mullan wrote an editorial in the April 2016 issue of the American Journal of Public Health, “Addressing Health Disparities Is a Place-Based Issue.”

Efforts to address these problems in particular communities are called “place-based interventions.” Ideally, these interventions come from a collaboration among community members, businesses, and other stakeholders, working together with police, urban planners, and other groups to improve their neighborhood. Community members are involved to make sure the interventions are based on their values.

Examples of place-based interventions include an effort to bring a farmers market to a neighborhood without a grocery store or promoting public safety so that residents feel safe walking on the street. Walking is a simple way to improve health, but there can be many barriers to walking, a fact highlighted in the Surgeon General’s Call to Action on walking.

Place-based interventions have been used successfully in rural areas, disadvantaged urban neighborhoods, and Indian reservations. People who live in such places tend to have particular health problems, such as diabetes and heart disease, and working to change the place-based conditions may help address health disparities.

Communities are complicated, and figuring out the best way to improve the health of all residents in a particular place can be a daunting task. “Part of the issue is that we do not have a best practices model for place-based interventions,” Dr. Dankwa-Mullan says. The editorial in the American Journal of Public Health was part of a new series on best practices for place-based interventions. Through this series, public health professionals will be able to learn how to develop place-based interventions.

One key to success of place-based interventions is involving the community. This is similar to community-based participatory research, a way of doing research in which the community sets priorities, ensuring that communities that are asked to participate in research get answers to the questions that are most important to them.

Read the full article.

 

Talking about Health Equity

Recently, the Health Policy Research Consortium create a YouTube Series, Conversations on Health Equity,  exploring health equity with leading experts. Available videos include

 

Useful Resource: Behavioral Health Equity

The Office of Behavioral Health Equity of the Substance Abuse and Mental Health Services Administration (SAMHSA) provides resources to address disparities related to mental health and/or substance use disorders in various populations. Available resources include: Data, Reports and Issue Briefs; SAMHSA Programs and Initiatives; SAMHSA Behavioral Health and In-Language Resources; and  Federal Initiatives and Resources. Items are organized by minority group:

Visit the Office of Behavioral Health Equity website to learn more.

Partnerships for Better Health Outcomes

In June, the Partnership for Healthy Outcomes: Bridging Community-Based Human Services and Healthcare issued the report “Working Together Toward Better Health Outcomes” detailing the findings from a national request for information that sought information about partnerships between healthcare organizations and community-based organizations (CBOs).  The data came from 200 respondents to the request for information with 67% of respondents from CBOs, 13% from healthcare organizations, and 9% from government agencies. The remaining respondents represented foundations, research institutions, consulting organizations, and for-profit CBOs. Responses came from all 50 states while California, New York, Colorado, Pennsylvania, and Minnesota were the most represented.

The following key findings come from the report’s executive summary.

  • There’s no one-size-fits-all formula: Respondents represented partnerships of many sizes, shapes, and contractual and funding arrangements; many were among healthcare providers and CBOs – but partners also included public health and other government agencies, private insurers, foundations, schools, supermarkets, and more.
  • Shared goals provide common ground: Most of the responding partnerships were initiated by CBOs and noted the value of developing shared goals to improve health outcomes and contain or reduce costs.
  • Most partnerships have some sort of formal agreement in place, though partner integration varied from communicating (sharing client information) to coordinating (aligning services toward better client outcomes) to collaborating (sharing staff, space, or resources) to integrating (becoming a collective entity with connected programs, planning, and funding).
  • Most commonly, partnerships provided services to impact immediate-term clinical needs, such as reducing hospital admissions or length of stay. This may be due, at least in part, to a funding environment with incentives for cost reduction. More than half of respondents reported that their partnerships include care coordination support to better organize services across multiple providers; fewer partnerships reported providing services that address underlying social determinants to improve health in the long-term. A majority (65%) of partnerships reported realizing cost savings.
  • Partnerships rely on an evolving variety of funding sources, including private foundations, healthcare systems, and government entities, and typically more than one. A number of partnerships were established through a one-time grant and have developed – or are developing – a long-term, sustaining funding model.
  • Nearly all organizations acknowledged expanding skills and capacities through partnership, particularly in network-building, improving programs, and generating new funding.
  • Advancing the field will require partners and funders to:1)Prioritize and invest time in relationship-building – the key ingredient to effectiveness; 2)Engage a wide range of stakeholders, including community members, early on and throughout the partnership; 3)Identify and fund the full cost of partnership to effectively support development and evolution; 4)Stay adaptable and nimble in an ever-shifting environment.

To learn more, download the full report.

Useful Resource: FedCommunities.org

Fedcommunities.org offers community development resources from all 12 Federal Reserve Banks and the Federal Reserve Board of Governors.  The information portal provides research, publications, and tools for those working in community development. “Healthy Communities” is one of the key areas of policy explored on the site. The available resources include

Examining Provider Bias In Health Care Through Implicit Bias Rounds

The following comes from the July 17, 2017, article by Vidya Viswanathan, Matthew Seigerman, Edward Manning, and Jaya Aysola on the Health Affairs Blog.


In 2015, a 27-year-old patient presented to our primary care resident practice in intractable pain, having been recently discharged from the hospital following surgery for a complex shoulder fracture. The orthopedic surgeons evaluated him the day before and scheduled a second surgery but did not adequately treat his pain. The inpatient nurse had told him he would be discharged with the oral pain regimen he had been taking for the past day or so within the hospital. But upon discharge, he found himself without those prescriptions and came to our primary care practice in severe pain. When we reviewed his inpatient record to determine the reason for this discrepancy, the attending physician discovered the phrase “drug-seeking” in the record. The rationale for this statement was not provided, nor the context. When questioned by his new primary care provider about this, the patient was shocked. He tried to recollect what he may have said to result in that assumption. He had no prior history of documented substance or prescription drug abuse.

The patient in question was a young black male and the victim of a drive-by shooting by a stranger. He had been sitting in the passenger seat of a stationary car when it happened. Standard practice in this type of case involves long-acting oral opioid medication, with gradual adjustments of a medication regimen tailored to meet the needs of the patient. But the patient didn’t receive the standard of care, and we naturally wondered why. The answer may be implicit bias.

The literature suggests that he would be more likely to be perceived as drug-seeking when requesting pain relief, compared to his white counterpart. Bias is particularly well-documented in pain management, with black children and adults receiving less adequate pain treatment than their white counterparts in the emergency department for the same presenting condition, even when accounting for insurance status and severity of pain. Longitudinal, national data on 156,729 pain-related emergency department visits found that even among those presenting with the same condition, non-Hispanic white patients were significantly more likely to receive an opioid than all other ethnic minorities examined. Researchers using an instrument to assess implicit bias in more than 2,500 physicians found a significant implicit preference for white Americans relative to black Americans among physicians of all racial/ethnic groups except for black physicians. Another study found that physicians were twice as likely to underestimate pain in black patients compared with all other ethnicities combined and also more likely to overestimate pain in nonblack patients than in black patients.

To address the case of our patient who was inadequately treated for pain based on apparently false assumptions—and other patients who have experienced a different standard of care due to implicit bias—we believe there needs to be formal discussion of this source of clinical errors at institutions. We propose the initiation of a new kind of case conference—“Implicit Bias Rounds”—to specifically identify and discuss these cases.

How Does Bias Occur?

We conceptualized Implicit Bias Rounds based on theories on why disparities in care occur despite well-intentioned providers and despite the recognition of the importance of cognitive error as a source of diagnostic error. Providers, when faced with the need to make complicated judgments quickly and with insufficient and imperfect information, may rely on assumptions associated with a patient’s social categories to fill in the gaps with information that may be relevant to diagnosis and treatment. Physicians are at risk for relying on stereotypes or assumptions for efficient decision making, even when attempting to be objective. In addition to the assumptions providers may make about patients that are dissimilar to them, they may also unconsciously favor patients whose identity they relate to. Such affinity bias may cause a provider not to consider the possibility of a drug problem in an adolescent that appears similar to him, despite a positive urine screen for marijuana. Current efforts in medicine to combat bias may also serve to perpetuate them: Physician-anthropologist Arthur Kleinman states that one problem with traditional cultural competency training is that it may erroneously characterize culture as static and cultural understanding as a technical skill.

It is not enough to merely consider potential sources of provider bias without considering proposed strategies to mitigate that bias. Evidence tells us that simply adjusting the explicit medical curricula is not enough to change implicit bias; increasing positive role modeling for medical trainees is more effective. Strategies proposed to combat implicit bias include consciously thinking of the patient’s perspective and approaching each provider-patient interaction as a shared negotiation between worldviews. Focusing on specific and unique details about an individual, instead of his or her social category, serves to combat biases by diminishing stereotyping and promoting empathy building. Clinicians who are trained to consider the unique perspectives and experiences of their patients are more likely to show empathy toward them, the study suggests. Priming physicians with information about the relevance or irrelevance of sociocultural factors in medical care can combat cognitive errors that stem from stereotyping. A regular intervention such as Implicit Bias Rounds would serve to implement these strategies on a consistent basis.

Read the full article.

Racial Differences in Outcomes Demand Greater Vigilance

The following excerpt comes from the July 17, 2017, article by Ada Stewart on the Leader Voices Blog: A Forum for AAFP Leaders and Members.


My father didn’t have a documented history of heart disease. He was never diagnosed as having hypertension, diabetes or other conditions that would have alerted us to the fact that he was at risk. So it was a shock — and one of the events that led me to the field of medicine — when he died of a massive heart attack at age 59.  

Unfortunately, his story isn’t unique.

It’s well documented that blacks are more likely than whites to suffer from an array of health conditions, including asthma, diabetes, hypertension and lung cancer. However, a study published this month in Circulation makes it clear just how different the outcomes are for black men compared with those for their white peers. Black men ages 45-64 (like my father) are twice as likely to die from a first heart attack.

My father lacked health insurance, so he rarely sought care and missed opportunities for discussions about risk factors and prevention, blood pressure and cholesterol screenings, as well as potentially life-saving treatment that may have resulted from such visits.

It’s a familiar story. One of the study’s authors said in an interview that “racial and institutional discrimination” and a lack of access to care are major factors in the wide difference in outcomes. In fact, researchers found that black patients actually have a lower risk for nonfatal cardiac events, but that lack of access to care means that too many black patients aren’t properly diagnosed with a heart condition until it’s too late.

Researchers said blacks have a higher burden of unfavorable social determinants of health,  and access to care is only one such factor. Others include limited access to nutritious food, social stressors, poor neighborhood safety and lack of recreational facilities.

Education and health literacy also are social determinants of health, and researchers said lack of patient awareness is a potential issue that should be considered regarding this issue. Although most patients likely would recognize that severe chest pain is a symptom of a heart attack, they might be less likely to recognize milder symptoms that could be cause to seek care.

So what can family physicians do? We can make sure our at-risk patients who do seek our care understand the symptoms of a heart attack and know when they need to seek treatment. We also can talk to them about exercise, nutrition, tobacco cessation and other prevention efforts, as well as the importance of follow-up when they are being treated for conditions such as hypertension and diabetes.

Read the full article.

Useful Resource: The Henry J. Kaiser Family Foundation

The Kaiser Family Foundation is a  national non-profit organization “focusing on national health issues, as well as the U.S. role in global health policy.” The organization’s programs consist of

Visit the Henry J. Kaiser Family Foundation website to learn more.