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.

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.

The Health Care System Is Leaving The Southern Black Belt Behind

The following excerpt comes from an article by Anna Maria Barry-Jester on FiveThrityEight.

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Sitting outside of a Starbucks on the corner of a strip mall in Tuscaloosa late last year, Dr. Remona Peterson described her hometown of Thomaston, Alabama, population 400. “Everybody loves our grocery store. That’s, like, our pride,” she said with a laugh. She was in Tuscaloosa, Alabama’s fifth-largest city, finishing her medical residency when Dave’s Market opened in an old Thomaston high school gym last year. Peterson said it became the only place to buy groceries for miles in any direction, and it was one of the few changes to the town she can remember from the last three decades.

Peterson wants to be a part of positive change in the region, which is why she’s back after a circuitous journey through medical school. She was valedictorian of her 29-person high school class and graduated summa cum laude from Tuskegee University, where she earned a full scholarship and the university’s distinguished scholars award. She went on to medical school and got the residency in Tuscaloosa. It was her first choice; she felt that the University of Alabama would best prepare her for her long-term goal: to add her name to the short list of African-American doctors working in the Alabama Black Belt who were also born and raised there.

The Black Belt refers to a stretch of land in the U.S. South whose fertile soil drew white colonists and plantation owners centuries ago. After hundreds of thousands of people were forced there as slaves, the region became the center of rural, black America. Today, the name describes predominantly rural counties where a large share of the population is African-American. The area is one of the most persistently poor in the country, and residents have some of the most limited economic prospects. Life expectancies are among the shortest in the U.S., and poor health outcomes are common. This article is part of a series examining these disparities.

The disparities partly stem from a lack of access to care — but access is a complicated notion. Early in the Republican efforts to repeal and replace the Affordable Care Act, the GOP homed in on the idea, saying the party wanted to guarantee “access to health care” for everyone. But the ongoing national policy conversation has hinged on insurance coverage, the main issue tackled by both the Affordable Care Act and the current GOP efforts. Yes, measuring who’s insured illuminates one way by which people have access to the health care system, but it’s only part of the picture. The term “access to health care” has a standardized federal definition that’s much broader: “the timely use of personal health services to achieve the best health outcomes.” And there’s a list of metrics to measure it. Researchers consider structural barriers, such as distance to a hospital or how many health professionals work in an area, to be important. As are metrics that gauge whether a patient can find a health care provider that she trusts and can communicate with well enough to get the services she needs.

Southern states have health outcomes that are among the worst in the U.S. overall, and they have some of the largest in-state health disparities, according to County Health Rankings, an annual report from the Robert Wood Johnson Foundation and the University of Wisconsin. Transportation options are limited, and health care worker shortages are routine. In Alabama, Black Belt counties have fewer primary care physicians, dentists and mental health providers per resident than other counties. They also tend to have the highest rates of uninsured people. Poverty rates, which are associated with limited access to care, are also high.

Read the full article.

Defining Health Equity

In May 2017, the Robert Wood Johnson Foundation released a report titled “What is Health Equity? And What Difference Does a Definition Make?” with the purpose “stimulate discussion and promote greater consensus about the meaning of health equity and the implications for action within the Culture of Health Action Framework.” In doing so, the authors identify crucial elements to guide effective action. The way we define health equity is important as it reveals the values and beliefs that are used to make decisions, justify actions, and promote policies.

The document provides a general definition of health equity:

Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.

In pointing out the importance of measurement for accountability, the authors added the following:

For the purposes of measurement, health equity means reducing and ultimately eliminating disparities in health and its determinants that adversely affect excluded or marginalized groups.

With those definitions as a starting point the report offers :

  • Series of definitions for different audiences
  • Explanation of key concepts
  • Criteria for defining health equity
  • Discussion of steps to advancing health equity
  • Guiding principles
  • Glossary of terms often arising in health equity discussions

See a summary of the report.

Download the report, Braveman P, Arkin E, Orleans T, Proctor D, and Plough A. What Is Health Equity? And What Difference Does a Definition Make? Princeton, NJ: Robert Wood Johnson Foundation, 2017.

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Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults

The following comes from a Commonwealth Fund summary of research first published in Health Affairs Web.


Synopsis
Low-income adults in Arkansas and Kentucky who obtained coverage under the Affordable Care Act’s Medicaid expansion had better access to primary care and preventive health services, lower out-of-pocket costs, improved medication compliance, and improved self-reported health status than did low-income adults in Texas, which did not expand Medicaid. Among adults with chronic conditions, ACA coverage was associated with better disease management and medication compliance and a significant increase in self-reported health status.

The Issue
Congress is currently weighing the future of the Affordable Care Act. Since becoming law, the ACA has helped more than 20 million Americans enroll in health insurance coverage, and national studies have noted improvements in coverage, consumer satisfaction, and access to care. In this Commonwealth Fund–supported study, researchers compared Kentucky, which expanded Medicaid as prescribed by the ACA; Arkansas, which obtained a waiver to use federal Medicaid funds available through the ACA to purchase private marketplace insurance for low-income adults; and Texas, which did not expand Medicaid coverage. Looking at these three states, the authors assessed ongoing changes in health care use and self-reported health among low-income adults, including those with chronic conditions, after three full years of the ACA’s coverage expansions.

Key Findings

  • By the end of 2016, the uninsured rate in Arkansas and Kentucky—the two expansion states—had dropped by more than 20 percentage points compared to Texas, the nonexpansion state. In 2016, the uninsured rate was 7.4 percent in Kentucky, 11.7 percent in Arkansas, and 28.2 percent in Texas.
  • Low-income adults in Kentucky and Arkansas who gained coverage experienced a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket costs, and a 23-point increase in the share of those who reported they were in “excellent” health.
  • Results were similarly positive for people with chronic illnesses who gained coverage because of the ACA. Low-income patients with diabetes, heart disease, hypertension, and stroke who gained coverage were 56 points more likely to report having regular care for their condition than were chronically ill adults in Texas, 51 points less likely than those in Texas to skip medications because of the cost, and 20 points more likely to report being in excellent health.

See the full summary.
See the original article.

 

‘Connectivity’ as the Key to Healthy Communities

The following excerpt originally appeared in in an article by Shannon Firth in MedPage Today  on May 11, 2017 summarizing a panel discussion that had taken place on May 9, 2017.


Keeping people connected to resources necessary to maintain good health — not least of which is other people — is a vital but often neglected factor in modern healthcare, policy experts and scholars said here Tuesday.

Transportation is an “underappreciated” health problem, said Dayna Bowen Matthew, JD, a nonresident senior fellow at the Brookings Center for Health Policy, at a panel discussion hosted by the Brookings Institution on Tuesday.

She noted that interstate highways aren’t always a means of connecting people to each other and to resources: in cities, they create barriers as well.

A grid of superhighways can mean a person living in a city’s southeast quadrant must take two buses and time off from work to reach a well-intentioned “food solution” in the northwest quadrant.

“That community’s not connected,” said Bowen Matthew, who is also a professor at University of Colorado Law School and the Colorado School of Public Health, and author of Just Medicine: A Cure for Racial Inequality in American Health Care.

Those families across town from farmers’ markets and other fresh food resources will rely on the more accessible options instead, which may be fast food.

Tuesday’s discussion focused heavily on the social determinants of health — nonmedical factors that greatly influence a population’s health such as transportation, housing, access to food — but one thing unites these influences: connectivity.

Social Networks are Key

The National Health Service in England has a “district nurse,” an individual responsible for keeping watch over certain neighborhoods, explained, Stuart Butler, PhD, a senior fellow in economics for the Brookings Institution.

Growing up in England, Butler’s mother ran a post office, which was a key source of “intel” for the district nurse on the community residents’ well-being. If Butler’s mother hadn’t seen someone for a few days, the nurse would learn of this and ride her bicycle to the person’s home.

Decades later and an ocean away, Matt Brown, RN, a geriatric nurse navigator at Sibley Memorial Hospital in Washington, learned quickly about the importance of follow-up phone calls to ensure smooth transitions back to the community.

During his first such call as part of a senior-focused transition project, he spoke to a patient who had just returned home after being hospitalized for pneumonia.

In the course of the phone call, the patient reluctantly admitted he had fallen and couldn’t get up off the floor of his home. Brown convinced him to call 911, rather than wait for the patient’s wife to come home. When the ambulance arrived, Brown spoke with the emergency medical technicians to confirm his patient was okay.

To further reduce the risk of injuries, the Sibley Innovation Hub has offered a short training course focused on transitions after certain surgeries, which they are now supplementing with animated patient education videos.

Read the full article.

How med student loan burdens can deepen health disparities

The following article by Caleb Zimmerschied originally appeared on AMA Wire on April 27, 2017.


The high loan burden associated with medical school can discourage students from underrepresented minority groups or lower-income families from pursuing a career as a physician. This creates a ripple effect of widening health care disparities that disproportionately affect the accessibility of primary care physicians in underserved areas.

Adjusted for inflation, the average medical student graduated in 2014 with a loan burden 3.5 times greater than a medical student in 1978. By 2014, the average loan burden was over $170,000.

Higher interest rates and unsubsidized loans for graduate students mean that they pay off more per dollar owed than undergraduate students. The Association of American Medical Colleges (AAMC) estimates that, accounting for interest under the Pay As You Earn repayment program, a student with $180,000 in loan burdens could pay almost $380,000 in total repayment. During a three-year residency, the AAMC estimates that total repayment to reach nearly $450,000. This amount increases further if a student pursues a specialty care field.

Those kinds of figures may be enough to intimidate any bright student considering a career in medicine. But students in ethnic and racial minority groups that are underrepresented in medicine, and those from lower-income families, can be particularly daunted by the prospect of six-figure loan burdens. According to the most recent AAMC report, 18.2 percent of black high-school sophomores said they aspired to apply to medical school, but only 6.7 percent actually applied. For Hispanic high-school sophomores, 24.4 percent said they wanted to go to medical school but only 6.8 percent applied.

According to 2014 AAMC data, while 13 percent of the U.S. population was black, they only made up 4.1 percent of the physician workforce. Hispanics accounted for 18 percent of Americans, but only 4.4 percent of the physician workforce. This in turn likely contributes to the lack of physicians making direct efforts to serve these communities. According to research published in JAMA, despite making up less than 30 percent of the physician workforce in 2013, physicians from underserved groups are significantly more likely to see nonwhite patients, and “nonwhite physicians cared for 53.5 percent of minority and 70.4 percent of non-English-speaking patients.”

Additionally, the cost of medical school likely deters applicants from lower-income rural communities as well. This could contribute to the fact that while 20 percent of Americans live in rural areas, only 10 percent of physicians practice where people in rural communities can access them. With a shortage of about 4,000 primary care physicians, 77 percent of rural U.S. counties are designated as health professional shortage areas.

Read full article

Because Social Science Is Necessary to Achieve Health Equity

The following article by Courtney Ferrell Aklin, Ph.D.(National Institute on Minority Health and Health Disparities (NIMHD) and Eliseo J. Pérez-Stable, M.D. (National Institute on Minority Health and Health Disparities (NIMHD), National Institutes of Health (NIH)) first appeared on the Why Social Science Blog? on April 25, 2017.


Living in an America in which all populations have an equal opportunity to live long, healthy, and productive lives is the vision of the National Institute on Minority Health and Health Disparities. As we bring National Minority Health Month to a close, it is important to remember that not all groups have obtained health equity. Racial and ethnic minorities, rural residents, people with disadvantaged socioeconomic resources and sexual and gender minorities carry a disproportionate burden of illness and disease. The search to determine the best way to reduce health disparities and to achieve health equity remains challenging for all of us.

The potential to live longer and healthier lives is greater than ever before with the emergence of medical and technical advances in healthcare and the adoption of healthier lifestyles. Despite these advances, health disparities continue to persist. A health disparity, defined as a health difference that adversely affects disadvantaged populations, based on one or more health outcomes, results from a series of complex and interrelated factors. To truly reduce and ultimately eliminate health disparities a framework must be applied that can address the multifaceted underlying causes of the disparity.

The social sciences have provided the very frameworks necessary for understanding the complexity of health disparities. Health, which is at the center of health disparities, is a combination of interactions among biological pathways, individual behavior, social interactions, physical or built environment, and the intersections with the health care system. Research to date shows that the development and maintenance of disease cannot be explained solely by genes and biological mechanisms. Behavioral and social factors are just as crucial to understanding the trajectory of health disparities as those contributed by biology. Important research questions such as adherence to treatment regimens, patient and clinician racial/ethnicity or gender match and its effects on health outcomes, and the interaction of chronic stress and health behaviors in development of disease are all derived out of social science theory.

The examination of where we work, live, and play, also known as the social determinants of health (SDOH) has taken a prominent role as a contributor to differences in health outcomes for health disparity populations. SDOH sit at the intersection of where social science theory and research methodology are applied to the practice of public health. Given the public health concern that continues to arise as health disparities persist, despite a myriad of targeted interventions to address them, NIMHD is committed to ensuring that all factors contributing to the etiology of health disparities are recognized.

Read the full article.

Medicaid Helps Schools Help Children

From the report by Jessica Schubel on the Center on Budget and Policy Priorities website:

Medicaid provides affordable and comprehensive health coverage to over 30 million children, improving their health and their families’ financial well-being.[1] In addition to the immediate health and financial benefits that Medicaid provides, children covered by Medicaid experience long-term health and economic gains as adults.[2] Many children receive Medicaid-covered health care not only at the doctor’s office, but also often at school.

For students with disabilities, schools must provide medical services that are necessary for them to get an education as part of their special education plans, and Medicaid pays for these services for eligible children. And Medicaid’s role in schools goes beyond special education, as it also pays for health services that all children need, such as vision and dental screenings, when they are provided in schools to Medicaid-eligible children. Schools can also help enroll eligible but unenrolled children in Medicaid or the Children’s Health Insurance Program (CHIP), and connect them to other health care services and providers. Medicaid also helps schools by reducing special education and other healthcare-related costs, freeing up funding in state and school budgets to help advance other education initiatives.

Read the full report to learn more about

  • Leveraging Medicaid for special education
  • Helping kids stay healthy and succeed academically
  • Connecting kids to coverage

Lancet series puts spotlight on health inequity in the U.S.

From the article by Paige Minemyer on FierceHealthcare:

Societal issues in the U.S., including systemic racism, poverty and mass incarceration, contribute to health inequity, a new series of studies has found.

The Lancet released a five-part look at health inequity in the U.S., titled the “United States of Health,” and researchers found that institutional racism, the increasing income gap and high rates of incarceration are all factors that make it harder for minorities and the poor to access healthcare. And the healthcare system, as it is financially structured today, only makes this problem worse, the researchers concluded.

…Poor Americans have made limited gains in life expectancy over the past 15 years, researchers found. Since 2001, the poorest 5% have not seen their survival rates increase at all, while while middle- and high-income people have seen their life expectancy increase by two years. The richest 1% of Americans live between 10 and 15 years longer than those who are among the poorest 1%.

Economic insecurity is a key factor in some of today’s biggest public health crises, including the opioid epidemic and increasing rates of obesity, study author Jacob Bor, Sc.D., assistant professor at the Boston University School of Public Health, said in announcement. But despite their increasing health concerns, it is becoming increasingly hard for Americans in poverty to pay for healthcare, creating a “health-poverty trap,” Bor said.

Poor Americans are also the most likely to be uninsured. Though the Affordable Care Act has made strides toward decreasing the number of people without insurance, a lack of options in ACA exchanges, particularly in states that did not expand Medicaid, leaves many poorer people in the U.S. with few avenues to get health insurance, researchers found. In 2015, for instance, about a quarter of poor Americans were uninsured, compared with just 7.6% of people with middle or high incomes.

Minority groups are also hit hard by societal barriers that lead to health inequity, and research reflects poorer outcomes—for instance, infant mortality rates for black populations are twice those for white ones, according to the study. Structural racism relegates many black Americans to neighborhoods with poor housing options, high rates of crime and air pollution. These neighborhoods may also be neglected by public health officials, worsening the problems, researchers found.

Read the full article.