2. Social Determinants of Health
2. Social Determinants of Health
Knowledge Objectives:
Learners will be able to describe:
1. Definition of health disparities and healthcare disparities, in the context of two moral frameworks - social justice and compassion.
2. Major classes of social determinants of health: race/ethnicity, socio-economic status, environment, behavioral factors, and health system characteristics.
3. Examples of negative health consequences of uninsured status.
Objective 1: Definition of health disparities and healthcare disparities, in the context of two moral frameworks – social justice and altruism/compassion.
Case 1
You are providing volunteer services with a mobile outreach clinic that provides blood pressure checks and diabetes screening for migrant farm workers. You note that, compared with people whom you usually see in your hospital-based clinic, there are many more hypertensive and diabetic patients who report that they do not have a regular primary care physician. Many more of those with high blood pressure or elevated blood sugar also report symptoms of heart disease and peripheral vascular disease.
In comparing the migrant workers with the hospital clinic patients, which of the following statements is correct regarding health disparities and health care disparities?
1. The increased burden of vascular disease is not considered a health disparity because the migrant workers have not been attending primary care visits.
2. The increased burden of vascular disease is not considered a health disparity because it is found in people with diabetes and high blood pressure.
3. The decreased identification of primary care is considered a health care disparity even if the migrant workers have chosen not to access a local primary care office.
4. Under the principles of social justice, health care disparity for the migrant workers can only be resolved if they are transported to the hospital clinic for their care.
Case 1 Answer
In comparing the migrant workers with the hospital clinic patients, which of the following statements is correct regarding health disparities and health care disparities?
1. The increased burden of vascular disease is not considered a health disparity because the migrant workers have not been attending primary care visits. Not Correct. Lack of primary care occurs for many social, environmental and behavioral reasons. Insufficient primary care is a common indicator of health care disparity that can also contribute to health disparity.
2. The increased burden of vascular disease is not considered a health disparity because it is found in people with diabetes and high blood pressure. Not Correct. Increased burden of disease and increased severity of disease sequelae are examples of health disparities experienced by disadvantaged populations.
3. The decreased identification of primary care is considered a health care disparity even if the migrant workers have chosen not to access a local primary care office. Choices are made for complex reasons, and may reflect disadvantages that contribute to disparity: perceptions of bias, lack of financial resources, lack of transportation, competing survival needs, and so on.
4. Under the principles of social justice, health care disparity for the migrant workers can only be resolved if they are transported to the hospital clinic for their care. Not Correct. Social justice is founded upon equitable, not necessarily equal, treatment of individuals. The hospital clinic may be an appropriate care setting for some populations, but other care models may also provide similar – or better – care for the health needs of the migrant worker population.
When a disadvantaged social group experiences worse health than a more advantaged social group, we call the health difference a health disparity[1]. The Institute of Medicine has defined a health disparity as a difference in health experienced by members of different groups that is not justifiable by the underlying health conditions or treatment preferences of patients[2]. Therefore, disparity connotes an unfair difference. Health disparities are potentially modifiable or avoidable, and are related to varying levels of social privilege, power, or status.
It is a troublesome fact that despite the relative affluence of the United States compared to other world nations, many U.S. citizens are medically disadvantaged due to socioeconomic status, sex, or race/ethnicity[3]. These disadvantaged groups experience health disparities, including disproportionate disease burden or behavioral risk factors that are otherwise modifiable. For example, even after controlling for income, insurance status, disease severity, etc. there are persistent disparities by race/ethnicity for a number of diseases such as cancer, cardiovascular disease, HIV/AIDS, diabetes, mental illness, and routine treatments for common health problems[2]. In our case example, the increased burden of vascular disease in the migrant worker population can be considered a health disparity.
Health disparities are the result of many complex social, environmental and behavioral factors, but are also partly the result of healthcare disparities, such as the lack of adequate primary care experienced by our case example of migrant workers. Health care disparities reflect systematic differences in access to or quality of health care services between more and less privileged groups[1] and cannot be explained by differences in the need for care or by the preferences among the individuals in these groups. Minorities and low-income individuals suffer from healthcare disparities with less access to high quality care. Clinical providers must be aware that provider bias and stereotyping can contribute to healthcare disparities. Biases may be subtle and may manifest as different values or worldviews, communication difficulties, or mistrust. Such subtle biases can result in disparities of patient engagement with the traditional health system, exacerbating health care disparities.
Because disparities in health and healthcare are related to social inequalities, they raise questions regarding theories of social justice. Social justice relates to equitable societal treatment of all persons, irrespective of their ethnic origin, gender, race, religion, income, wealth, etc. Importantly, equitable treatment need not always mean equal treatment, as population needs differ. For example, an equitable and just society may provide women but not men with routine screening for breast cancer, while providing men but not women with access to testicular cancer treatment. Fundamentally, a just society is structured to provide all citizens with equal liberties and rights, such that all citizens are treated with dignity. Social justice does not preclude all inequalities; it precludes unethical inequalities[4]. Discussions of social justice, healthcare disparities, and health disparities are frequently intertwined in bioethics literature and in literature regarding public health.
Another bioethical principal, compassion, relates more explicitly to the medical profession and to individual providers responding to disparities of health and healthcare. Compassion is a recognized foundation within ethical codes for physicians. The American Medical Association’s Code of Medical Ethics indeed incorporates compassion into it’s very first principle: “I. A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.”[5] Compassionate care is also a fundamental expectation for competency in patient care, as endorsed by the Accreditation Council for Graduate Medical Education among other health professions institutions. Within this bioethical framework, clinicians have a responsibility to provide compassionate care that recognizes and responds to inequities of health and healthcare.
Key points:
· A health disparity is a potentially modifiable or avoidable difference in health that is not justifiable by the underlying health conditions or treatment preferences of patients.
· Health disparities are related to varying levels of social privilege, power, or status.
· A healthcare disparity is a systematic difference in access to or quality of healthcare services between more and less privileged groups.
· Health disparities and healthcare disparities raise concerns regarding social justice, which relates to equitable treatment of persons.
· Clinicians are expected to treat all patients with compassion and respect, and this ethical expectation is one reason for clinicians to recognize and address disparities in health and healthcare.
Objective 2: Major classes of social determinants of health: race/ethnicity, socio-economic status, environment, behavioral factors, and health system characteristics.
Case 2
You are caring for a homeless HIV positive man. He is uninsured and depends upon a pharmaceutical program for monthly medication supplies. His CD4 count is 42 and his viral load has recently been increasing. He complains of a 20 lb. unintended weight loss over the past few months. He reports that he is eating a couple of meals most days, but sometimes goes a day without a meal.
Which statement best describes the determinants of his health?
1. His viral load and CD4 count are the strongest determinants of his health.
2. His CD4 count is the strongest determinant of his health but his homelessness also contributes to his health status.
3. His viral load and his insufficient food intake are equally strong determinants of his health.
4. His insufficient food and homeless status are stronger determinants of his health than his viral load or CD4 count.
Case 2 Answer
Which statement best describes the determinants of his health?
1. His viral load and CD4 count are the strongest determinants of his health.
2. His CD4 count is the strongest determinant of his health but his homelessness also contributes to his health status.
3. His viral load and his insufficient food intake are equally strong determinants of his health.
4. His insufficient food and homeless status are stronger determinants of his health than his viral load or CD4 count. Social determinants of health can be stronger than biomedical determinants, as in this person with environmental barriers to subsistence food and shelter.
Disparities in health and healthcare are related to complex social factors. These factors are known as social determinants of health. Major classes of social determinants of health include: race/ethnicity, socioeconomic status, environment, health-related behaviors, and health system characteristics.
Minority ethnicity is strongly associated with negative health disparity and negative health care disparity, even after controlling for factors such as insurance status and income[2]. According to the 2012 National Healthcare Disparities Report produced by the Agency for Healthcare Research and Quality, blacks received worse care than whites for 41% of monitored healthcare quality measures, and Hispanics received worse care than non-Hispanic whites for 36% of quality measures.[6] For example, in measuring the quality of care for persons with HIV, ethnic minorities experience poorer care, increased morbidity, and poorer HIV survival rates, even after controlling for income, insurance, health status and severity of disease [2].
Socioeconomic status (SES) shows a particularly strong association with health status and health disparity, as persons with lesser education, lesser employment stability, and lower income experience worse health than persons with higher SES. The gap between high and low income patients is particularly stark, with poor people having received worse quality care than high income persons in 47% of quality measures, and worse access to care than high income people for 89% of those measures.[6] It is important to note that the relationship between SES and health does not simply demonstrate a lower/upper income divide; rather, the correlation carries across the gradation of income and education levels, such that middle SES persons self-report health at lower perceived level than the most affluent/educated[7].
Race/ethnicity and SES are closely related to a third social determinant of health: environment. Environmental determinants of health include available subsistence needs such as housing, food, hygiene support, and clothing. Ethnic minorities and persons of lower SES are disproportionately likely to be located in neighborhood environments with poor access to healthcare, limited safe options for exercise, poor air quality and toxin exposure, and insufficient access to healthy food[7]. Environmental barriers are particularly apparent for the homeless population, as struggles to meet basic subsistence needs can preclude adherence with biomedical treatment plans. In the HIV positive homeless population, for example, unmet subsistence needs were more highly correlated with health status than CD4 count or viral load.[8]
Environmental attributes may, in turn, influence another social determinant of health: behavior. Health behaviors comprise a wide range of personal and community health-related behaviors that are influenced by traditions, opportunities, education, environmental resources, and personal resources. These behaviors include diet, physical activity, educational attainment, tobacco and substance usage, health beliefs and traditions, and health literacy.
Clinical providers have some direct influence over another key social determinant of health: the health system. Health system structure affects access to care and therefore quality of care. Fundamentally, barriers to access can reduce appropriate utilization, resulting in missed opportunities for disease prevention and management. Health workforce distribution is of particular concern for disadvantaged populations residing in areas with health professional shortages. Health insurance structure limitations can exacerbate such access barriers, and individual clinical practices may enact further barriers through preferred payment criteria. More subtle health system characteristics affecting health include lack of diversity in the clinical workforce, the traditional work-week office schedule, and the poorly portable nature of the average patient medical record.
Key points:
· Social determinants of health contribute to health disparities and health care disparities
· Race/ethnicity is a recognized social determinant of health.
· Socioeconomic status is a strong social determinant of health. Socioeconomic status includes income, education, and employment.
· Environment [e.g. physical, social, community, food security] and behavioral factors [e.g. health behaviors, health beliefs, health literacy] are independent yet closely related social determinants of health.
· Health system characteristics [e.g., health insurance, accessibility, provider characteristics] are social determinants of health for which health care providers have special influence.
Objective 3: Examples of negative health consequences of uninsured status.
Case 3
You are working at a free care clinic sponsored by the local synagogue. Your first patient is a 59-year-old man who is working part time for a local hardware store. He reports nagging low abdominal pain that has been worsening over the past 6 months and occasional rectal bleeding. He is single and has no children. He is uninsured and reports that he has not seen a doctor in years. He has never had a colonoscopy.
According to the Kaiser Commission, approximately 4% of adults with private health insurance have foregone care in a prior year due to cost. What percentage of adults without health insurance has foregone care in a prior year due to cost?