Social Determinants of Health

1. Social Determinants of Health

2. QUIZ • According to the National Academy of Medicine (aka IOM), what portion of the modifiable contributors to population health is attributable to medical clinical care? a. 65-75% b. 40-50% c. 25-35% d. 10-20%

3. Modifiable contributors to population health outcomes

4. Contribution of Public Health From 1900 – 1999, US life expectancy at birth increased from 47 years to 77 years. Experts believe 25 of those 30 years can be attributed to public health advances such as: antibiotics for infectious diseases vaccination programs for preventable disease sanitation and clean water programs contraception and family planning motor vehicle safety anti-smoking campaign But the impact of the direct care of physicians is limited.

5. Terminology: Social Determinants of Health • Societal forces—the set of influences and systems that shape the conditions of daily life • Social determinants of health- the conditions in which people are born, grow, live, learn, play, work and age • Health outcomes- measures of morbidity and mortality

6. SDH factors • Income • Employment • Housing • Education • Neighborhood Conditions • Political Power • Social Standing

7. Per capita health care spending USA is high

8. US Life Expectancy low compared to comparable countries

9. Maternal mortality rate in USA is much higher than comparable countries

10. SDH influenced by “upstream” societal forces • Political priorities and policies • Economic policies and inequities • Environmental policies • Social Service Funding • Life circumstances • Geography • Resources • Culture • Social structures and inequities • Difficult to Measure • Often temporally and spatially distant from ultimate health outcome

11. “Downstream” factors • Personal behavior and choices • Medical intervention • Relatively apparent • Temporally and spatially close to health outcome • Easy to measure Most medical research in the USA focuses on medical intervention, i.e. health as something we get at the doctor’s office.

12. SDH Example: Educational Attainment Braveman, P. Egerter, S and Williams D. Annu.Rev.Public Health 2011.32:381-398

13. SDH example: Housing • Heat • Electricity • Safety • Accessibility • Age of dwelling • Lead • Water supply • Contaminated wells • Toxic exposures • Pesticides • Radon

14. SDH example: Women veterans • Fastest growing cohort within the veteran community • Approximately 11% of the total veteran population by 2020 • Barriers to access to VA medical services • Lack of info on eligibility for VA services esp specific to women’s care • Lack of transportation to VA clinic, convenient appt, or childcare • Lack of women-only clinic, espimpt for veterans who have previously experienced threat or force of sex • Mental health stigma- more than half of women veterans indicate they have needed mental health care (depression, PTSD) • Prior sexual trauma- VA facilities have historically male-dominant culture VAMC April 2015

15. SDH Example: Racial disparities* ACOG CO #649* Editors note these data are subject to many limitations described in document.

16. SDH Example: Rural women • 22% of US women aged 18 or older • 80+% non-Hispanic white • Less than half live wi 30 minute drive of health care services • Decreased availability of trial of labor after Cesarean • Decreased availability of publicly funded contraception services • Lower rates than urban women of: • Screening for cervix CA • Screening for breast CA • Initiation prenatal care first trimester • Higher rates than urban women of: • MVA • Stroke • Suicide • Cigarette smoking • Obesity • Cervical cancer incidence • Pregnancy complications ACOG CO #586

17. SDH Example: LGBTQ • 1.1% of women identify as lesbian • 3.5% of women identify as bisexual • Lesbians • Higher prevalence of obesity • Higher prevalence substance use • Stress from isolation, prejudice, stigmatization • May not be covered under partner’s health insurance • May not have access to fertility services • Transgender • Most insurance plans do not cover cost related to gender transition • Transgender individuals are disproportionately homeless • May be denied access to shelters or gender appropriate housing • May turn to exchange of sex for food, clothing, shelter • Increases risk of STI and victim of violence ACOG CO #512, 525

18. SDH Example: Disabled • Approximately 12% of US population is disabled • 4x as likely to report poor or fair health compared to the able • Higher rates obesity, lack of physical activity, smoking • Heightened risk of injury • 1.5x as likely to be victim of nonfatal violent crime • 2+x as likely to report rape or sexual assault, women more than men • May have gaps in insurance coverage • Public emergency plans often inadequate AJPH 2014

19. SDH Example: Immigrants Unauthorized immigrants Authorized immigrants 5 year waiting period after “green card” before Medicaid eligibility-remain uninsured Children’s Health Insurance Program Reauthorization Program Act (CHIPRA)-2009 allows states to apply to pregnant women or to children. Multiple states cover children Many states cover pregnant women • One half CA,TX,FL,NY • Women 47%, children 10% • Most live in poverty, low rates of insurance coverage • Later prenatal care, fewer visits, higher birth complications and higher neonatal morbidity • Increasing rate of cervical CA • “Emergency Medicaid” for childbirth www.medicaid.gov, ACOG CO #627

20. SDH Example: Violence Direct exposure Indirect exposure Community violence Increased risk of Anxiety Depression PTSD Aggressive behavior Sexual risk-taking Sleep disorders Smoking and substance use Diminished health-promoting social support and resources Social disorganization “Food deserts” • Child maltreatment • Intimate partner violence • 1 in 4 women during lifetime • Increased risk of LBW, PTB and neonatal death • School violence/bullying • 80% of students have witnessed a threat of violence at school • Work violence/bullying • Violence in communities RWJ 2011

21. Reflection Activity Think about your own patient population. Think about the patients you have seen in clinic over the last week. Think of the social determinants of health which are prominent in your patient population. Are you aware of resources or referrals available for your patients who may have food insecurity, unstable housing, or are at risk from domestic violence?

22. Screening your patients for SDH Review the SDH tool kit on the Health Leads website www.healthleadsusa.org. What questions would you use to develop a screening tool for the patients you see in your continuity clinic?

23. References • Braveman, P., Egerter, S. and Williams, D. ,The Social Determinants of Health: Coming of Age, Annu. Rev. Public Health 32: 381-398, 2011. • Department of Veterans Affairs, Study of Barriers for Women Veterans to VA Health Care, April 2015. • Marmot, M. and Allen, J., Social Determinants of Health Equity, Editorial, Am J Public Health, Supplement 4, Vol 104(54):S517-S519, Sept 2014. • Robert Wood Johnson Foundation, Violence, Social Disadvantage and Health, Exploring the Social Determinants of Health Series, Issue Brief #10. • Health Leads, Social Needs Screening Toolkit, July 2016. Available at www.healthleadsusa.org. • https://nam.edu/social-determinants-of-health-101-for-health-care-five-plus-five/ • ACOG Committee Opinion #649: Racial and Ethnic Disparities in OBGYN