UNE SDoHM - SDOHM Topics

Throughout Social Determinants of Health Month, we hope to discuss some of the conditions that impact health, as well as the social, political, and economic systems that perpetuate them.

Over the next month, SDOHM will explore examples of social determinants of health and how healthcare professionals make changes that will positively impact their community and patient populations.

SDoHM 2023 Educational Posts:

Social Determinants of Health

According to Healthy People 2030, the initiative put forth by the US Department of Health and Human Services, “social determinants of health are the conditions in the environment in which people are born, live, learn, work, play, worship, and age,” that have an impact on their individual health. These factors are grouped into conditions of: economic stability, healthcare access and quality, education access and quality, social and community context, and neighborhood and built environment.

As future providers, it is important that we understand the conditions that affect our patients’ health, disease, and well-being. Throughout Social Determinants of Health Month, we hope to explore some of the conditions that negatively impact health, as well as the social, political, and economic systems that perpetuate them.

Please visit the CDC website at CDC Social Determinants of Health and Healthy People 2030 at Healthy People 2030 for more information about social determinants of health.

Access to Healthcare

Access to quality healthcare is greatly disproportionate amongst individuals in the United States. Those who are impoverished, who have disabilities, or face racism and discrimination have less access to healthcare and overall lower quality healthcare.

There are many barriers to accessing healthcare – some which may be based in physical obstacles like necessary transport to and from medical appointments, the location of those appointments, the accessibility of office (like ramps, elevators, stairs, or doorways). Additionally, barriers to communication, like differences in language or mental ability can breakdown equitable access or quality of healthcare. Other barriers are based in social systems, including racism, discrimination, and implicit bias or political/economic systems like access to medical insurance or the financial ability to pay for care.

It is important for future providers to understand the difficulty or ease with which a patient presents to their office. It is equally as important that providers acknowledge the barriers to healthcare might affect their patients’ health and the systemic causes of these barriers.

More information on Access to Healthcare can be found at: HealthyPeople.Cov- Healthcare Access and Quality

Gender Disparity

Women face inequities in physical and mental health based on their gender. Structural social stratification, power dynamics, and status relative to men all impact a woman’s ability to access healthcare and the quality of care she receives. Furthermore, women are underrepresented in medical research and as people with positions of power within medicine. Still, women have different economic and social consequences of illness, they have different health needs, including reproductive needs, and different exposures to health-impacting factors.

The Women and Gender Equity Knowledge Network studied these gendered differences and recommended 7 different approaches to bridging the gap of inequality between genders. The report also recommends that all facets of healthcare and society should take action to end gender disparity in healthcare.

More information can be found at: WHO Social Determinants of Health - Women Gender

Discrimination Against LGBTQIA+ Individuals

Homophobia, oppression, and discrimination play significant roles in access and quality of healthcare for LGBTQIA+ individuals. According to the CDC, “Members of the LGBT community are at increased risk for a number of health threats when compared to their heterosexual peers. Differences in sexual behavior account for some of these disparities, but others are associated with social and structural inequities, such as the stigma and discrimination that LGBT populations experience,” (1).

In the US, LGBTQIA+ individuals face legal discrimination in access to health insurance, employment, housing, marriage, adoption, and retirement; are not protected from anti-bullying laws; and lack social programming specific to their community. In fact, the Office of Disease Prevention and Health Promotion, “discrimination against LGBT persons has been associated with high rates of psychiatric disorders, substance abuse, and suicide,” (2).

In addition to knowledge of preventative health measures and cultural competence, physicians should recognize that many of the health disparities that affect LGBTQIA+ are systemic - and a consequence of social stigma, discrimination, and denial of LGBTQIA+ civil and human rights (2).

For more information, please visit HealthyPeople.gov and the CDC website.

Sources:

(1) https://www.cdc.gov/lgbthealth/about.htm(2) https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health(3) https://academic.oup.com/her/article/15/1/97/775710(4) https://medicine.yale.edu/news-article/9458/(5)https://journals.lww.com/aidsonline/Fulltext/2015/06190/Hidden_from_health___structural_stigma,_sexual.15.aspx

Racial Discrimination in Healthcare

“Identifying and implementing effective strategies to eliminate racial inequities in health status and medical care should be made a national priority.” - Williams et al, Understanding and Addressing Racial Disparities in Health Care

Racial disparity in healthcare has been shown independent of socioeconomic status - indicating that racism in healthcare alone impacts the individual health outcomes of minority racial/ethnic groups (1). Racism in healthcare works at different levels - including structural, in which racism is inherent to the social institution of medicine; cultural, or within the cultural norms of medicine including bias and stereotyping; and individual, or at personal level, where individuals experience explicit discrimination or racism within the healthcare setting (1).

It is important for providers to understand these mechanisms of racism in healthcare - and understand that they have the power to help dismantle it. Public health researchers recommend that healthcare workers learn, understand, and accept the legacies of racism and oppression in the United States’ history and in the development of US healthcare. Then, they recommend providers understand how racism shapes the narrative of disparities in healthcare - one that recognizes that disparities are largely based in systems of oppression rather than inherent or biological differences between race/ethnic groups. Third, they recommend that providers define and name racism when it is evident in medicine. Lastly, they call for a cultural shift in healthcare; one that diversifies medicine, allows for more community-based interventions and research, and ensures representation of oppressed and under-resourced individuals in power within medicine (2).

Resources:(1) Racism and Health: Evidence and Needed Research(2) Structural Racism and Supporting Black Lives — The Role of Health Professionals(3) Understanding and Addressing Racial Disparities in Health Care

Mental Health Prevalence, Stigma, and Access to Care

Mental health, and the stigma that surrounds it, is a major public health concern. In 2017, the National Institute of Mental Health found that 1 in 5 adults live with mental illness. The public stigma of mental illness in the U.S. continues to be widespread among children and adults and continuously prevents individuals from seeking treatment or care for mental illness.

“Public stigma also results in discrimination, reduced autonomy and self-efficacy, and segregation. For instance, individuals with mental illness are more likely to experience housing and employment discrimination and homelessness compared to people without mental illness. Furthermore, stigmatizing beliefs about the competency of individuals with mental illness compromise individuals’ financial autonomy, restrict opportunities, and may lead to coercive treatment and reduced independence (e.g., through institutionalization),” (1).

It is important for future providers to understand the prevalence, stigma, and access to care that patients with mental illness experience. It is also crucial for providers to educate themselves about the systems that have created and promote these barriers (like social stigmatization of mental disorders, the criminalization of mental illness, and mass incarceration), so that we can better understand how to remedy them.

(1) Public Stigma of Mental Illness in the United States: A Systematic Literature ReviewThe National Institute of Mental Health (NIMH)

Adverse Childhood Experiences

ACEs, or Adverse Childhood Experiences, are potentially traumatic events that occur in childhood. ACEs may include violence, abuse, or neglect that a child experiences themselves or that they witness, such as a family member or caregiver who is violent; a family or caregiver with a mental illness, including substance use disorders; a family member who is incarcerated; or living in environment that undermines the child sense of safety, stability, or ability to bond with their caregivers.

According to the CDC, “ACEs are linked to chronic health problems, mental illness, and substance misuse in adulthood. ACEs can also negatively impact education and job opportunities,” (1). ACEs are also very common, affecting about 61% of adults, and 1 in 6 adults have four or more types of ACEs.

ACEs and related conditions, such as living in under-resourced or segregated communities, food insecurity, or frequently moving, can cause what the CDC calls toxic stress, or extended or prolonged stress, which can change brain development and have lasting effects on the child’s psyche. Children who live in conditions of toxic stress have difficulty forming healthy relationships, may have difficulty with attention, decision making, learning, and coping with stress. Toxic stress in childhood can affect an adult’s ability to hold a stable job and can affect their financial security, occupation, and mental health later in life. ACEs are also linked to increased risk of injury, STIs, mother and child health problems, and chronic diseases like diabetes, cancer, heart disease and suicide.

ACEs are associated with systems of oppression – women and people of minority groups are more likely to have one more ACE. Further, systemic racism, racial or ethnic segregation, under-resourcing, food deserts, and systems perpetuating poverty like disparity in education access and economic stability, can lead to toxic stress and experiencing ACEs.

It is part of a provider’s responsibility to understand how ACEs may affect our patient populations and also to serve as advocates in the community to end social systems that perpetuate conditions that lead to ACEs. Providers can help recognize abuse, can offer patient-centered services, can learn trauma-informed care, and can be informed of outside resources, including how patients can get help from other community-based or social services.

For more information, please go to the CDC ACEs website.

Resources:(1) https://www.cdc.gov/violenceprevention/aces/fastfact.html

Implicit Bias in Medicine

Implicit Bias are the attitudes or stereotypes that unconsciously affect our understanding, actions, and decision. These subconscious thoughts are involuntary and not under our intentional control and maintain attitudes about other people based on certain characteristics including race, ethnicity, age, and appearance (1). In fact, research shows that implicit biases do not necessarily align with our declared beliefs or reflect what we explicitly say or do. Even so, everyone has implicit biases (1).

It is also important to note that while racism can be structural or explicit - and on its own, is a root cause of health and living disparities - implicit bias also contributes to and in synergy with racism to influence opportunity and access leading to differences in housing, education, health, and social justice (1).

“Well, no doctors are racist,” one may think. And hopefully that is true. However, one study found that healthcare providers have the same levels of implicit bias as the general population - and that these biases are likely to influence diagnosis and treatment decisions as well as level care (2). Another study went further, stating, “Most health care providers appear to have implicit bias in terms of positive attitudes toward whites and negative attitudes toward people of color,” which lead to health disparities in Black, Hispanic, Latino/Latina, and dark-skinned groups when compared to white people (3).

Although implicit bias is unconscious, it can be consciously reworked. In other words, our implicit biases can be gradually unlearned (1).

Recognition of implicit bias and its impact in healthcare and social justice is one of the first steps in curtailing its negative effects. Further, promoting self-awareness and accepting the pervasiveness of implicit bias within our own attitudes can help in dismantling it - and let us more easily work with ourselves to lessen our implicit bias. Discussion groups, implicit bias training, and tool sets can also help to minimize bias (4).

(1) Understanding Implicit Bias - Kirwan Institute for the Study of Race and Ethnicity(2) Implicit bias in healthcare professionals: a systematic review(3)Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review(4) Strategies to Address Unconscious Bias - University of California San Francisco

Climate Change, Health, and Social Justice: Defining Environmental Racism

Extreme heat, drought, wildfires, air quality, allergens, rising sea levels, increased intensity of storms, increased flooding, food/nutrition insecurity are all worsening because of climate change. Further, studies have shown that these environmental conditions disproportionally affect people of color or people living below the poverty line - and contribute to widening health disparity and social inequity. Many of these disparities are also related to racial and ethnic segregation, differences in health access, and other political systems that perpetuate social inequality (1).

Statistically:

African Americans are more likely to live in neighborhoods with few trees and more heat-trapping pavement. The rate of heat related deaths of African Americans is 150 to 200 percent greater than that for non-Hispanic whites.
Native American and Alaska Native communities lack access to clean, potable drinking water at higher rates than others; Native American and Alaska Native diets, including hunting and fishing practices, are at risk due to climate change.
Nearly one in two Latinos live in counties with poor air quality; Latino children are twice as likely to die from asthma as non-Latino whites; and Latino children living in areas with high levels of air pollution have a heightened risk of developing type 2 diabetes.
A higher proportion of Pacific Islanders in the US live in counties with a pollution exceeding the federal air quality standards when compared with Asians and other racial groups.

(all statistics were taken from the American Public Health Association)

For more information, please visit the American Public Health Association webpage. Resources:
(1) American Public Health Association - Climate Change, Health, and Equity(2) Environmental Racism Has Left Black Communities Especially Vulnerable to COVID-19(3) Environmental Racism (Lumen Learning- Sociology)(4) The Atlantic - Trump's EPA Concludes Environmental Racism Is Real

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