understanding the social determinants of health: a …

Medical College of Wisconsin CONFIDENTIAL. Do not share.

Leonard E. Egede, MD, MSProfessor of Medicine & Eminent ScholarChief, Division of General Internal MedicineDirector, Center for Advancing Population ScienceMedical College of Wisconsin, Milwaukee, Wisconsin, USA

UNDERSTANDING THE SOCIAL DETERMINANTS OF HEALTH: A NEW ERA FOR HEALTH CARE PROFESSIONALS

ADA’s 67th Advanced Postgraduate CourseFebruary 1, 2020


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Presenter Disclosures• No conflict of interest


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Learning Objectives• Identify and describe social determinant of health• Articulate the impact of social determinants of health on

chronic disease outcomes• Understand the intersection of social determinant of health

with the health care system • Identify effective interventions to address social

determinants in individuals with chronic disease


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Outline• Overview of social determinants of health• Overview of definitions and terminologies• Evidence for impact of social determinants of health on

chronic disease outcomes• Screening tools • Summary of our research on social determinants in T2DM• Our funded grants as models for addressing social

determinants


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Case 1• AA male, age 61, lives alone• Presents with asthma, hypertension and type 2 diabetes • Patient was non-responsive, 911 called, and hospitalized for diabetes• Blood glucose reading was 559 • Patient reported not taking medications due to cost and stretches them out

by skipping doses• Cannot afford test strips • Does not have transportation, takes bus to clinic• Lives in inner-city and afraid to walk around neighborhood due to gun and

gang violence, so stays indoors• Unemployed with limited income and support network

OVERVIEW OF SOCIAL DETERMINANTS OF HEALTH

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Overview of Social Determinants of Health

• Social determinants of health (SDOH) include the social and economic conditions that influence health status.

• Resources to meet daily needs, • Access to educational, economic and job opportunities, • Availability of community-based resources and opportunities,

• Studies have found associations between SDOH and increased incidence, prevalence and burden of disease.

World Health Organization, 2018

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Overview of Social Determinants of Health

• SDOH are best illustrated through social gradient in disease, and differences in life expectancy across countries.

• Several models have been developed for understanding how to address health inequity on a global level by targeting SDOH through policy and action.

• Three main frameworks/models are used to achieve these goals.


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Overview of Social Determinants of HealthSocial Model of Health – Dahlgren & Whitehead, 1991

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Overview of Social Determinants of HealthHealthy People 2020

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Overview of Social Determinants of HealthWorld Health Organization Framework


SOCIAL DETERMINANTS TERMINOLOGY

Social Determinants Terminology

• Terminologies vary and do not always mean the same thing:• Social determinants of health• Social risk factors • Behavioral risk factors• Social needs

Social Determinants of Health

“The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”

(World Health Organization)

Social Risk Factors

• Social risk factors refer to adverse factors such as low education level or housing instability that occur at the individual level.

• Use of social risk factors to specify adverse factors that impact health clarify that social determinants as they are defined are not negative or positive.

(Alderwick and Gottlieb, 2019.)

Behavioral Risk Factors

• Behavioral risk factors are also distinguished from social risk factors.

• A behavioral risk factor includes behaviors that place health at risk like smoking, substance use, lack of physical activity, and poor diet.

• Behavioral risk factors can be shaped by social factors.


Social Needs

• Social needs are distinct from social factors because they are based in preference and priorities.

• Social needs are foundational for prioritizing interventions because social needs are at the forefront of a patient’s lived experience.

• A social risk screening tool can be used to identify social risks like food insecurity – however this may not be a priority for the patient based on other social needs.


TERMINOLOGY FOR CLINICAL SETTINGS

Social Prescribing • Social prescribing is terminology used in the UK to

identify the social needs of a patient within a clinical setting.

• Problems with this definition is that social needs, social risks, and behavioral risks do not have prescription or immediate solution that can be given to a patient in a clinical encounter.


Social Needs Informed Care

• Social needs informed care includes “activities that involve modifications to traditional medical care to account for patients’ social circumstances”.

• Examples include providing transportation to appointments, translators for patients with language barriers.


Social Needs Targeted Care

• Social needs targeted care includes “activities in clinical settings that seek to address patients’ social needs directly – for example, helping patients access income assistance if they lack financial resources”.

• Depending on the focus of care, one or both approaches may not be adequate.


EVIDENCE FOR SDOH

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Economic Stability as SDOH

• Economic stability includes areas such as housing, employment, food security, and poverty.

• Evidence for the role of economic stability:• Housing: Housing quality is associated with chronic disease, infectious disease, injury,

malnutrition, and poor mental health (Krieger and Higgins, 2002). • Employment: Employment is associated with mental and physical health, including

general physical functioning and quality of life (van der Noordt et al. 2014). • Unemployment increases risk for food insecurity and poverty compounding existing

health challenges (Nord et al.2007).

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Education as SDOH

• Education includes areas such as literacy, completing high school, and early development.

• Evidence for the role of education:• Literacy: Literacy level is associated with increased hospitalization, screening and

prevention behaviors, physician visits, health behaviors, and chronic disease (DeWalt et al. 2004).

• Completing high school: Completing high school as well as quality of education received is related to health outcomes including depression and risk of obesity (Dudovitz et al. 2016; Eide et al. 2011 ).

• Early development: Maternal health, childhood environments, housing, education, and nutrition impact adult outcomes (Moore et al. 2015).

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Social and Community as SDOH

• Social and Community Context are broad and includes areas such as social cohesion and discrimination.

• Evidence for the role of social and community context:• Social cohesion: Social cohesion is related to lower rates of mortality, decreased

neighborhood violence, and health behaviors (Healthy People, 2020). • Discrimination: Exposure to discrimination negatively impacts health through increased

stress and increased risk for chronic illness (Gee et al. 2007).

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Built Environment as SDOH• Neighborhood and Built Environment includes areas access

to transportation, healthy foods, and neighborhood crime and violence.

• Evidence for the role of neighborhood and the built environment:• Access to Healthy Food: Availability and access to healthy food options impacts eating

habits, nutritional status and an individuals ability to prevent as well as manage disease (Healthy People, 2020).

• Neighborhood Crime and Violence: Exposure to violence and crime during childhood and adulthood is associated with increased stress, poor mental health, and increased risk for poor health (Healthy People, 2020).

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Health and Access as SDOH

• Health and access includes areas such as access to healthcare, access to primary care, and health insurance coverage

• Evidence for the role of health and access:• Access to Health Services: Access to healthcare as well as availability, affordability,

and acceptability of care are all factors that impact health status and health outcomes (Douthit et al. 2015; Bodenheimer et al. 2010). Access alone does not improve outcomes or prevent disease.

SCREENING TOOLS

Screening Tools

• Screening for social determinants of health within the clinical setting have implications for health outcomes, cost, and use of services.

• National Academy of Medicine has recommended standardizing the collection of measures of social determinants of health in electronic health records (EHRs).

(Health Affairs, 2019; Gottlieb et al. 2016; National Academy of Medicine, 2014 )

Screening Tools

• Three Frequently Used Screening Tools1) The Accountable Health Communities Health-Related

Social Needs Screening Tool – most used 2) The Protocol for Responding to and Assessing Patients’

Assets, Risks, and Experiences (PRAPARE)3) CLEAR Toolkit

(Health Affairs, 2019; Gottlieb et al. 2016; National Academy of Medicine, 2014 )

Screening Tools

The Accountable Health Communities Health-Related Social Needs Screening Tool is a 10-item screener that assesses need across housing, food, transportation, and utility help need.

Screening Tools The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) aligns with Healthy People 2020 goals and items are actionable. Has both core and optional measures.

Screening Tools

The CLEAR Toolkit McGill Department of Family Medicine. Free assessment tool available in 10 languages and manual for implementing across clinical settings.

https://www.mcgill.ca/clear/download

(McGill University CLEAR Collaboration)

Existing Challenges around SDOH Screening

1) Lack of standardization of tools for the electronic health record is a major challenge facing clinicians.

2) Provider time to screen. 3) No standardized crosswalk between SDOH and

diagnostic codes.

(Health Affairs, 2019; Gottlieb et al. 2016)

SUMMARY OF OUR RESEARCH ON SDOH IN ADULTS WITH TYPE 2 DIABETES

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Quantifying direct effects of social determinants of health on glycemic control in adults with type 2 diabetes• Findings:

• Psychological distress, social support, and self-efficacy have direct effects on both self-care and glycemic control.

• No direct path from self-care to HbA1c

Walker et al., Diab Tech Therapeutics, 2015

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Pathways for the relationship between diabetes distress, depression, fatalism and glycemic control in adults with type 2 diabetes

• Findings: • Diabetes distress is the

pathway through which both depression and fatalism influence self-care and glycemic control.

• Separate pathways exist by which distress influences self-care and glycemic control.

Asuzu et al., J Diabetes and Complications 2017

*p<0.05, **p<0.01, ***p<0.001

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Pathways between food insecurity and glycemic control in individuals with T2DM• Findings:

• Food insecurity was shown to influence HbA1c through a pathway of stress and self-care

• Suggests importance of both food supplementation and diabetes education/skills training

• Walker et al. 2018 Public Health Nutr. *p<0.05, **p<0.01, ***p<0.001

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Validation of theoretical pathway between discrimination, diabetes self-care, and glycemic control

• Findings: • Discrimination was

significantly associated with stress, which served as a pathway to influence self-care and glycemic control.

• There was no direct pathway between discrimination and glycemic control.

Dawson et al. 2016, J Diab and Complications*p<0.05, **p<0.01, ***p<0.001

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Conceptualizing the effect of community and neighborhood factors on T2DM health outcomes

• Findings: • Social cohesion and medication

adherence have a direct effect on glycemic control.

• Factors that had a total effect on glycemic control include:

• Medication adherence• Food insecurity• Social cohesion

Smalls et al. 2017 Environment and Behavior *p<0.05, **p<0.01, ***p<0.001

FUNDED GRANTS

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Funded Grants – Observational Study• COME ALIVE Milwaukee

• Award: $2.8 million• Foundation Funding • Duration: 6 years

• Population: African Americans in inner city Milwaukee, WI• Goal: Reduce the burden of chronic disease in minority

communities in Milwaukee, WI by developing and testing novel community level interventions and recruiting and training the next generation of change agents.

Funded Extramural Grants - Interventions• R01 DK118038 – HOME DM-BAT: Home-Based Diabetes-Modified

Behavioral Activation Treatment for Low Income Seniors with T2DM• NIH/National Institute of Diabetes and Digestive and Kidney Diseases (PI: Egede)• $3.2 million, April 1, 2019 – January 21, 2024

• R01 DK 120861 – Financial Incentives and Nurse Coaching to Enhance Diabetes Outcomes – FINANCE-DM

• NIH/National Institute of Diabetes and Digestive and Kidney Diseases (PI: Egede) • $3.3 million, April 15, 2019 – March 31, 2024

• R01 MD 013826 – Lowering the Impact of Food Insecurity in African American Adults with Type 2 Diabetes Mellitus (LIFT-DM)

• NIH/National Institute of Diabetes and Digestive and Kidney Diseases (MPI: Egede/Walker)• $3.2 million, May 3, 2019 – December 23, 2023

• 1-19-JDF-075 – Lowering the impact of food insecurity in African Americans with diabetes

• American Diabetes Association Junior Faculty Award (PI: Walker)• $590,000, January 1, 2019 – December 31, 2022

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Case 1 - Revisited• AA male, age 61, lives alone• Presents with asthma, hypertension and type 2 diabetes • Patient was non-responsive, 911 called, and hospitalized for diabetes• Blood glucose reading was 559 • Patient reported not taking medications due to cost and stretches them out

by skipping doses• Cannot afford test strips • Does not have transportation, takes bus to clinic• Lives in inner-city and afraid to walk around neighborhood due to gun and

gang violence, so stays indoors • Unemployed with limited income and support network

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Conclusions• SDOH plays a significant role in chronic disease outcomes• Socioeconomic, psychosocial, and neighborhood/built environment are

important drivers of outcomes• Chronic stress is an important common pathway• Interventions directly targeting SDOH are feasible and likely effective• Clinicians and health systems need to incorporate SDOH factors into

routine care plans• Researchers need to push the envelope in scope and size of studies in

this area of research in order to change policy

understanding the social determinants of health: a …

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