Discussion Post: Social Determinants of Health in Practice

Prompt: Based on the video and reading, select two specific social determinants of health (such as employment and access to healthy food) that might impact a patient with a disability or as a member of a special/specific group. Propose one community resource or intervention that could help address these SDOH barriers.
Points: 10 points (meets learning objective: Describe the considerations regarding the provision of medical care to those with disabilities or special healthcare needs. (LO 1 / B2.06a, B2.18))

if you have any questions, please let me know!
Assigned Reading: Disparities in Health Care
Disparities in risks of disease, morbidity, and mortality are marked and broadly documented across different population groups, reflecting inequities in health care access, income level, type of insurance, educational level, language proficiency, and provider decision making.[58],[59] This section focuses on important factors that potentiate unequal treatment in the clinical encounter and approaches to help mitigate them.
DISPARITIES IN HEALTH CARE
Social Determinants of Health
Racism and Bias
Cultural Humility

SOCIAL DETERMINANTS OF HEALTH

There is a growing understanding of the remarkable sensitivity of health to the social environment and to what have become known as the social determinants of health (SDOH). The World Health Organization (WHO) defines social determinants of health (Fig. 1-11) as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.” Simply, these are the social, economic, and political conditions that influence the health of individuals and populations (Box 1-11).[60] You will quickly learn that, far more common than their individual genetic susceptibilities, your patient’s health is strongly influenced by social determinants of health such as stress, early life, social exclusion, working conditions, unemployment, social support, addiction, healthy food, and transport policy.

KEY SOCIAL HEALTH DETERMINANTS

Economic stability (employment, food insecurity, housing instability, poverty)
Education (early childhood education and development, enrollment in higher education, high school graduation, language and literacy)
Social and community context (civic participation, discrimination, incarceration, social cohesion)
Health and health care (access to health care, access to primary care, health literacy)
Neighborhood and built environment (access to foods that support healthy eating, patterns, crime and violence, environmental conditions, quality of housing)

Source: Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020. Healthy People 2020: An Opportunity to Address the Societal Determinants of Health in the United States.

SocietalDeterminantsHealth.htm. Accessed: March 30, 2019.
Although challenging for both decision makers and public health advocates, the “development of policies and action for health needs to address the social determinants of health, attacking the causes of ill health before they can lead to problems.”[61] An increasing body of evidence guides clinicians and other health care professionals to improve patient health and reduce inequities at the patient, practice and community levels. At the patient level, clinicians can be alert to clinical flags, ask patients about social challenges in a sensitive and caring way, and help them access benefits and support services. At the practice level, clinicians can offer culturally safe services, use patient navigators, and ensure that care is accessible to those most in need. At the community level, partnering with local organizations and public health agencies, getting involved in health planning, and improving environments for health is possible.[62]

RACISM AND BIAS

Implicit bias is a set of unconscious beliefs or associations that lead to a negative evaluation of a person on the basis of their perceived group identity.[63] Research has shown that implicit clinician biases can have a negative effect on the patient encounter, and more broadly, contribute to health care disparities among various demographic groups.[64] A patient assuming a female doctor is a nurse upon meeting or a doctor audibly sighing in frustration about a patient’s substance use disorder are examples of implicit bias. These examples reveal unconscious stereotypes generated by the knowledge, beliefs, and expectations of that individual.[65] These unconscious biases can permeate the patient encounter through nonverbal behaviors such as poor eye contact, speech errors, and other subtle avoidance behaviors that convey distrust or dislike.[66] More importantly, while they may appear minimal in scale, the aggregation of these implicit biases, and others like it, can lead to a structural system of privilege (institutional bias) that leads to a misallocation of care, particularly for the most marginalized demographic groups.[67] Thus, in order to address these disparities, we must investigate the role implicit bias plays in our patient care.[68],[69]

One of the challenges to addressing implicit bias in health care is its relation to explicit bias. Explicit bias is the conscious or deliberate decisions or preferences founded on beliefs, stereotypes or associations on the basis of a perceived group identity. A patient who refuses to see a African American doctor because they “want a qualified doctor” or a clinician who believes that all gay males are at risk of HIV are examples of explicit bias. Although implicit bias lies within the subconscious of the subject, explicit bias can be acted on consciously.

A growing body of literature illustrates how patient characteristics (race, gender, sexual orientation, age, etc.) can influence various aspects of the patient encounter such as: questions within the clinical interview, diagnostic decision making, symptom management, treatment recommendations, referral to specialty care, and nonverbal behaviors (poor eye contact, speech errors, etc.).[66] In particular, this becomes problematic when physicians use different communication styles and provide different information reflecting their biases about different patient groups.
To address implicit bias in clinical encounters, we must first understand how this type of bias arises. As we process countless pieces of information, unconscious mental processes help sort and organize patterns to improve cognitive efficiency. These unconscious processes help us predict and prepare for whatever encounters may arise from the information that is processed. Thus, implicit bias is one byproduct of such a cognitive system. As a society, we are constantly exposed to imagery, values, media, and emotions that depict wide-ranging stereotypes associated with different demographic groups. Particularly in an environment where this is commonplace, it is not difficult to see how these implicit biases are formed.
There are several skills that clinicians can use to mitigate the impact of bias in their clinical encounters (Box 1-12).
BOX 1-12

SKILLS AND PRACTICES TO MITIGATE BIAS IN YOUR CLINICAL ENCOUNTERS[68]–[70]

Reflect on patterns of emotion and behavior. Pay attention to how you feel and how you behave around patients of different identities. The patterns you recognize may reflect biases that impact your interactions with patients as well as your clinical reasoning. Being aware of these biases is the first step in reducing their impact on patient care.

Pause before starting an encounter and prepare for potential triggers of bias Once you are aware of your potential biases, pay attention to situations that may trigger them. Simply being aware of a bias can help minimize its effect. You may take deliberate actions to reduce the impact of your biases.
Generate alternative hypotheses for biases anchored in behavior Many biases are anchored in clinician assumptions about observed patient behavior (nonadherence, substance use, etc.). Make it a habit to consider what structural forces (socioeconomic status, race/racism, homophobia, etc.) impact patient behaviors, and how they can challenge assumptions you make about patients.
Practice universal communication and interpersonal skills Often, clinicians will not recognize when a bias is at play in a clinical encounter. The foundational communication and interpersonal skills described in this book (see Chapter 2, Interviewing, Communication, and Interpersonal Skills, p. 43) can reduce the impact of such truly unconscious biases on the way you interact with patients.

 

Explore your patients’ identities Many biases are anchored in clinician assumptions about patient identities. By simply asking patients to clarify what their identities mean to them, clinicians can dismantle their assumptions and better understand their patients. Many approaches to exploring patient identities are presented in this book (see pp. 2–3).

Explore your patients’ experiences of bias Clinical encounters are influenced by patients’ prior experiences of implicit and explicit bias in their health care. Exploring and understanding these experiences can help you be a better partner with your patients. “Unfortunately, many of my patients have had negative experiences with health care. What have been your experiences with health care?”

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