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The SEED’s of Health: Exploring the Impact of Social, Economic, and Educational Determinants PRESENTERS: ANTHONY SALERNO PH.D. & PETER CAMPANELLI, PSY.D.
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Commission on Social Determinants of Health (CSDH)… Circa2008-20010
The Commission on Social Determinants of Health, created to marshal the evidence on what can be done to promote health equity and to foster a global movement to achieve it. It is a global collaboration of policy makers, researchers, and civil society, led by commissioners with a unique blend of political, academic, and advocacy experience.
Defining Social Determinants
Health: Basic Human Right ‣ There are two principal reasons for regarding health as
a special good:
(1) Health is directly constitutive of a person’s well-being;
(2) Health enables a person to function as an agent (3) Inequalities in health are thus recognized as
“inequalities in people’s capability to function” which severely compromises freedom
The United Nations : Human Rights “A human rights perspective removes actions to relieve poverty and ensure equity from the voluntary realm of charity … to the domain of law”. The health sector can use the “internationally recognized human rights mechanisms for legal accountability” to push for aggressive social policies to tackle health inequities, since international human rights instruments “provide not only a framework but also a legal obligation for policies towards achieving equal opportunity to be healthy, an obligation that necessarily requires consideration of poverty and social disadvantage”.
Social Determinants: A trans- Discipline Concept ‣ Public Health : Population Disease Management ‣ Public Policy: Advocacy & Resource Sufficiency ‣ Health Care Disparities: Access & Quality ‣ Individually targeted Interventions
Social Determinants of Health: World Health Organization (WHO) ‣ The social determinants of health (SDH) are 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.
‣ The determinants of health include: • the social and economic environment, • the physical environment, and • the person’s individual characteristics and behaviors.
Theories on the social production of health and disease ‣ “Social selection”, or Social mobility; ‣ “Social causation”; and ‣ Life course perspectives. • Each of these theories and associated pathways and
mechanisms strongly emphasize the concept of “social position”, which is found to play a central role in the social determinants of health inequities.
The Central Role of Power in the Social Determinants of Health ‣ Human rights embody a demand on the part of oppressed
and marginalized communities for the expression of their collective social power.
‣ The central role of power in the understanding of social pathways and mechanisms means that tackling the social determinants of health inequities is a political process that engages both the agency of disadvantaged communities and the responsibility of the state.
‣ Second, it is important to clarify the conceptual and practical distinction between the social causes of health and the social factors determining the distribution of these causes between more and less advantaged groups
Structural Determinants of Health: Core Elements ‣ Structural mechanisms are those that generate
stratification and social class divisions in the society and that define individual socioeconomic position within hierarchies of power, prestige and access to resources.
‣ Structural mechanisms are rooted in the key institutions and processes of the socioeconomic and political context.
Most Important Structural SDH ‣ Income ‣ Education ‣ Occupation ‣ Social Class ‣ Gender ‣ Race/ethnicity.
Intermediary Determinants Of Health ‣ Material circumstances include factors such as housing
and neighborhood quality, consumption potential (e.g. the financial means to buy healthy food, warm clothing, etc.), and the physical work environment.
‣ Psychosocial circumstances include psychosocial stressors, stressful living circumstances and relationships, and social support and coping styles (or the lack thereof).
‣ Behavioral and biological factors include nutrition, physical activity, tobacco consumption and alcohol consumption, which are distributed differently among different social groups. Biological factors also include genetic factors.
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The SDH Conceptual Framework
Policy Action Challenges for the SDH ‣ Interventions and policies to reduce health inequities
must not limit themselves to intermediary determinants, but must include policies specifically crafted to tackle the social mechanisms that systematically produce an inequitable distribution of the determinants of health among population groups
‣ To tackle structural, as well as intermediary, determinants requires inter-sectoral policy approaches.
Framework for Tackling SDH Inequities
Person Centered SDH …action through the individual and his or her choices versus action on structural social determinants
‣ The role of the individual should be integrated with the social determinants approach for three reasons.
‣ Firstly, plausible, individual-level determinants can be identified and so need to be accepted, not least because they are integrally entwined with social factors.
‣ Secondly, we cannot assume that individual change will flow as a direct consequence of social and economic change.
‣ Finally, the opportunity to influence policy depends partly on presenting a message that accords with current government thinking
Resource Insufficiency and Culture ‣ Social factors such as poverty and its sequelae
substantially affect people’s abilities to adopt healthy behaviors;
‣ Individual factors such as functional differences and cultural beliefs also facilitate or constrain behavior change.
The Role of the Science of Individual Behavior Change and SDH ‣ Individual-level determinants can be identified and so
need to be accepted, not least because they are integrally entwined with social factors.
‣ We cannot assume that individual change will follow as a direct consequence of social and economic change.
‣ The opportunity to influence policy depends partly on presenting a message that accords with current government thinking.
Homelessness: One Of Our Most Persistent Public Health Problems ‣ Approximately 1 million people will spend at least 1
night in an emergency shelter or in transitional housing (U.S. Department of Housing and Urban Development [HUD], 2010).
‣ In 2013, 610,042 people in the United States were homeless on any given night. Of this group, nearly 20% were individuals with disabilities who had been continually homeless for 1 year or more or had experienced four or more episodes of homelessness in the past 3 years (HUD, 2013)
Serious Chronic Disease Tracks with Homeless Populations ‣ Compared with housed individuals, people
experiencing homelessness have higher rates of heart, liver, and kidney disease; diabetes; HIV=AIDS; hepatitis C; tuberculosis; and cancer (LeBrun-Harris et al., 2013; National Coalition for the Homeless, 2009; U.S. Department of Health and Human Services, 2011).
‣ Mental illness and substance use disorders run rampant in this population. Prevalence estimates suggest that 50–70% of people experiencing homelessness have at least one mental illness, and 30%–50% have substance-abuse problems (Folsom & Jeste, 2002.
Estimated Current NYC Need ‣ Coalition for the Homeless, NYC reports July 2014
• 56,454 people living in NYC Shelters • 8616 single men • 2979 single women • 44895 people in families • 23979 are children in families
‣ Disparities: African American and Latino disproportionately effected…linked to poverty
‣ Homeless have significantly higher rates of serious mental illness, SUD, and comorbid physical health problems
Estimated Deaths Attributable to Social Factors in the US - 2000 ‣ Low education: 245,000 ‣ Racial segregation: 176,000 ‣ Low social support: 162,000 ‣ Individual level poverty: 133,000 ‣ Income inequality: 119,000 ‣ Area level poverty: 39,000
‣ In comparison:
• Acute MI: 192,898 • Cerebrovascular diseases: 167,661 • Lung cancer: 155,521
Estimated Deaths Attributable to Social Factors in the US. Galea S et.al.
AJPH:June 16,2011;eprint.
Life Expectancy in the Bay Area
Oakland, CA
People who live in West Oakland can expect to live on average 10 years less than those who live in the Berkeley Hills. People who live in Bayview/Hunters Point can expect to live on average 14 years less than their counterparts on Russian Hill
Residents of Bay Point can expect to live on average 11 years less than people in Orinda
Compared to a white child born in the Oakland Hills, a black child born in West Oakland is: ‣ Likely to die almost 15 years earlier ‣ 5x more likely to be hospitalized with diabetes ‣ 2x as likely to die of heart disease ‣ 3x more likely to die of stroke ‣ 2x more likely to die of cancer ‣ 7x more likely to be born into poverty ‣ 4x less likely to read at grade level by grade 4 ‣ 4 x as likely to live in a neighborhood with high density
of fast food and liquor outlets ‣ 5.6x more likely to drop out of school
Alameda County Department of Public Health
Across racial and ethnic groups, higher income*, more physically active adults
* Similar by education NHIS 2001-2005 Age-adjusted
Racial Disparity: Life Expectancy
How could income effect health?
Income directly shapes: Nutrition & physical
activity options Housing quality Neighborhood
conditions Social networks &
support Stress due to inadequate
resources to face daily challenges Medical care
Parents’ income shapes the next generation’s: Education, which
shapes their Working conditions
(physical & psychosocial) & Income
Center on Social Disparities in Health, UCSF
Health Impact of Resolving Racial Disparities
‣ 1991 to 2000 • Medical advances averted 176,633 deaths • Equalizing the mortality rates of Whites and African
Americans would have averted 886,202 deaths ‣ “The prudence of investing billions in the development of
new drugs and technologies while investing only a fraction of that amount in the correction of disparities deserves reconsideration. It is an imbalance that may claim more lives than it saves.”
Wolff S. Satcher D., et.al. The Health Impact of Resolving Racial Disparities: An Analysis of US Mortality Data. Am J Public Health. 2004;94:2078–2081
How could a neighborhood affect health? ‣ Safe places to exercise ‣ Access to healthy food ‣ Exposure to targeted advertising of harmful
substances ‣ Social networks & support ‣ Norms, role models, peer pressure ‣ Fear, anxiety, stress, despair ‣ Violence and fear ‣ Quality of schools
Disparities in the Clinical Encounter: The Core Paradox How could well-meaning and highly educated health professionals, working in their usual circumstances with diverse populations of patients, create a pattern of care that appears to be discriminatory?
Disparities in Health Care ‣ African Americans are 50% less likely to get heart
bypass surgery
‣ African Americans are 25% less likely to get pain medication
‣ African Americans are 54% as likely to get colon cancer screening procedures
‣ African Americans with lymphoma are 34-45% as likely to undergo a bone marrow transplant
‣ African Americans are 12.7% less likely to get surgery for lung cancer
Disparities in the Clinical Encounter: The Core Paradox ‣ Bias • No evidence suggests that providers are more likely than
the general public to express biases, but some evidence suggests that unconscious biases may exist
‣ Uncertainty • A plausible hypothesis, particularly when providers treat
patients that are dissimilar in cultural or linguistic background
‣ Stereotyping • Evidence suggests that physicians, like everyone else, use
these ‘cognitive shortcuts’
Stereotyping: When Is It in Action? Situations characterized by: ‣ time pressure ‣ resource constraints ‣high cognitive demand
Promote stereotyping due to the need for cognitive ‘shortcuts’ and lack of full information.
Hispanics and African Americans More Likely to Feel Treated with Disrespect
Source: The Commonwealth Fund 2001 Health Care Quality Survey
*Felt disrespected because of ability to pay, to speak English, or of their race/ethnicity.
Percent of adults who felt they were treated with disrespect*:
Access to primary care and use of emergency care by race and ethnicity
Summary Of Findings ‣Social and economic stratification, bias,
stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare.
What can be done about SDH?
How do we do it?
Person Centered SDH …action through the individual and his or her choices versus action on structural social determinants
‣ The role of the individual should be integrated with the social determinants approach for three reasons.
‣ Firstly, plausible, individual-level determinants can be identified and so need to be accepted, not least because they are integrally entwined with social factors.
‣ Secondly, we cannot assume that individual change will flow as a direct consequence of social and economic change.
‣ Finally, the opportunity to influence policy depends partly on presenting a message that accords with current government thinking
Policy Action: Developing an Intervention Science ‣ Targeted programs for disadvantaged populations; ‣ Closing health gaps between worse-off and better-off
groups; ‣ Addressing the social health gradient across the whole
population. ‣ Maximizing available resources and minimizing
resource insufficiency
Recommendations 1. Integrate safety and wellness into all aspects of
community life 2. Create “healthy community” demonstrations to
evaluate the effects of a full complement of health-promoting policies and programs
3. Develop a “health impact” rating for housing and infrastructure projects that reflects the projected effects on community health and provides incentives for projects that earn high ratings
4. Ensure that decision makers in all sectors have the evidence they need to build health into public and private policies and practices
Recommendations 5. Health systems need to assess social factors, especially
economic and social insufficiency as part of routine healthcare processes
6. Insurance companies need to recognize that housing, access to care and access to all community resources/social safety net services are health interventions.
7. Healthcare systems need to collect and analyze data related to health disparities and
8. Engage in quality improvement strategies to address health disparities based on racial, ethnic, educational level, degree of acculturation and language barriers.
Building an Infrastructure to Sustain SDH Interventions ‣ To identify successful examples of inter-sectoral action on SDH in
jurisdictions with different levels of resources and administrative capacity;
‣ To characterize in detail the political and management mechanisms that have enabled effective inter-sectoral programs to function sustainably.
‣ To demonstrate how participation of civil society and affected communities in the design and implementation of policies to address SDH is essential to success.
‣ Empowering social participation provides both ethical legitimacy and a sustainable base to take the SDH agenda forward
‣ Finally, SDH policies must be crafted with careful attention to contextual specificities, which should be rigorously characterized using methodologies developed by social and political science.
Cross Walking This Framework into American Politics ‣ Where would you place the following in this grid?: • Health Care Insurance Expansion • Fight for $15/ Hr. • Building a Wall • Free College Education • Expanding Electoral Participation to previously
disenfranchised groups • Contaminated Drinking Water in Public Schools and Cities • Human Rights: Women's Rights
Q&A
Upcoming Webinars Youth Care Workers as First Responders: Making Decisions
When Time is Short and the Stakes are High August 11, 2016
1:00-2:00PM
Trauma-Informed Supervision August 24, 2016 12:00-1:00PM
Legacies of Pain and Resilience: Clinical Implications for
Understanding Historical Trauma and Race August 25, 2016 12:00-1:00PM
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