The COVID-19 pandemic has put a spotlight on the relationship between social determinants of health and health outcomes. Not only are these determinants complex, but medical educators are still grappling with how to incorporate them into training, according to Academic Medicine.
Here's a look at social determinants of health, their impact on health and healthcare delivery and how providers can give contextually appropriate care in the space of sensitive patient conversations.
What are social determinants of health?
Social determinants of health are the unspoken factors that influence health status. In other words, our health is influenced not only by biological and genetic components but also by a range of socioeconomic and environmental factors. These factors include:
- Access to care.
- Income and socioeconomic status.
- Culture.
- Race and the impact of racism.
- Social support.
- Childhood experiences and adverse childhood events.
- Education.
- Employment.
- Environment (home, work and community).
- Health behaviors.
- Gender.
- Biology and genetics.
How do social determinants interplay with healthcare?
The spaces in which we live, work and learn impact our health risks and our outcomes. Economic status, for one, has an undeniable impact on our ability to access healthy meals and healthcare services. Educational attainment impacts our ability to gain employment, access affordable health insurance and, ultimately, achieve better health outcomes. As a whole, social determinants can create barriers to health equity.
A significant body of literature describes how social determinants of health interact with our biological and genetic potential and subsequently impact healthcare. The Centers for Disease Control and Prevention, for example, maintains an extensive database of research on social determinants of health.
COVID-19 and social determinants of health
Medical advice in the age of the coronavirus has been two-fold: adequate hand hygiene and social distancing. The latter is simple in principle — decrease human-to-human contact to decrease the rate of viral spread. In practice, though, it's not so simple, highlighting how social determinants impact whether an individual can carry out medical guidance.
Privilege is inherent in the ability to engage in social distancing and to quarantine. The individuals who are most vulnerable to the virus and viral spread are those least likely to have the luxury of working from home and to have the economic ability to store away goods for a multiweek quarantine. They may also live in concentrated spaces that don't lend themselves to social distancing; these communities may include those who are incarcerated, homeless individuals and individuals in resource-poor conditions.
This pandemic demonstrates not only how social determinants can impact risk for disease acquisition, but also how these very same determinants can worsen said outcomes.
How can we navigate socially conscious care?
The conversations between patients and their providers in hospital and clinic rooms are sacred. As providers, we have the ability to ask any question we want and receive answers. We ask our patients — some strangers and some we have cared for in the past — about their substance use, sexual health and overall health behaviors. We ask these questions because human behavior, as a health determinant, impacts health risk. Our patients answer because they know their answers impact our clinical decision-making.
Beyond this, our behaviors are shaped by our environment. It's not a coincidence that there are higher rates of tobacco use (and other high-risk behaviors) among those of a lower socioeconomic status. These sensitive patient conversations require an awareness of social determinants of health and an approach to care that accounts for these health inequities. Consider how you can take the following steps in your patient interactions.
1. Express gratitude
These conversations can be uncomfortable for both the provider and the patient. It's important to express gratitude that your patient has been so open and honest about behaviors and activities that they likely know won't be perceived as healthful.
2. Acknowledge the challenge
Change is hard. Psychologists have created models for behavioral change, and these models are similar in two ways:
- On the road to change, relapse is not uncommon.
- Change requires readiness.
As we encourage our patients to adopt new behaviors, we must remind them to set realistic goals and to forgive themselves when they inevitably meet challenges. Furthermore, it's important to acknowledge the factors that our patients cannot change.
3. Connect with resources
We don't have all the answers, but we do have a robust support system. I frequently connect my patients and their families with our clinical site's patient legal advocate and social workers. These resources often can't make up for current healthcare inequities, but they're invaluable all the same.
Most importantly, our patients should know that whether or not they're able to make our recommended changes, we'll stand alongside them on this journey and advocate for them and for health equity.
Want to learn more about social determinants of health? Read:
- "Social Determinants of Health" on Lippincott NursingCenter
- "Expert Consensus on Inclusion of the Social Determinants of Health in Undergraduate Medical Education Curricula" in Academic Medicine
- "Social Determinants of Health: What's a Healthcare System to Do?" in the Journal of Healthcare Management
- "Addressing Social Determinants of Health Through Advocacy" in Nursing Administration Quarterly
- "Social Determinants of Health: A Timely Topic for Case Management" in Professional Case Management