Getting personal can effectively address all factors of health
Sharing your personal business may feel uncomfortable or like an invasion of privacy. But it may be just what you need to do. As a physician, I know this too well.
Years ago, a pediatric patient came into the office, after not appearing for follow ups for more than a year. After chiding the parents about the importance of routine checkups, I asked where their oldest son was since he had attended the last visit with his family.
His mother explained that he had passed away. I asked what happened to this normal, healthy boy. She said he had suffered an asthma attack and that they lived so far from the hospital that he died while waiting for the ambulance to arrive.
After the visit, I couldn’t help but wonder if I had really met the needs of the patient and family.
As physicians, we often perceive patients who are frequent no shows or don’t follow instructions very well as noncompliant. We try to whip them into shape with scary stories about their disease in its worst pathologic state and then follow it up with a few disapproving glares in hopes that we will eventually coax them into doing what we ask.
This method has turned out to be effective for a few patients. But for the others, I have realized that there’s much more to compliance than want and will power.
Social determinants of health such as neighborhoods, physical surroundings, access to health care, healthy food, education, and economic stability actually play the largest role in overall health. Unmet needs in these areas can contribute to health care disparities — and in some cases, death.
The Centers for Disease Control and Prevention in 2013 updated its original CDC Health Disparities and Inequalities Report examining how factors such as income, education, disability, ethnicity, and environment can contribute to the overall health of a person and how these barriers to health equity can be removed.
The CDC report revealed that asthma attacks are more prevalent among females, children, the poor, persons of multiple races, and Puerto Ricans. The white population had a longer life expectancy than the black population. The prevalence of periodontitis was significantly higher in blacks and Mexican-Americans when compared with whites.
By education level, periodontitis was highest among persons with less than a high school education and prevalence of periodontitis increased as incomes reached the federal poverty level or lower. Persons with low socioeconomic status were more likely to be affected by chronic diseases such as diabetes, hypertension, and human immunodeficiency virus (HIV) infection and were less likely to be screened for colorectal cancer and receive a flu shot.
The report highlights persistent disparities between population groups in health outcomes, access to health care, adoption of health promoting behaviors, and exposure to health-promoting environments. Disparities were found between race and ethnic groups across all the areas examined and the work to remove the barriers that create these disparities needs to continue.
The Healthy People 2020 (HP2020) campaign from the federal government provides a comprehensive set of 10-year, national goals and objectives for improving the health of all Americans. The initiative tracks the nation’s health through objectives that cover multiple public health topics.
As of March 2014, the latest HP2020 update showed that only four of the 26 Leading Health Indicators had met or exceeded their goal. The study shows fewer adults smoking cigarettes, fewer children exposed to secondhand smoke, more adults meeting physical activity targets, and fewer adolescents using alcohol or illicit drugs. Initiatives to address and combat these factors are emerging but there is still a lot of work to be done.
The Agency for Healthcare Research and Quality recently announced finalists on a national challenge to use data to better identify and predict health-care needs on a large population level. The goal of the Visualization Resources of Community-Level Social Determinants of Health Challenge is to for policy makers, advocates, public officials, health-care providers and more to understand more accurately the needs of those affected most by the social determinants of health.
As doctors, we know making it to a clinic appointment is important, but showing up is only a small piece of the health-care puzzle. Research shows that diet, exercise and tobacco use are health behaviors that are affected by social and economic factors.
For example, the average income for a person without a high school diploma is around $27,000 annually, according to the Bureau of Labor Statistics. This means low income housing will likely be the only option for shelter.
Low income housing is usually situated in vulnerable neighborhoods that have dilapidated sidewalks and playgrounds, limited access to public transportation, few economic opportunities, increased crime, and are usually devoid of grocery stores due to overall disinvestment.
Researchers estimate that about 40 percent of health-care outcomes are based on social and economic factors and health behaviors are a close second at 30 percent. Where you are born, live, work, and play can determine health care outcomes and create health-care inequities. The Association of American Medical Colleges and its member medical schools and teaching hospitals have made it their mission to “improve the health of all.”
Nonprofit hospitals and health systems, including teaching hospitals, are now required to conduct a community health needs assessment that identifies and prioritizes local health needs of the population they serve. Each hospital must make the assessment widely available to the public and develop an implementation strategy that describes how the hospital will address the needs of their community.
Teaching hospitals are now looking more closely at food access, social support, poverty, education, housing, and transportation needs of their patients and putting programs in place to support those who have needs in these areas.
Social and economic disadvantages contribute to health-care disparities which in turn impact overall health. Addressing the social determinants of health can offer insight into the lives of the patients we serve and help us improve their health and the quality of the care we provide.
As a physician, I am not an expert on population health or the economic disadvantages of under education. But I do know that handing someone a prescription and letting them walk out the door isn’t what’s going to make them well.
As doctors, we need to be compassionately nosy. We need to ask personal questions, not just hand out a survey and hope for the best. We can start a dialogue and make it personal.
We can build on the doctor-patient relationship already established by finding out why the patient missed the last two appointments. We can ask our patients if they feel safe at home and inquire about why they aren’t taking their medicines.
We can determine if the patient is making the painful choice between purchasing medicine or purchasing food. A brief conversation and a referral to the proper resources will increase awareness regarding the social factors that impact the health behaviors of patients, improve the effectiveness of our treatment plans, and make a huge difference in the life of the patient.
It might be the difference between life and death.
Laura Deon, M.D., is an assistant professor in the Department of Physical Medicine and Rehabilitation at Rush University Medical Center where she specializes in Pediatric Rehabilitation. She teaches the Health Equity and Social Justice Course at Rush Medical College and is also a Public Voices Fellow with The OpEd Project.