Elephant in the room: Social determinants of health


My interest in social determinants of health and gaps in care has grown the longer I have worked as a nurse practitioner and seen how there is only so much one can do when only treating the surface problems a patient presents with. As defined by the U.S. Department of Health and Human services, social determinants of health are “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks”. Social determinants can be grouped into five domains of: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. Examples of social determinants of health might include access to nutritious foods and physical activity opportunities; polluted air and water; safe housing, transportation, and neighborhoods; racism, discrimination, and violence; and language and literacy skills. Each of these factors, or a combination of these factors, can have a very significant impact on an individual’s health outcomes.

It seems there is an elephant in the room sometimes when providing care to a patient because these factors are not always taken into consideration when providing healthcare. For example, if you are treating a patient who requires a course of antibiotics to treat an infection but does not have stable housing or finances, then expecting them to have the funds to purchase the medication and then take the course of antibiotics consistently for several days and as directed seems a bit silly; their priorities are likely putting food on the table that night and making sure they have a roof over their heads. This is just one example but its not uncommon. Social determinants of health contribute to the health outcomes of a patient and ignoring them is not only inappropriate, but it is negligent as well. Pretending that your job solely involves prescribing the medication and sending your patient on their way is not quality healthcare. If your role is to help patients get better, then that needs to include helping create successful health outcomes through addressing the various factors inhibiting health. Now you don’t need to address every factor on your own. But first appreciating the complexities of care outcomes and then providing resources and referral services as necessary are key. Social workers are wonderful referral partners you should be familiar with regardless of what specialty you work in as a nurse practitioner.

At times I have felt stressed and helpless in my role as a nurse practitioner, knowing that despite the care I provide, I am not addressing other very important impacts on a patient’s health. I previously worked in one of the poorest cities in the country in Youngstown, Ohio, where poverty, lack of education, unfavorable geographic location, and lack of opportunity were constant factors affecting the mental health (and physical health) of the patients I was serving. Health disparities are detrimental on health outcomes but there is hope for how health equity can be achieved.

Achieving Health Equity

The Institute of Medicine (IOM) has several recommendations for addressing health disparities. Two recommendations stand out to me in particular: increasing awareness of racial and ethnic disparities in healthcare among the general public and key stakeholders; and increasing the proportion of underrepresented U.S. racial and ethnic minorities among health professionals. These are only two ways to address health disparities which is one domain under the social determinants of health umbrella.

Increase Awareness

To increase awareness of disparities in healthcare for the general public and key stakeholders, I think the approach will vary based on the intended audience. For example, for the general public, there needs to be a way to garner attention and interest, particularly for factions of the public who are not immediately affected by health disparities.

This may involve utilizing media outlets such as creating and disseminating a greater number of TED Talks discussing health equity and providing more support for news outlets and shows such as John Oliver’s Last Week Tonight that tend to discuss topics like equity to shed light on health disparities in this country, like this one1. I think awareness can be best cultivated in a media format for the general public, because unless someone is independently very interested in this topic, lack of awareness will persist.  

Policy-level Involvement

In her TED Talk2, Dr Renaisa Anthony discusses how medicine and public health without the involvement of policy is problematic because decisions are made at the federal level that then trickle down to the state level, local level and finally hospital level. As a result of the significance of policy, key stakeholders will need to be engaged on a political level. Creating a persuasive policy brief on the importance of addressing health disparities creates awareness of the issue to then facilitate action. A brief serves as an avenue for providing policy advice and advocates for the desired solution to a particular problem3.

Developing a public policy position statement involves conveying ideas that are “balanced and defensible but with strong assertions”3. The position statement needs to let the reader know what could happen if something does not change and it needs to highlight the writer’s recommendations using “clear, concise, appropriate, and directly actionable language”3. Regarding health disparities, a position statement needs to clearly indicate what poor health outcomes will continue to arise by ignoring health disparities and it needs to delineate the steps to implementing recommendations.

Increase number of minority health professionals

A second way to address health disparities involves increasing the proportion of underrepresented racial and ethnic minorities among health professionals. Increasing the number of minority healthcare professionals helps address health equity because the minority healthcare provider has a lived experience in common with their minority patients. The gap to understanding issues is smaller and the minority healthcare provider is often a natural strong advocate to addressing health disparities. This is not to say that non-minority providers cannot, and are not, strong advocates for health equity because many are. An additional benefit to having more minority care providers is that when a patient sees a provider who looks like them, there is often increased comfort and trust in that patient-provider relationship. Ways to incorporate this IOM recommendation into practice may involve incentivizing minority providers to enter the healthcare profession through scholarships and grants.

These are only two recommendations the IOM makes among several to address health disparities; there are numerous ways to work towards health equity. The vehicle for doing so is not important. An elephant is clearly eaten one bite at a time. What needs remembered is that this elephant in the room, social determinants of health, is just too big to ignore.

1LastWeek Tonight. (2019 August 19). Bias in medicine: Last Week Tonight with John Oliver (HBO). [Video]. YouTube. https://www.youtube.com/watch?v=TATSAHJKRd8&ab_channel=LastWeekTonight

2Tedx Talks. (2012). A Recipe for Health Equity in the 21st Century: Renaisa Anthony at TEDxOmaha.

3DeMarco, R., & Tufts, K. A. (2014). The mechanics of writing a policy brief. Nurse Outlook, 62, 219-224.

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