Social Determinants of Health 2023.pptx

Social (and Political) Determinants of Health, Health Disparities, and Vulnerable Populations D R. C O N T R E RA S PREVENTIVE MEDICINE FA L L 2 0 2 3 Objectives 1. Define social determinants of health, health disparity, and vulnerable populations. 2. Describe biological and sociological mechanism...

Social (and Political) Determinants of Health, Health Disparities, and Vulnerable Populations D R. C O N T R E RA S PREVENTIVE MEDICINE FA L L 2 0 2 3 Objectives 1. Define social determinants of health, health disparity, and vulnerable populations. 2. Describe biological and sociological mechanisms through which the determinants of health operate. 3. Discuss the social risk factors that affect patients’ health and well-being. 4. Recognize the barriers to health facing patients and families from diverse socio-economic backgrounds. 5. Explain the historical basis for mistrust of the medical system in marginalized communities. 6. Discuss strategies for building trust and communicating effectively with members of marginalized groups. Definitions Social (and political) determinants of health- conditions in which people are born, grow, work, live, age, and worship, as well as the wider set of forces and systems shaping the conditions of daily life, including economic policies and systems, development agendas, social norms, social policies, and political systems. Health disparities- differences in overall health or unequal burden of disease and/or health outcomes between populations that are attributable to social, political, economic, and environmental factors. (systemic, avoidable, and considered unfair or unjust) Vulnerable populations- refers to those who have poor access to health care, receive poor-quality care, and experience poor care outcomes — often resulting from societal injustices related to race, ethnicity, poverty, gender, sexual orientation, age, first language, or physical or mental health, etc. Health outcomes- Mortality, Morbidity, Life Expectancy, Health Care Expenditures, Health Status, Functional Limitations. Equality vs. Equity Right to Health Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. (W.H.O.) “Everyone should have access to the health services they need, when and where they need them, without suffering financial hardship.” “No one should get sick and die just because they are poor, or because they cannot access the health services they need.” History of Medical Mistreatment of People of Color Tuskegee Syphilis Study (1932 – 1972, Alabama) • U.S. Public Health Service clinical study • Enrolled 400 black men diagnosed with Syphilis with promise of adequate medical care • Men were subsequently denied the known treatment (penicillin) to allow for the study of the natural progression of this disease • Many men died directly from syphilitic lesions or from complications associated with syphilis Henrietta Lacks (1951) • Treated at Johns Hopkins Hospital for cervical cancer at age 31 • A biopsy of cervical tissue was taken from Lacks without her knowledge or consent • Cells isolated by American physicians from this biopsy were used to isolate the first immortalized cell line (now known as HeLa cells) • These cells were subsequently commercialized and used for extensive biomedical research, including the development of cancer treatments and vaccines (including the study of COVID-19) • The Lacks family never received any financial benefits until the Henrietta Lacks Foundation was established by Rebecca Skloot (author of The Immortal Life of Henrietta Lacks) Social determinants of health ECONOMIC EDUCATION COMMUNITY STABILITY Literacy AND SOCIAL Employment Language CONTEXT Income Early Childhood Social Expenses Education Integration Debt Vocational Training Support Medical Bills Higher Education Systems Support Community Housing instability Engagement HEALTH & HEALTH CARE SYSTEM Discrimination FOOD Access to healthcare Stress Hunger Health Literacy Access to Healthy Health Coverage Options Provider Availability Provider Linguistic and Cultural Competency Quality of Care NEIGHBORHOOD AND PHYSICAL ENVIRONMENT Housing (quality) Transportation Safety Parks Playgrounds Walkability Zip Code/Geography What influences health? 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. Implicit bias Set of unconscious beliefs or associations that lead to a negative evaluation of a person on the basis of their perceived group identity. 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. ◦ 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. ◦ This may appear minimal, but the aggregation of these implicit biases, and others like it, can lead to a structural system of privilege (institutional bias) that leads to misallocation of care, particularly for the most marginalized demographic groups. Cultural humility A process that requires humility as individuals continually engage in selfreflection and self-critique as lifelong learners and reflective practitioners in an effort to address power imbalances and to advocate for others. The practice of cultural humility helps mitigate implicit bias, promotes empathy, and aids clinicians in acknowledging and respecting patients’ individuality. It has been proposed to moderate disparities in healthcare, clinicians should engage in self-reflections, critical thinking, and cultural humility as they experience diversity in their clinical practices. Three dimensions of Cultural Humility 1. Self-awareness: Learn about your own biases, we all have them. 2. Respectful communication: Work to eliminate assumptions about what is “normal.” Learn directly from your patients; they are the experts on their culture and illness. 3. Collaborative partnerships: Build you patient relationships on respect and mutually acceptable plans. 5Rs of Cultural Humility 1. Reflection- Clinicians will approach every encounter with humility and understanding that there is always something to learn from everyone. 2. Respect- Clinicians will treat every person with the utmost respect and strive to preserve dignity at all times. 3. Regard- Clinicians will hold every person in their highest regard, be aware of, and not allow unconscious biases to interfere in any interactions. 4. Relevance- Clinicians will expect cultural humility to be relevant and apply this practice to every encounter. 5. Resiliency- Clinicians will embody the practice of cultural humility to enhance personal resiliency and global compassion. Core values of Medical Ethics 1. Nonmaleficence- (“first, do no harm”) directive that health care professionals should avoid causing harm to patients and minimize the negative effects of treatments. 2. Beneficence- dictum that clinicians are to act for the patients’ good by preventing or treating disease. 3. Respect for autonomy- commitment to accept the choices patients with decisional capacity make about which treatments to undergo, including to reject treatment. The addition of this value to medical ethics changed the clinician-patient relationship from a paternalistic one to a more collaborative one. 4. Decisional capacity- ability to make an autonomous choice that clinicians should respect. 5. Confidentiality- duty to prevent the disclosure of patient’s personal information to parties who are not authorized to learn that information. 6. Informed consent- principle that clinicians must elicit patients’ voluntary and informed authorization to test or treat them for illness or injury. This principle also encompasses the responsibility to inform patients of diagnoses, prognoses, and treatment alternatives. 7. Truth telling- value that clinicians should disclose information beyond that required by informed consent that may be relevant to patients (e.g. the number of procedures previously performed.) 8. Justice- Value that all patients with similar medical needs should receive similar medical treatment and should be treated fairly by clinicians. What can you do as future healthcare workers? 1. Learn to think beyond your patient’s clinical/medical history ◦ Each patient has a unique cultural and ethnic identity within the context of their social environment and their personal experiences 2. Investigate mistrust as a barrier to healthcare ◦ Review relevant literature resources ◦ Elicit your patients' viewpoints, beliefs, concerns 3. Explore and expose personal and/or institutional racial biases ◦ Self-examination and reflection ◦ Cross-cultural training/educational programming throughout your medical education and career Improve patient health, reduce inequity 1. Patient level ◦ ◦ ◦ Alert to clinical flags Ask patients about social challenges in a sensitive and caring way Help them access benefits and support services 2. Practice level ◦ ◦ ◦ Offer culturally safe services Use patient navigators Ensure care is accessible to those most in need 3. Community level ◦ ◦ ◦ Partner with local organizations and public health agencies Get involved in health planning Improve environments for health Be a PA = Patient Advocate 1. Establish interpersonal trust ◦ Listen attentively to patients and their concerns/fears ◦ Maintain eye contact ◦ Practice and utilize learned clinical skills ◦ Summarize encounter frequently ◦ Empathize with the patient and their situation 2. Maintain end-goal clarity  Ask patients to clearly identify what their goals are for the visit 3. Focusing on promoting self-advocacy and empowerment  Support patients with an ultimate goal of independent ownership of their health and healthcare References & Additional Resources CDC https://www.cdc.gov/chronicdisease/healthequity/social-determinants-of-healt h-and-chronic-disease.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov% 2Fchronicdisease%2Fprograms-impact%2Fsdoh.htm Healthy People 2030 https://health.gov/healthypeople/priority-areas/social-determinants-health W.H.O. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1