It’s a phrase heard frequently during public health discussions — the social determinants of health.
What it means, said Gianfranco Pezzino, M.D., Shawnee County health officer and strategy team leader for the Kansas Health Institute, is the external factors that will maximize the opportunities for people to be as healthy as they can be.
Much work remains on understanding how social determinants affect physical health, but more research is being put forth and more data collected that point to issues communities must address, he said, because they have long-term impacts.
“You make the healthy choice easy,” Pezzino said. “You think about food. They closed Dillons (on Huntoon). What’s the easy choice for the people living in the area? To walk to the BP gas station on the corner.”
Robert St. Peter, president and CEO of KHI, pointed to the school lunch line.
“There have been lots of studies that have shown, depending on which foods you put near the beginning of the line and how you lay out the choices, that influences how often different foods are selected by kids,” he said, adding that the school food service program may be paid incentives by vendors of different products to get better placement.
Everything from poverty, access to transportation, traumatic childhoods, stress and access to healthy food affect a person’s physical health throughout their lifetime. It’s a subject that’s becoming more discussed as community leaders recognize what folks in public health have always known — changes need to be made to affect social determinants in order to change the population’s health.
In the United States, where obesity, diabetes and other health problems are on the rise and the life expectancy in 2016 dropped for the second time in two years and after decades of increasing, more communities are looking at what can be done to change the trends.
St. Peter said he explains the issue to medical students in a very simple way.
“The average medical visit is about 10 minutes,” he said. “The social determinants of health is everything that happens to that patient in their life outside of that 10 minutes in your office. So when they show up in your office, they are coming from a neighborhood, they are coming from an economic situation, an educational background, the exposures to things in their households, in their neighborhoods.”
Ignoring those factors means medical practitioners will miss 99.9 percent of what’s happening with the patient. Pezzino said those things outside that 10-minute office visit account for about 80 percent of how healthy an individual is.
“If the focus is just medical care, then it’s impossible to understand why we lag behind all the industrialized nations in any kind of health care indicators you want to look at and why we spend more than anyone else in the world on health,” he said.
That’s why the Topeka Community Foundation is launching a collaborative community health initiative, and why Shawnee County Commissioners and even the city’s economic development plan, Momentum 2022, all take a look at such issues now, when in the past they wouldn’t have made the connections.
St. Peter said he’s seeing hospitals shift into thinking about the community health aspect. Randy Peterson, president and CEO of Stormont Vail Health, said his organization is turning itself into a population health system, knowing that it’s a shift from being profit-centered based on number of visits or procedures to focusing on keeping people healthy and essentially out of their facilities.
One of the challenges, St. Peter said, as this shift occurs is how hospitals will be reimbursed.
“If the goal is to produce health and the hospital is actually a cost center in producing health, the incentives are totally different than they were under the old system,” he said. “And that’s a very scary thing for hospitals to think of, that change in their own identity.”
Cindy Samuelson, vice president at the Kansas Hospital Association, said it’s a situation that will be grappled with over the coming years. In the industry, they believe there will be reimbursement to go along with keeping quality of health care and people healthy rather than the old volume-based system.
Pezzino, in his role as health officer at the Shawnee County Health Department, said those organizations statewide face the same issues. Most of their revenue comes from fees for services like well-baby clinics, breast-feeding clinics and immunizations.
“But nobody’s going to pay them to organize a meeting with the partners to discuss how to set up exercise and wellness facilities in the community, for example,” he said.
Despite reimbursement challenges, movement is being made in the health community to get its arms around social determinants and factors affecting health care. Samuelson pointed to the Kansas Health Matters initiative that outlines top 20 key health indicators, and highlights where states are in regard to those indicators and also what communities are doing to address them.
“The great thing about this site is that it breaks it down, the state as a whole, but you can also look at regions of our state, you can look at counties and we’ve just added city data,” she said.
Such access to evidence-based ideas and also data will encourage the collaboration necessary to take on the social determinants of health and their impact on communities.
Because there is no doubt the social determinants of health need to be understood and addressed.
“We tend to go to health care when the topic of health comes up,” said Dan Partridge, director of the Lawrence-Douglas County Health Department. “That’s an important part of it. It’s not the most important part. Our behaviors, our environment, the communities we live in, those are the things that really matter, and of those, the education we get and the income we receive, those are the two biggest drivers.”
Pezzino and St. Peter in their roles at KHI have been taking the deep dive into understanding social determinants and where and how to move forward. It’s not easy. Just having doctors educate a patient on the importance of exercise and losing weight to control diabetes, for instance, doesn’t work.
“People change behaviors usually when there are three conditions that come into play. One, they need to have an opportunity to change behavior,” he said. “That opportunity has to be easy for them to make the healthy choice the easy one. Two, they must have the skills and the capacity. If you ask somebody in a wheelchair to climb stairs up and down for exercise, they can’t do that. Three, then comes the motivation.”
Although a physician discussion about weight loss or exercise is important, it’s not typically enough motivation to change behavior, Pezzino said.
“There’s a big tension between individual responsibility and sort of community responsibility, and I think it’s really both,” St. Peter said. “It’s not either/or. You want individuals to be motivated to do the right thing, but if they face endless obstacles in their own world that they come from, that 99.9 percent of the time when they’re not in the doctor’s office, it’s just not really very realistic to expect them to be able to overcome that.”
Many of the issues can be affected by the right policies, Pezzino said.
“Just about everything, going through the list — public transportation, access to healthy food,” he said. “Eventually everybody will be responsible for their own decisions, and that remains a fact. It cannot be removed. But you an make those decisions much easier than they are now.”
There is still much to learn about social determinants, St. Peter said.
When he and Pezzino were asked what has surprised them most about factors affecting health, they both said race.
“We know that race is associated with income and educational achievement,” St. Peter said. “But even in studies when you can control for income and educational achievement, people who are minorities have worse health problems and don’t live as long. It’s probably related to a complex (issue) of chronic stress that they’re exposed to over a lifetime. We never really understood how stress and all these environmental things get under the skin and into the biology, but we’re beginning to understand the science around that now. Being exposed to chronic toxic stress, especially at pivotal periods of a young person’s life, has lifelong consequences from a health perspective.”
“No matter how you slice it, African-Americans and Native Americans in this country come last in any kind of health indicator you want to measure,” he said. “After you adjust for poverty, education and everything else, they still come last on everything from access to healthy behaviors to screening to early mortality. Oh, my gosh. The years of potential life lost. That was the most shocking part for me, and still is.”
Partridge said he remembers his shock at reading research that indicated the influence that location has on health.
“If you do nothing else in your life other than move from a low-income to either a mixed-income or higher-income level, don’t change your employment status, don’t change your behaviors, nothing else, your health improves,” he said. “For a lot of reasons, and racism is one of them and discrmination and the redlining that’s part of our past, populations like African-Americans and minorities are locked into places that aren’t healthy. It’s our charge to try to create equal opporutnity for health, and when you think about the power of place and how people are locked in these neighborhoods and what it would take to get them out and to integrate neighborhoods and to create mixed-income neighborhoods — it seems very daunting.”
Much is to be learned, and both men see KHI’s role clearly in that process.
“I think what you’ve hear us say is there isn’t a lot of good science out there on some of these things,” St. Peter said. “It’s just developing. I think our role is just we have our ears to the ground and her about new ideas and new approaches to this that we can try to make policymakers and communities aware of in Kansas. And encourage people to collect data, collect information on how it goes, so we know what works and what doesn’t work.”
Awareness, Pezzino said, is critical. And that awareness must extend to individuals, but also to policymakers, nonprofits, medical providers, local and state government officials… everyone.
“I think that a very important message is that improving the health of our community isn’t just the responsibility of the hospital and the doctors,” St. Peter said. “It’s really the entire community has to be engaged. The people who make decisions about transportation and sidewalks and bike paths and water and playgrounds and schools and grocery store development, housing, safety at work. It’s the criminal justice system, the mental health system. If you want to address health at a community level over a long period of time, you’ve got to look way outside just the health care system.”