If you work in healthcare at all, you’ve likely heard of the social determinants of health. It was probably covered in school a few times, most likely in one of those first professional development classes. Unfortunately, there’s a good chance we didn’t pay as much attention that day in class because we were too worried about an upcoming anatomy exam…
Social determinants of health is one of those things we hear and say “oh yeah, that sounds kind of important.” Well it is. Maybe even more than you realize. Some argue that the social determinants of health impact patients more than any amount or quality of clinical care.
If that’s the case, we ought to know what these determinants of health are, how they show up in PT practice, and how we can possibly help our patients navigate them.
What Are Social Determinants of Health? And Why Are They So Important?
Social determinants of health have a pretty simple definition. They’re the major non-medical considerations that impact health outcomes. This includes, but not limited to, a person’s place of birth, economic status, education level, job, neighborhood, and community.
They’re extremely important because these factors can impact results even more than the clinical care a patient receives. So basically you may be the best damn PT, OT, SLP, nurse, PA, doctor, surgeon, whatever – but it doesn’t matter for the patients if we completely ignore these factors or don’t at least try to address them. And no, we can’t solve all these, but understanding and dealing with social determinants of health can improve patient outcomes, reduce health inequities, and make communities healthier.
At the heart of it, social determinants of health are really complicated, large scale issues. And as individuals we are all just healthcare providers trying to do our best, in a crazy healthcare system, and go home with most of our sanity intact at the end of the day. So I’m not going to get into how we solve the problems of the world. But I do want to look at each of these determinants to break down how they affect health and where they might show up in practice so we can better understand them. I also want to share what micro-actions we as individuals may take, or try, in order to better help our patients.
Economic Stability
Economic stability refers to employment, income, job security, and financial stability and is probably the most crucial social determinant of health. They say money can’t buy you happiness, but in some cases it can buy you health. Or at least make it easier to access.
Most jobs are stressful, at least to some extent. However, someone with a high paying and/or secure job probably has less stress regarding financial issues vs someone with a lower income or less job security. Financial stressors are shown to be EXTREMELY taxing on a person’s emotional and physical health. Just think how you’d feel if you weren’t sure how you’d afford rent, food, the electric bill, the water bill – the basic necessities of life.
Don’t get me wrong, there are people who have secure and high paying jobs with lots of stress. Stress in general is linked to several health issues. However, someone with higher income has the ability to deal with those health issues. They have money to afford most, if not all, their healthcare. They also have the ability to prevent health issues because they can afford nutritious food, a gym membership, or personal trainer. All things that lead to better health.
Conversely, lower income individuals are at higher risk for common health issues such as obesity, HTN, and cardiac disease because they don’t have extra funds for gym memberships, home exercise equipment, or enough time for long workouts multiple times a week because they’re at their job 5-6, sometimes 7 days a week.
Where I work, many of my patients are considered low income. It is one of the biggest hurdles I see them face. This mainly becomes a problem when they’re needing equipment or weight to appropriately load them outside of the clinic.
This is where I try to find them low cost options for equipment – usually from Amazon. We also shift some of the focus to body weight exercise and dial in sets and reps that still challenge them. (It’s totally doable to get a good workout with just bodyweight!). We may get creative with what to use for weights – bottles or gallon jugs filled with sand or dirt or laundry detergent containers can work a lot like a kettlebell – basically anything they have lying around. I will turn them on to trusted Apps or YouTube Channels for them to try rather than pay for personal trainers or classes.
When it comes to food, I provide a list of foods that are generally very affordable but also healthy. Some of this is education is to debunk common misconceptions about food. For instance, the idea that everything needs to be bought organic in order to be healthy. Some people also believe the high sodium TV dinner they’re eating is less money than buying whole ingredients to make a nutritious meal that they get multiple servings out of.
These are all ways we can work around the patient potentially being unable to contribute a lot of money to things for their general health and fitness. Economic stability is the most common issue we see. Heck in this economy, it may have even affected yourself in the past! There’s about a million ways this can show up in practice. What other ways do you see economic stability affect your patients? And how do you deal with it?
Education
Closely related to economic stability is education. Education can influence job opportunities. Better jobs usually come with better benefits – including healthcare (more on that later). Better jobs also usually come with better income, which affects economic stability. (See economic stability section above). Education can also affect access to health information. I see this A LOT.
Poor health literacy is a lot more common than we think. The National Institute of Health estimates 34% of the US population has low health literacy. I’ve talked in other blog posts not to assume what our patients know about general health and wellness. No, I’m not saying to assume patients don’t know anything to the point of insulting them.
What I am saying is take some time to educate patients on what we consider basic health and wellness knowledge. Maybe they have heard some of it before. Your patients have maybe heard different versions of the same information. However, with all the misinformation and unreliable sources out there, especially on the internet, patients don’t know which one to listen to! You could be that voice of clarity and reason because we all know there’s some crazy health and fitness advice being thrown around out there.
Sometimes patients genuinely just have not been exposed to health and wellness knowledge or had those conversations. I once had a patient ask me what the difference was between a stretching and strengthening exercise. A person doesn’t know what they don’t know. We can close that educational gap by recognizing some individuals’ health literacy is going to be lower than others and by really no fault of their own. As healthcare providers we should be aware this can put those patients at a disadvantage when it comes to their health.
Now it’s understandable that we can’t sit everyone down and give them health education 101. That’s not what I’m saying. But spend a little time on it. Sprinkle those little educational pieces throughout the plan of care. Refer patients to trusted sources you know that patients can turn to for some education to close that gap. We can’t give everyone a formal education. BUT we can easily take these steps to help improve someone’s health literacy.
Healthcare Access & Quality
It’s maybe pretty obvious how healthcare access and quality would affect a person’s healthcare outcomes. However, I want to discuss it because other than economic stability this is the determinant of health I see affect patients the most. This social determinant of health refers to things like insurance coverage, availability of healthcare providers, and quality of care.
Someone without health insurance or with poor coverage will likely skip or delay medical care. It’s been shown time and time again that delayed care leads to poorer outcomes. Sometimes the patient has fewer cheaper, in-network options so they end up waiting a long time for an appointment. Rural patients may have more difficulty as well. Many rural hospitals and clinics do not have certain specialists, meaning they have to travel in order to have access to that kind of care.
Unfortunately we can only do so much when it comes to access. We can vote for policies that maintain and improve access to healthcare. We can also lobby for and start programs in our own workplaces that improve access. What we CAN definitely control is the quality of care we give to patients. Now you can’t control the care of your entire workplace but again, you can start programs or policies within them to improve it. Most importantly YOU are in charge of YOU and you can make sure you give patients great care. This means both your clinical knowledge and bedside support.
As providers we’re all frustrated with our broken healthcare system. I think one of the most exhausting parts of our job is the system. It’s because so much of it affects us and our patients but is largely out of our control. Sometimes you have to focus on what you can control and not what you can’t.
To be clear I’m not saying we give up. The system needs to change for sure. But what I’m saying is perhaps a shift of mindset. By focusing on what we can do versus can’t, maybe we’ll find some solutions. The micro-actions of voting for increased access, looking at policies and programs in our workplace, and owning the quality of care we provide at an individual level could possibly lead to those bigger changes.
Neighborhood & Built Environment
A person’s neighborhood and environment including housing, transportation, safety, and access to healthy food can significantly influence health. Someone exposed to unsafe conditions is not only at risk for violence-related injuries but we have to also consider the chronic stress that puts someone under. As we all know, higher stress = higher cortisol = more health issues. Food deserts are definitely an issue. Without access to healthy food, patients fall into unhealthier diets that also lead to poor health.
People need reliable transportation to get to their healthcare appointments, but not everyone has that. This leads to a lot of missed visits and delayed care. I see the struggle with transportation a lot. Thankfully, we do have some programs through the hospital I work at and the city to potentially help people get to their appointments. If this is a problem your patients face I suggest finding local programs or organizations and direct patients in need to those resources.
Patients have also frequently expressed to me wanting to work on their walking or endurance, but don’t feel safe in their neighborhood. This is where I have to tailor my HEP to meet the patient where they’re at. I often suggest mall walking or I change exercise sets/reps/rest time schemes to more endurance focus if that is one of the patient’s main goals.
There’s usually not anything we can do about the environment a patient lives in, but we can usually at least find ways to help them work around those obstacles.
Social & Community Context
Closely related to neighborhood and environment is social and community context, or basically the people and groups a patient interacts with. Support networks like family and friends and community cohesion through work, school, or church are big parts of this. It also includes things like social norms and discrimination.
Sometimes rehab, or any other healthcare journey, can be taken alone and sometimes the patient needs support. In certain situations a patient is physically unable to drive or do basic housework. They need rides to appointments or help at home in order to recover. If they don’t have a community around them, this can significantly affect their health due to the extra physical and mental strain.
Much like where a person lives, we can’t do a lot about who they surround themself with. We can turn them to support groups if needed. Sometimes this may come in the form of educating families on the patient’s needs at home. I have been in situations where I needed to explain to spouses or other family members that a patient needs to be resting and not doing all the household work they normally would. Conversely, I’ve also had to tell families to stop babying the patient and let them do things on their own.
Discrimination has also been widely studied in healthcare. The research shows this results in lower quality care and poorer outcomes. Discrimination is probably where we can have the most impact at least as far as how we give care. I’ve said before, we all have biases. We often make first assumptions on patients just by looking at them. And honestly they probably do the same to us. For example, the patient looks at me and they go “shit, I got the new grad.” However, we can acknowledge, control, and adjust these biases. Know what yours are and adjust yourself and your clinical care accordingly.
An important thing to note about treating without discrimination is that it doesn’t mean we don’t see gender, color, or culture, but that we try to educate ourselves on how that makes patients unique in terms of their health. An example would be the different symptoms women can sometimes feel during a heart attack compared to men. When I worked in long term care I dealt with a lot of wound care. I had to learn things like how a stage I pressure ulcer looks on darker skin vs lighter skin to make sure I wasn’t missing them. Again, the biggest control we have is over ourselves and the care we give.
Okay sorry guys that was kind of a long one. If you made it through the whole thing, thanks for sticking with it! Each of these social determinants probably could have been their own blog post. I do feel this is such an important topic. Which social determinants of health do you see affect your patients the most and how? And how do you try to address them? Share in the comments. It’s likely someone else out there has the same problem and they’re wondering what to do about it too. If you want to make sure you don’t miss new posts when they come out, hit that subscribe button below to get them directly to your inbox. Finally don’t forget to follow @the_pt_page on Instagram, so you can stay up to date on all things PT.
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