Social Determinants Of Health: Holy Grail Or Dead-End Road?
At the 2018 Milken Institute Future of Health Summit, Congressman Bill Cassidy said, “Obesity is often linked to social determinants that have nothing to do with food.” To bolster the point he shared a hypothetical but realistic example of family living in a food desert and relying on public transportation to and from the grocery store. While unfathomable for many health care leaders, policymakers and investors, transporting multiple grocery bags on public transportation is a cultural norm for many of the nation’s poor. Lack of convenient access to healthy food is among the social determinants of health (SDH) now so feverishly discussed as if they were the Holy Grail for improving health outcomes among the poor. While SDH must be considered in devising health care interventions, findings from our qualitative research study funded by the Commonwealth Fund* suggest incorporation of SDH as a strategy to improve health outcomes are unlikely to be successful without concomitant long-term commitment to addressing a few social and cultural challenges.
First, food literacy is low. Participants understood the link between food and good health and expressed interest in learning more about healthy food. A conversation about food with one participant led to a discussion about her inability to identify an eggplant or distinguish a zucchini from a cucumber. She is not alone. Therefore, consistent and sustainable food education is essential. This includes identification of foods, reading and understanding food labels and skills development to prepare meals. Also, modifying food-related policies to facilitate access is a critical step but the impact of these changes will only be realized if we also shift the food culture and perspectives about healthy food relative to the food choices persistently available in poor communities. For example, a few participants discussed their preferences for fast food and carry out options over fresh fruits and vegetables. These preferences were linked to flavor rather than cost. Thus, although improving access to conveniently located healthy food is imperative for good health, community-wide adoption of healthy food choices will require a gradual shift in the community’s palate and a change in the way low-income communities think about and value food.
Second, transportation benefits are vital but can’t replace trust. One of the most tangible and measurable SDH-related interventions is improving access to transportation. In many primary care clinics serving the poor, the no-show rates are persistently high and these missed appointments are often reportedly due to lack of transportation. To address this challenge, many health systems and insurance carriers now provide non-emergency medical transportation to health care visits. However, the participants who discussed transportation benefits suggested that often the reasons for not keeping appointments have little to do with transportation and that if they felt the visit was essential, they could identify options for attending health care visits. Some shared negative experiences with the health care system and reported the single biggest determinant of returning for follow-up was the relationship with the provider and the health system environment. Several participants shared experiences they perceived as disrespectful, unwelcoming, judgmental and condescending. One participant said, “People don’t care about you if you are poor and [they] won't give you the best treatment.” Among Hispanic participants, trust was named as a powerful predictor of consistent engagement in health care.
Finally, poverty and lack of economic opportunity are driving health inequities. Overall, many people were disengaged from their health and the health care system because their economic survival was in constant competition with what they perceived as non-immediate threats like health. Both black and Hispanic participants shared examples highlighting how lack of job and financial security forced them to delay health care needs. One participant described delaying medical evaluation for a shoulder injury for seven months because a missed day of work meant lost opportunity for future work because he would immediately be replaced by another worker. For the poor, desperate financial need clouds the ability to prioritize health, particularly when most preventable health conditions are often intangible and thus perceived as non-threatening. The need to address financial security as a means to achieve better health outcomes is increasingly recognized and has led to a movement exploring medical financial partnerships. These partnerships explore integration of SDH with financial empowerment interventions. The approach is a new paradigm for the US but is poised to revolutionize the delivery of social, financial and medical integration of service delivery.
Integrating SDH interventions into healthcare delivery is likely to nudge some individual health outcomes. However, recent and pervasive discussions about SDH suggest a belief among many that they are the Holy Grail for achieving the long-sought but elusive health outcomes for low-income populations. These discussions with study participants suggest a need to further evaluate proposed approaches for and expectations from burgeoning SDH interventions. Achieving population-based shifts in health outcomes for low-income communities requires moving far beyond text message reminders, Uber rides to clinic visits and vouchers for farmer’s markets and food pantries. These shifts demand bold and transformative steps to address poverty by providing education, economic opportunity and a pathway to lifelong economic stability. Congressman Bill Cassidy also said, “Prosperity is the key to improving health outcomes”. As we develop interventions for the social determinants of health, unless we begin to heed this message, in the years ahead rather than finding the Holy Grail, we will instead certainly find ourselves on the path to a dead-end road.
* The objective of this qualitative study was to assess the feasibility and acceptability of digital health among the poor. Coincidentally, some of the most important findings were unrelated to digital health.