• Feature

    Addressing Social Determinants of Health

    Health is affected by far more than the presence or absence of health care. PTs and PTAs can help improve the health of populations by using a wide array of strategies.

    Addressing Social Determinants of Health

    It might seem reasonable to assume—particularly for health care professionals—that health care is among the most important factors in determining a person's or a population's health.

    It isn't.

    Although health care plays an important role, it's actually a relatively weak health determinant, according to studies1,2 cited by the Henry J. Kaiser Family Foundation (KFF). According to a KFF issue brief, research suggests that health behaviors such as smoking, diet, and exercise are the most important determinants of premature death. Furthermore, health behaviors are only one element of a much bigger picture.3

    "Efforts to improve health in the US have traditionally looked to the health care system as the key driver of health and health outcomes. However, there has been increased recognition that improving health and achieving health equity will require broader approaches that address social, economic, and environmental factors that influence health," KFF explains.

    Health is influenced by many factors that extend beyond the clinic or the direct application of medicine. Health—whether at an individual or a population level—extends into the home, workplace, school, neighborhood, and community. Social determinants of health (SDOH) include not only access to health services but also quality education, economic stability, social and community support, and healthy environments.4 "There is "growing recognition that social and economic factors shape individuals' ability to engage in healthy behaviors," KFF notes.

    The federal Healthy People 2020 initiative highlighted the importance of addressing social determinants, with the goal of "creating social and physical environments that promote good health for all."5 Physical therapists (PTs) and physical therapist assistants (PTAs) are addressing these determinants in innovative ways both in the United States and abroad.

    Health and Rehab Services

    An estimated 92% of the global burden of disease—measured in terms of attributable years of life lost—is related to causes requiring some level of physical rehabilitation. Further, countries with the highest burden of disability-related health conditions tend to be those with the lowest supply of health workers skilled in rehabilitation services.6

    To address this unmet need, various PTs have created nonprofit organizations that increase access to quality rehabilitation services in underserved areas of the United States and developing countries.

    One such nonprofit—Move Together—aims to develop and sustain rehabilitation clinics in Guatemala and the United States. Cofounder and Chief Executive Officer Efosa Guobadia, PT, DPT, now lives in Guatemala, where he oversees the development of clinics. "We build new clinics typically in rural areas without rehabilitation services, or where indigenous people lack the means to access or pay for the services," he says.

    Move Together's vision is to establish fully operational clinics by empowering local PTs. The goal is to have those clinics financially sustainable through local resources. Guobadia hopes that eventually clinics in the same country or region will become interconnected to provide mutual support and growth.

    Move Together's first clinic was constructed in Villa Nueva, Guatemala, in 2017 with the help of a short-term team of US PT volunteers who also provided clinical treatment.

    Today, Move Together provides the clinic's "hardware"—the materials and labor for clinic construction, as well as equipment and educational tools. Funds from the local municipality pay the salaries of 2 full-time PTs who staff the clinic, provide leadership, and mentor and coordinate PT students who rotate through the facility.

    "Because of the funding arrangement, the Villa Nueva clinic doesn't charge patients for visits, which numbered nearly 5,000 sessions in the first 6 months of operation," Guobadia says.

    "We have learned that the economic model has to be flexible," he adds. "In smaller towns that lack municipal resources, the clinic may have to charge a small fee per session to generate the income to cover a full-time PT's salary."

    Move Together has since built 2 additional clinics in Guatemala, is planning on building 2 more by the end of this year, and hopes to expand its clinic- development program to Rwanda.

    Meanwhile, in the United States, Jessica McKinney, PT, MS, and Laura Keyser, PT, DPT, MPH, in December 2016 cofounded Mama LLC, a public health and physical therapy consulting agency based in Boston and Baltimore that is dedicated to improving women's and girls' health both domestically and internationally. Its work includes education, physical therapy capacity-building, research, health promotion, and advocacy, using a health and human rights framework.

    Globally, women experience substantial health disparities, including lack of access to the services of PTs who are women's health specialists.7 More than 20 million women in the United States and more than 250 million worldwide have urinary incontinence,8 a condition for which a skilled PT can have a positive impact.

    "The [women's health care] specialty is not growing fast enough to meet the demand here in the US or abroad" McKinney says. "While the disparity is greater in low-resource areas, it exists even in wealthy neighborhoods, regardless of other social determinants, including income and education." She is vice president for medical affairs and clinical advocacy at Renovia Inc, a digital health care startup that is developing diagnostic and therapeutic tools to address pelvic floor dysfunction in women.

    Mama has joined with numerous international organizations to build physical therapy capacity and train PTs in women's health. For example, since 2015, it has partnered with EngenderHealth's Fistula Care Plus project to build women's health physiotherapy services in the Democratic Republic of Congo (DRC) and Nigeria. It provides programmatic support to the Panzi Hospital and Foundation in the DRC and its community outreach programs.

    Mama's SUDA Project—a collaboration between the World Confederation for Physical Therapy, Handicap International, and USAID—is designed to strengthen physiotherapy services in the West African nations of Niger, Mali, and Senegal. In November 2017, Keyser participated in a regional conference to provide expertise and training to more than 100 physiotherapists on the topics of obstetric fistula, pelvic floor disorders, and maternal health.

    Pro Bono Clinics In the US

    The Arlington Free Clinic (AFC) in Northern Virginia serves about 1,600 low-income, uninsured adults who cannot afford health care services or are ineligible for insurance, according to President Nancy White, PT, DPT. Most are immigrants from Central and South America, East Africa, and Asia who are employed in physical jobs and have limitations in their education, English-language skills, and literacy. "An injury or illness can prevent them from working and supporting their families," says White.

    AFC is a comprehensive medical home that provides free primary and specialist care through a network of volunteer physicians and nurse practitioners. The clinic also provides mental health services, physical therapy, pharmaceuticals, education (in nutrition, exercise, and diabetes management), and oral health care. Paid staff include pharmacists, nurses, and medical assistants who schedule and coordinate care for patients.

    "Several years ago, we began looking at health more broadly and addressing barriers. For example, transportation can be a barrier for dialysis or cancer patients who need to get to treatment from their jobs. We have a program through Lyft that provides several thousand dollars in credit to help our patients get to appointments," says White.

    AFC recently hired a social services case manager to coordinate referrals from providers and connect patients with local agencies and organizations that can meet their needs.

    PTs from a local practice and retired PTs volunteer weekly at AFC, providing direct patient care and leading the healthy living program.

    "The case worker frequently helps PTs obtain reduced or free access to county recreation facilities, including exercise facilities and pools, so that their patients can become more physically active. Additionally, PTs frequently refer patients for mental health care when their mental and emotional problems interfere with their progress," says White.

    At AFC, PTs begin to understand how myriad social determinants become barriers to health. "For example, a patient who is at risk of losing his or her home or is renting a space and living on a couch in an apartment with 3 other families may have trouble finding a place and time to do prescribed home exercises" White notes. "That awareness affects how PTs approach treatment planning."

    AFC and 3 local safety-net partners will be collecting data on SDOH among Arlington's poorest and sickest residents. Questions will address housing, safety, transportation, social isolation, and childcare—all factors that can negatively affect their health. The data will be used to improve services within each of the safety-net clinics and will be shared with county leaders so that funds can be directed to help address these problems, White says.

    Move Together also has a Pro Bono Incubator (PBI) program that is designed to support sustainable development and innovations identified by new and existing pro bono programs in the United States.

    The PBI program also provides annual grants, mentorship, and other resources to individuals or groups that offer rehabilitation services to the underserved. Since 2017, PBI has given $20,000 in grants to 11 entities, according to Guobadia. Examples of funded innovative projects range from a program providing alternatives to and transitioning from opioids to reintegrating patients with neurological conditions into the community through an outdoor and community adventures cohort program.

    Social and Community Context

    "As a population health researcher, I consider all SDOH, with a particular focus on how culture and social networks influence health," says Dawn Marie Magnusson, PT, PhD. She is assistant professor of physical medicine and rehabilitation in the University of Colorado's School of Medicine in Denver.

    She became interested in social determinants when she worked as an early-intervention pediatric PT with low-income minority families in rural Wisconsin. "Some families struggled to pay their rent or electricity and put food on the table. I knew that early intervention couldn't be their priority and wanted to better understand how I could support these families so that they would be ready for early intervention."

    Magnusson's recent research has explored the health beliefs of mothers from low-income and minority populations regarding such concepts as child development, developmental delay, and early intervention.

    "A finding of our 2017 study9 was that parents relied more on their social networks, including close friends and family members, than on health care professionals to gain information about early intervention," says Magnusson.

    For example, one woman chose to pursue early intervention for her child only after talking with a close friend. Another woman felt uncomfortable making health decisions for her son without her husband's input.

    "As a health care provider, I need to think beyond just educating my patient and consider including people from the patient's social network," Magnusson adds. "I have started asking patients: ‘Who supports you and helps you make decisions?'"

    Her research also has shown that families and health care professionals often have diverging beliefs about child development and developmental delay. "I now talk with families I work with about what these concepts mean, to help them better understand their perceptions."

    Another aspect of her work is translating developmental screening guidelines and early intervention recommendations into more meaningful and culturally appropriate concepts for families and other community members. "I stepped back and let community members decide what's most important to them and what they need to understand to facilitate engagement in the system and process," she says.

    Domestic and International Concerns: All on a Continuum

    Keyser and McKinney view the health concerns of women and girls around the world as experiences on the same continuum. "While women in low-income, low-resource settings in many parts of Africa and South Asia may suffer severely debilitating birth trauma, such as obstetric fistula, many women in the United States also suffer pelvic health problems, including incontinence, pelvic or sexual pain, and the associated shame, depression, and isolation," says Keyser, an independent consultant as well as Mama cofounder.

    Magnusson adds, "So much of my current work in neighborhoods in Denver mirrors my international work in Belize and Guatemala. Many of the underlying cultural and social issues are the same when it comes to health disparities."

    She uses a similar approach to learn about local communities. "I want to know how best to connect in a meaningful way with parents of children with developmental delay. And how do we engage them in the process? What we do to address their health needs must reflect the values and priorities of that community," says Magnusson.

    It's easy for health care professionals to forget that their own culture and cultural biases shape their perceptions of the world, she says, adding, "I have realized that my Western medicine perception of development and developmental delay often differs from that of the families with whom I am working."

    Economic Stability

    When people are unemployed and/or living in poverty—2 issues that hinder economic stability—their health can be adversely affected. Gender inequality often compounds the problem.

    "Women are important contributors to community-based economies and foundational to their country's economic growth," says McKinney, an observation that she notes is backed by the World Bank and other leading organizations engaged in economic development.10

    When a health care system doesn't adequately address maternal health issues, such as obstetric fistula, and lacks rehabilitation services, a woman's ability to contribute economically is limited. While this is true in all settings, it is more pronounced in emerging economies, McKinney says.

    The World Health Organization and other international bodies use maternal mortality as an indicator of the health and development of a nation. "As maternal mortality rates improve, there is an inherent rise in morbidity, which is connected to disability burden. This raises the question of how can we, as health care and rehabilitation professionals, support these women so they can contribute economically to their families and communities," says McKinney, who spent nearly a decade working with Keyser in women's health in the eastern DRC.

    The effects of gender-based and sexualized violence on girls and women are apparent in the DRC, she says, which has experienced decades of violent conflict. "When the trauma is unresolved among individuals, groups, and populations, the psychological and physical effects, such as unintended pregnancies, work against a woman's ability to seek and sustain employment and earn income for her family," Keyser adds.

    She points out that women from low-resource settings also may lack the income to pay for services to manage their condition. Further, McKinney says, "They may lack the knowledge or health literacy to know that they have a treatable condition and seek help."

    Neighborhood and the Built Environment

    Environmental physical determinants of health include climate change and the built environment—buildings, sidewalks, bike lanes, roads, schools, recreational settings, and so forth. They also include crime and violence, and the quality of housing.

    Water and food shortages, floods and rising sea levels, and increased spread of disease are some of the effects of climate change, says Rose Pignatoro, PT, DPT, PhD, associate professor and director of the physical therapy program at AdventHealth University in Orlando, Florida. The American Public Health Association and other health organizations have declared that climate change is a major public health threat.11

    "People with preexisting conditions are among the most vulnerable to the effects of climate change. For example, poor outdoor air quality due to pollutants or hazardous substances will affect people with respiratory conditions such as COPD [chronic obstructive pulmonary disease] and asthma," says Pignatoro. Children and the elderly also are vulnerable to extreme hot and cold temperature fluctuations due to their less-efficient thermoregulatory systems.

    Pollutants affect water quality, reducing access to clean water sources. Toxins, whether in water or food, are more difficult for people with kidney or liver disease to filter, says Pignatoro. Another facet of global warming, she explains, is that rising sea levels have increased flooding in many areas, "which impacts people with disabilities who are less mobile and need assistance to evacuate during environmental crises."

    She suggests that PTs advocate for these vulnerable populations, noting that "the scope of PT practice is shifting from a focus on the individual to the community level."

    Community-level changes can improve both individual physical activity and the environment. For example, when PTs advocate for safe walking and bicycle paths, those changes facilitate their patients' ability to walk, bike, or use public transportation, with the added benefit of reducing carbon emissions.

    Agricultural toxins also contribute to greenhouse gasses and climate change. "PTs typically recommend healthy diets to patients and can guide them toward plant-based diets, which benefit the environment and reduce obesity, hyperlipidemia, diabetes, and hyperglycemia," says Pignatoro.

    Small changes in PTs' practices can have positive environmental impacts. For example, instead of handing clients plastic water bottles, PTs can buy a water cooler or reusable nonplastic water bottles bearing their practice logo. PTs also can consider switching from printing exercise instructions on paper to using electronic resources and directing clients to online videos—"depending on the generation and patient preference," suggests Pignatoro.

    Because research shows that people with disabilities are more likely to use tobacco,12 PTs can work with state and local governments, health departments, schools, and colleges to promote policies that promote smoking cessation, says Pignatoro.

    Other ways in which PTs can have an impact include voting for candidates who support environmental protections and serving as ecological role models. "We can work on reducing our own carbon footprints and, hopefully, others will follow suit."

    Social and Community Context

    One of Health People 2020's 5 SDOH is "social and community context," which includes civic participation, discrimination, incarceration, and social cohesion.

    "We need to better understand how we're approaching and providing care to people of color in order to discover what, if any, disparate health practices exist in our profession," says Terry Nordstrom, PT, EdD, FAPTA, vice president of enrollment and student services and a professor of physical therapy at Samuel Merritt University (SMU) in Oakland, California.

    He would like academic PT programs to integrate learning outcomes on SDOH into their curricula. "These efforts could address students' understanding of social determinants, how determinants are perpetuated in the health care system, and whether the best care is being provided."

    However, while PTs can provide the best care for every patient, that won't change policies that lead to disparities or inequities, Nordstrom adds. He suggests that PTs pursue policy research in underrepresented communities. "We need to understand the upstream fundamental social and structural causes of health inequities that originated from longstanding public policies in the United States," he says. "This can facilitate advocating for changes in public policy at the local, state, and national levels.

    Nordstrom participated in the National Study of Excellence and Innovation in Physical Therapy Education and coauthored papers published in 2017.13,14 "We found that most educational institutions and PT clinics, including pro bono clinics, did not talk about social determinants of health explicitly or address the underlying structures and inequities of the people coming to the clinics."

    Nordstrom, a site visitor for the Commission on Accreditation in Physical Therapy Education, suggests that accreditation standards should reinforce curricula to identify broader topics of social determinants' structural inequalities, screen for them, and measure and evaluate student learning outcomes.

    "Accreditation can create opportunities for innovation and pilot projects that allow us to push forward on social determinants of health while still meeting base standards," he says.

    For example, he asks, how can PT education programs with a strong track record in accreditation create innovative approaches to address some of the bigger issues in education and practice through strategies such as interprofessional learning?

    Another innovation could occur with clinical experiences. "Accreditation counts full-time clinical experiences that are supervised by PTs toward the minimally required number of weeks for clinical education," Nordstrom notes. He asks: How can PTs gain experience in underserved communities where supervisors are not PTs but, instead, public health nurses?

    He also recommends a mission- backed admission policy that intentionally includes students from diverse backgrounds. "If it's related to the school's mission, we have a lot of leeway with admission practices to be more inclusive of students who are committed to equity and meeting underserved needs," he says.

    When SMU began promoting community involvement on its website by all its health professions, "we started attracting more students who cared about social and health justice issues, who then pushed the faculty and university to develop more inclusive practices and further develop our community engagement with students from all of our programs," Nordstrom says.

    Magnusson incorporates SDOH into a course she teaches at the University of Colorado, addressing health and wellness. "I teach about structural violence and our role in identifying and ameliorating the social determinants of health in our clinical populations and communities."

    She explains that structural violence can take the forms of oppression, poverty, and discrimination, which contribute to health disparities. Students are asked to read and reflect on the profession's core values that encourage PTs and PTAs to advocate for social policies that promote the health needs of clients and their communities.

    "I want to raise their consciousness so they can better understand the root causes of health disparities—and then how we can address them in our practice and communities," says Magnusson.

    Keyser suggests integrating public health coursework into educational programming to provide students with a population health lens through which they can better understand SDOH and their applicability to PT practice. "Many students at CSM [APTA's Combined Sections Meeting] expressed interest in this work, but there are few resources, and only a limited number of PTs" with sufficient grounding in public health issues, she says.

    To that end, Keyser and McKinney are collaborating with Andrews University's new women's health academic certificate, embedded within the postprofessional doctor of science program within the Michigan institution. "We are developing a women's health and human rights course," Keyser says, which will be available online to postprofessional students and for continuing education.

    While having a public health background may be helpful, the PTs interviewed for this article say, don't let the lack of one stop you from getting involved. All PTs and PTAs, they emphasize, have a role in moving the needle on the successful transition to population health.

    Christine Lehmann is a freelance writer.

    References

    1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270(18):2207–2212. doi:10.1001/jama.1993.03510180077038. https://jamanetwork.com/journals/jama/article-abstract/409171. Accessed May 3, 2019.
    2. Mokdad AH, Marks JS, Stroup DF, et al. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238-1245, doi:10.1001/jama.291.10.1238. https://jamanetwork.com/journals/jama/article-abstract/198357. Accessed May 3, 2019.
    3. Artiga S, Hinton E. Beyond health care: the role of social determinants in promoting health and health equity. Issue Brief. May 2018. Henry J Kaiser Family Foundation. https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/. Accessed May 3, 2018.
    4. Understanding Social Determinants of Health. Healthy People 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health/objectives. Accessed May 3, 2019.
    5. Secretary's Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020. Healthy People 2020: An Opportunity to Address the Societal Determinants of Health in the United States. July 26, 2010. https://www.healthypeople.gov/sites/default/files/SocietalDeterminantsHealth.pdf. Accessed May 3, 2019.
    6. Neeru G, Castillo-Laborde C, Landry MD. Health-related rehabilitation services: assessing the global supply of and need for human resources. BMC Health Serv Res. 2011;11:276.
    7. Hornbuckle LM, Amutah-Onukagha N, Bryan A, et al. Health disparities in women. Clin Med Insights: Women's Health. 2017;10:1-4.
    8. Wu JM, Hundley AF, Fulton RG, et al. Forecasting the prevalence of pelvic floor disorders in US women: 2010 to 2050. Obstet Gynecol. 2009;14(6):1278-1283.
    9. Magnusson DM, Minkovitz CS, Kuhlthau KA, et al. Beliefs regarding development and early intervention among low-income African American and Hispanic mothers. Pediatrics. 2017;140(5):e20172059.
    10. Marquez PV. Healthy Women Are the Cornerstone of Healthy Societies. The World Bank. January 12, 2017. https://blogs.worldbank.org/health/healthy-women-are-cornerstone-healthy-societies. Accessed April 16, 2019.
    11. National health and medical organizations issue declaration, urge bold action to fight climate change declaration on climate change and health [news release]. American Public Health Association; April 4, 2016. https://www.apha.org/news-and-media/news-releases/apha-news-releases/2016/declaration-on-climate-change-and-health.
    12. Centers for Disease Control and Prevention. Disability and Health: Cigarette Smoking Among Adults with Disabilities. https://www.cdc.gov/ncbddd/disabilityandhealth/smoking-in-adults.html. Accessed May 3, 2019.
    13. Jensen GM, Nordstrom T, Mostrom E, et al. National study of excellence and innovation in physical therapist education, part 1—design, method, and results. Phys Ther. 2017;97:857–874.
    14. Jensen GM, Nordstrom T, Mostrom E, et al. National study of excellence and innovation in physical therapist education, part 2—a call to reform. Phys Ther. 2017;97:875–888.

    Key Areas of Social Determinants of Health

    The social determinants of health have been defined for the United States in Healthy People 20201 and for the world by the World Health Organization (WHO).2 The determinants overlap, with WHO including factors that are particularly applicable to developing countries.

    Healthy People 2020 Social Determinants

    Economic Stability

    • Employment
    • Food insecurity
    • Housing instability
    • Poverty

    Education

    • Early childhood education and development
    • Enrollment in higher education
    • High school graduation
    • Language and literacy

    Social & Community Context

    • Civic participation
    • Discrimination
    • Incarceration
    • Social cohesion

    Health & Health Care

    • Access to health care
    • Access to primary care
    • Health literacy

    Neighborhood and Built Environment

    • Access to foods that support healthy eating patterns
    • Crime and violence
    • Environmental conditions
    • Quality of housing

    World Health Organization Social Determinants

    Employment Conditions

    • Measures to clarify how different types of jobs and the threat of unemployment affect workers' health

    Social Exclusion

    • The relational processes that lead to the exclusion of particular groups of people from engaging fully in community and social life

    Public Health Programs & Social Determinants

    • Factors in the design and implementation of programs that increase access to health care for socially and economically disadvantaged groups

    Women & Gender Equity

    • Mechanisms, processes, and actions that can be taken to reduce gender-based inequities in health by examining different areas

    Early Child Development

    • Opportunities provided to young children that are crucial in shaping lifelong health and development status

    Globalization

    • How globalization's dynamics and processes affect health outcomes: trade liberalization, integration of production of goods

    Health Systems

    • Innovative approaches that effectively incorporate action on SDOH

    Measurement & Evidence

    • Development of methodologies and tools for measuring the causes, pathways, and health outcomes of policy interventions

    Urbanization

    • Broad policy interventions related to healthy urbanization, including close examination of slum upgrading

    References

    1. Understanding Social Determinants of Health. Healthy People 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health/objectives. Accessed May 3, 2019.
    2. World Health Organization. About Social Determinants of Health: Key Concepts. http://www.who.int/social-determinants/sdh_definition/en/ Accessed April 15, 2019.

    Web Resources

    Screening Tools for Social Determinants

    The Health Leads Screening Toolkit

    Health Leads

    healthleadsusa.org/resources/the-health-leads-screening-toolkit/

    Upstream Risks Screening Tool and Guide

    HealthBegins

    https://cl.ly/3M051Q1M1O1O

    Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health

    Centers for Disease Control and Prevention

    www.cdc.gov/nccdphp/dch/programs/healthycommunitiesprogram/tools/pdf/sdoh-workbook.pdf (.pdf)

    PT Organizations and Volunteer Opportunities

    Move Together

    www.movetogether.org/

    PT Day of Service

    http://ptdayofservice.com/

    Mama

    www.themamas.world/about.html

    Arlington Free Clinic

    www.arlingtonfreeclinic.org/


    Comments

    Excellent article and important topic. But you start off talking about health care, whether it is pro bono or aimed at marginalized populations it is still health care which is not addressing the social determinants of health. Yes health care access is important but later in the article you discussed more clearly about the importance of housing, education, employment, transportation and the role PTs can play in a community to improve these conditions. Providing pro bono care is important and setting up clinics as well but that charity work does not address the sustainable problem of lack of social justice in these areas whether they are domestic or international. We must get PTs to work in public health and advocate for those that have poor outcomes by improving the social conditions not just the health care they receive. We do that by voting, getting involved in communities and changing the social environmental conditions. Good start but PTs need to know there is more to do than just providing charity care.
    Posted by Ira Gorman on 7/8/2019 1:59:44 PM

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