When Health Decisions Aren’t a Matter of Choice: Addressing Social Determinants of Health
Physical therapists (PTs) and physical therapist assistants (PTAs) focus on both restoring movement in those with decreased function and promoting healthy behaviors to prevent health problems such as obesity or high blood pressure. But in doing so, they also must consider how social determinants of health—economics, education, neighborhood, and other factors—influence the lifestyle choices patients and clients make.
Zachary D. Rethorn, PT, DPT, a home health PT, board-certified orthopaedic clinical specialist, doctoral student in health promotion and wellness, and adjunct professor at the University of Tennessee at Chattanooga, has been giving these ideas careful thought and incorporating them into his practice. In 2018, he co-presented on the topic of social determinants of health at APTA's NEXT Conference and Exposition, and earlier this year he published a blog post that further explored the topic. In the post, he writes:
. . .the narrative in our country is one in which personal responsibility is emphasized so much that we can forget we live in communities and systems which influence the choices we make. Say you have a prized rose bush (like I do). If it doesn't bloom this year am I going to uproot it, chuck it out, and get a new one? Of course not! When a flower doesn't bloom you fix the environment in which it grows. Not the flower.
#PTTransforms interviewed Rethorn to learn how PTs and PTAs can incorporate these concepts at the point of care.
#PTTRANSFORMS: In your blog post, you write about the 5 areas of social determinants of health: economic stability, education, social and community context, health and health care, and neighborhood and built environment. Most of these areas pertain to things that neither the patient nor the provider can change, for the most part. You can't change the fact that your neighborhood isn't safe for you to get more physical activity, for example. How can a clinician use this information? Should we be screening for social needs?
ZR: The first question we have to ask ourselves is are we a profession which delivers health services? Or are we a profession that promotes the health of our neighborhoods, communities, cities, and states? If we believe that our role is to advocate for and improve the health of those we serve, then a good place to start is by considering the social and environmental context in which our patients live.
Screening for social needs can be very different from our typical medical or health screening tools. I want to caution readers that screening must be linked to the ability to provide appropriate referrals and treatment. Screening without the capacity to assist is ineffective and potentially unethical.
To mitigate negative unintended consequences of screening, here are 5 tips:
- Be patient-/family-centered in screening.
- Integrate screening with referral and linkage to community-based resources.
- Perform screening within the context of a comprehensive system that supports early detection.
- Acknowledge and build on strengths of patients, families, and communities.
- Engage the entire practice population, rather than targeted subgroups.
#PTTRANSFORMS: How can a clinician evaluate this information and use it to help with shared decision making to improve the patient's health?
ZR: There are a number of evidence-based toolkits that clinicians and health systems can use to screen for social needs, including HealthLeads, PRAPARE, HealthBegins, and the Accountable Health Communities Screening Tool. These tools all provide a starting point with recommended core domains such as food insecurity, housing instability, utility needs, and financial resource strain. Based on a community's needs, additional domains such as child care and social isolation may be added.
Whatever tool you choose to use:
- Make it short and simple—no more than 12 questions, written at a fifth-grade reading level, translated into appropriate languages.
- Choose clinically validated questions designed to open a conversation.
- Integrate the tool into clinical workflows.
- Elicit patient feedback to prioritize screening items.
- Pilot before scaling.
Once a clinician has gathered information about an individual's social context, it is essential to open a conversation with that individual regarding what he or she wants and believes will be most helpful. This is place where the clinician can provide advice and not only refer the individual to other services, but also facilitate access to those services in a sensitive, culturally acceptable, and caring way.
#PTTRANSFORMS: What modifications can a PT make to account for, say, a neighborhood where a patient feels unsafe? Or lack of access to fresh fruits and vegetables?
ZR: The first step to take if individuals are saying that a neighborhood is dangerous or there is no access to fresh fruits and vegetables is to understand what local resources are available. Often, there are resources available that the person may not be aware of.
For the first few years of my practice, I worked in a neighborhood where many of my patients felt unsafe going outside. But as I got to know the neighborhood better, I realized there were opportunities for physical activity outside but perhaps in ways different from what I first envisioned. Instead of coaching individuals to take walks by themselves, I started walking groups. Suddenly, this became a feasible way for many of the older adults I worked with to feel safe and be more social in their neighborhood.
If a creative solution is truly unavailable, this is where advocacy comes into play. My clinic was located in a food desert, where the closest grocery store with fresh produce was 2 miles—but 3 bus changes and 50 minutes—away. As I heard more and more that lack of access to healthy food was a perceived need in my population, I took this to a local farming nonprofit that agreed to begin hosting a mobile market in the neighborhood 2 afternoons per week.
These examples are not extraordinary. They come from carefully listening to the individuals I serve and reimagining my role as a PT from one who simply delivers interventions to one who is invested in and cares about the health of my patients. Caring about the health of my patients necessarily means that I care about the social and environmental context they live in, because the context is what shapes their health behaviors and choices.
#PTTRANSFORMS: When working with a patient, how do you balance empowering the individual to make healthy choices with the knowledge that some things you just cannot control?
ZR: When I work with a patient, I am considering health influences at multiple levels. At purely an individual level, I am examining their health behaviors such as physical activity, diet, stress, and sleep. During my history taking, I will ask about these factors and coach the patient to change their health behaviors based on their desires and resources.
At a wider level, I am cataloguing the individual and systemic barriers that individuals are relating to me. Perhaps a number of individuals are telling me that the sidewalks in their neighborhood are in disrepair. At this point, I can gather more information from a neighborhood association, search for data related to sidewalks in the city, or go to a city councilor to bring up the need related to sidewalk repair.
The goal is to find pain points where social and economic factors present barriers to individuals' ability to engage in health behaviors. From there I can use clinical experience and research evidence to advocate for social change which will improve the health of the population I serve.
#PTTRANSFORMS: Is there a danger of implicit bias here? How can clinicians avoid making assumptions about the relationship between a patient's health and these 5 areas? Or do social determinants of health help us respect the personal, economic, and cultural circumstances our patients face?
ZR: Current data suggest that, first, implicit bias is a real phenomenon. We all hold underlying attitudes and stereotypes toward members of other groups. But not only is it real, health care providers exhibit the same amount as the general population. This bias is shown in positive attitudes toward Whites and negative attitudes toward people of color. Further, this implicit bias may impact the clinical decision making of health care providers toward their patients.
Addressing implicit bias must be a conscious decision. One way to avoid making assumptions is to commit to screening for social determinants of health across your entire patient population and not just for select subgroups. If you target only demographic variables such as age, education, residence, underrepresented minority status—it may reinforce stereotypes and prejudicial presumptions and could stigmatize the screening process.
Another strategy is to improve your understanding of health disparities and bias in health care. Once I understood the daily challenges that my population faced, I became more empathetic and better equipped to facilitate positive changes in the community.
#PTTRANSFORMS: Do you see social determinants of health taking a larger role in health research in the future? How so?
ZR: Research on the social determinants of health is already robust. The influence that the social and environmental context plays on individuals' and populations' health is clear. The question is: Do we have the social will to take what we already know and implement it? Are we willing to address health where it starts, not just where it ends? Can we make the healthy choice the easy choice in culturally sensitive and appropriate ways from neighborhood to neighborhood and city to city?