Understanding the Importance of Social Determinants of Health

Several years ago, I sat trying to figure out a proper hashtag for my Instagram post on “Bump Day.” I wanted to highlight maternal-fetal prenatal and postnatal care, emphasizing my own post-birth complications that led to sepsis and serious illness, but I was cautious about choosing what to say, fully aware that my favorable outcome was fortunate. My baby became compromised during normal labor, so she was subsequently born (healthy) via an urgent C-section. Unknown to me and the physician, I suffered a surgical complication at that time which later manifested in severe infection, nearly costing me my life. Five weeks after her birth, after being transferred to a skilled hospital, treated for sepsis, ventilated in the ICU, and in surgery twice over, I came home with a wound vacuum, home-health nursing services, and significant medical trauma. A community of family and friends rallied around me. I found a quick recovery, and we rejoiced because God had been gracious to me and my family.

Though the entire occurrence was unfortunate and frightening, my baby was alive, and so was I. And months later, when things began to return to normal, I thought to educate myself about maternal health outcomes, partly for my own recovery journey. I read stories from advocacy and awareness groups and sifted through statistics in prominent medical journals. A stark reality became apparent: For every good outcome, there were scores more stories with endings unlike my own, especially among minority groups. In fact, a Black woman between the ages of 30-34 has a pregnancy-related mortality rate four times higher than that of myself, a white woman of the same age.

By no means am I an expert on health disparities. However, I am greatly interested in better understanding, assessing for issues, and ultimately improving upon statistics like the one mentioned above. There are volumes of well-written, rigorously academic papers detailing specifics in data analytics, research, and more. Many voices have contributed significantly to shining a light on leveling health outcomes among minority groups, and yet we have much to learn.

I grew up in a rural part of western Pennsylvania, and having graduated with 64 other white people, I had never met anyone with darker skin until I went to college. I did, however, have the luxury of being born to parents who believed that differences among humans (be it color of skin, intellect, ability, or other) were not that significant, and thankfully they lived out the virtuous concept that all people are created equal and deserve dignity. In part, these ideals drove me into the practice of medicine, hoping to serve God in a tangible way by taking care of people.

I have spent much of my career trying to positively impact Appalachian health statistics daily, noting challenging barriers to health care and holistic health for patients in West Virginia. I had the privilege of serving as a healthcare provider at a free clinic for almost 12 years. For the first few years, I fumbled around with my prepared “script” I had developed through my schooling: talking at my patients; insisting upon healthier habits (such as eating more fresh produce and exercising more); admonishing their smoking habits; highlighting the benefits of Omega-3s and other supplements; chastising them for not taking their medications as directed; telling them to decrease stress and quit drinking soda and keep their appointments and sleep more…

All this advice proved to be mostly fruitless in impacting the overall lives of my patients.

My advice wasn’t bad, necessarily, but it was tone-deaf. I didn’t know what I didn’t know, as they say. It took time, but I began wanting to better understand the barriers which kept patients from wellness. I grew a more refined sensitivity to patients’ abilities, needs, and desires.

My concept of health care changed entirely as I began to better understand that “health” and “wellness” were words on a spectrum, impacted by innumerable factors. My medical schooling led me to believe that patients would be coming to me to receive care and a partner for their wellness, both of which would be of major importance in their life. Although that theory wasn’t explicitly taught, it was a generally well-understood background concept that lacked nuance.

The reality proves that in much of Appalachia and most minority communities across the country, despite the stress of poor health, becoming healthy or receiving health care is not a priority for many. As I became better educated about social determinants of health and health disparities, proverbial lights flipped on, and my practice of medicine brightened and changed for the better.

The World Health Organization defines social determinants of health as “nonmedical factors influencing health outcomes.” These are the conditions in which people are born, grow, work, live, and age. And it also includes the broader systems that impact daily life, such as economic policies, social norms, racism, political parties, and more. Research shows that social determinants can be more important than healthcare or lifestyle choices in influencing health.

Numerous studies suggest that social determinants of health actually account for more than 60% of health outcomes.

Lack of income or education, unemployment or underemployment, job insecurity, food insecurity, poor familial or community support, unsafe neighborhoods/housing, language barriers, or access to affordable health services all play significant roles in whether someone will be “healthy.”

If you can visualize the 1990s food pyramid taught in every high school health class, you can conjure an appropriate image to explain this concept better. If you recall, the top of the pyramid depicting the smallest portion, reserved for sweets and oils, was labeled: “use sparingly.” The bottom foundation holding the largest slot was dedicated to whole grains, encouraging having multiple servings of this category daily. Noble fruits, vegetables, and dairy took substantial middle places. I once saw a health graphic that used this pyramid concept, and it helped provide a clear visual for me to understand better how social determinants of health impact overall health. As a health care provider, I was shocked to see that the pyramid contents were the opposite of what I would have expected for most people.

Instead of leaving the biggest space at the base of the pyramid for “health care engagement,” it was the smallest “use sparingly” section which held “health care, etc.” Meanwhile, things such as “safe housing,” “transportation,” “nonviolent relationships,” “food,” “employment,” “mental health access,” and “money” made up the bulk of the pyramid layers below.

For so many patients, life’s troubles consume much of their energy and attention. Figuring out how to afford groceries, get a ride to work if the bus doesn’t run, find childcare, get a refill on their insulin, pay past-due bills, leave a codependent relationship, or find a new place to rent takes precedence.

These things actually make up one’s health. Upon recognizing this truth, that tiny space at the tippy top of the pyramid holding “health care, etc.” suddenly made more sense. Once I recognized the weight of the massive social issues that most of my patients faced, I could better understand why their health and wellness were rarely prioritized and why health disparities persisted in certain places.

A better understanding of social determinants of health gave me context for better addressing health disparities among the patients I cared for.

So, as I sought to use my personal social media profile as a platform for awareness about maternal prenatal and postnatal care, finding a hashtag to consume my newfound awareness proved difficult. I had to reconcile that although the conventional medical system was indeed a part of my personal recovery, my own social determinants of health weighed heavily. I could not deny that I was afforded opportunities based on where I lived, who I knew, and what resources were available in my community, and it was a sobering thought.

I had access to a health care facility where I had personal associations which advocated for me when I could not advocate for myself. I had an engaged, loving spouse. I had health insurance that permitted me to be transferred to the best health care facility in our area, which was in another state and still an hour’s drive away.

We had transportation for my husband to get there. I had supportive neighbors and a faith community that helped care for my newborn baby. I had a biological family that stood by my bed and supported both me and my husband. I had an employer who held my job, and I qualified for short-term disability leave. I had friends who made healthy food for me when I came home. A friend helped me wash my hair and get dressed when I couldn’t do it for myself. My faith community visited and prayed for me.

I had a licensed mental health clinician friend who provided trauma-processing-counseling to me in my home as I recovered. My husband had the flexibility to pause his work while I was hospitalized.

We had childcare while we went to follow-up visits. I had a safe, clean home to recover in, in a safe, clean neighborhood. I have a medical degree and could participate in my own recovery, including doing dressing changes with a wound vacuum and being watchful for signs of reinfection. I could afford the medication I needed to take afterward. And I’m sure the list could go on.

I certainly don’t list those things to disparage or compare boastfully. I list those things to note the multifaceted resources it took to recover from such an encompassing medical trauma and illness. My outcome was favorable for various reasons, and my own social determinants of health should not be overlooked as contributory factors.

As I have gone forward in clinical practice, I have sought to be mindful of the social situations, home lives, personal issues, and societal challenges patients may face. I often think of the pyramid image. When a challenging health issue presents itself for a patient, personalizing care with an eye on specific social determinants of health can improve health outcomes. Patients should not feel embarrassed or ashamed by limits or barriers preventing them from achieving wellness.

Paradigm shifting among clinicians can help us stratify patient risk if we are quick to collaborate with social services, normalize mental health care, be knowledgeable of and use community resources, refer for social services, address spiritual health, and communicate with supportive family members if necessary. I believe intentional, personalized care can improve health outcomes among minority groups. Statistics can change—awareness matters. When we think about social determinants of health, my goal as a clinician is to provide equitable, quality care to every single patient, and it is my hope that the overall field of medicine begins to understand these things better as well so that we can positively impact our marginalized communities and minority groups in the years to come.