Leveraging the Social Determinants of Health

Spend enough time studying healthcare in the US and one conclusion becomes increasingly clear: racial and ethnic minorities and the economically disadvantaged suffer from disproportionately poor health outcomes and a variety of other healthcare disparities. Whether the subject is incidence and prevalence of specific diseases, burden of illness, mortality, unequal access to healthcare services, satisfaction with patient—clinician relationships, or a variety of other measures, minority and underserved patient populations face many challenges.

CDC statistics demonstrate this time and again. The death rates from heart disease are 30% higher for African Americans than for Caucasians. The death rate for stroke is 40% higher. Diabetes rates are 2.3 times higher in American Indians and Alaska Natives, 1.6 times higher in African Americans, and 1.5 times higher in Hispanics than among Caucasians. While America may boast state-of-the-art care for some segments of society, and produce the lion’s share of groundbreaking research in medical treatments and advances in healthcare technology, for those on the bottom rung, many of these advances might as well have not happened. The poor, underserved, and most in need are the last to benefit and the most likely to be left behind.

Taking control of the future

Recognizing this growing gap, the Institute for Alternative Futures created the Disparity Reducing Advances (DRA) Project, with the goal of acting as a catalyst for change by “identifying the most promising advances for bringing health gains to the poor and underserved and accelerating the development and deployment of these advances to reduce disparities.”

While many organizations have similar goals, the DRA Project has been particularly grounded and strategic in its work by selecting very specific advances to promote and finding experienced organizations to partner with to carry out these advances at the patient level. Clement Bezold, PhD, who in 1977 co-founded the Institute for Alternative Futures to encourage foresight in government actions, explains that “we asked ourselves what are significant—either actual or potential—health advances that can help reduce health disparities. And the disparities that we are talking about are the ones that are avoidable and unfair. That itself is a moving target.”

The DRA Project took particular care to scrutinize what advances could make a measurable difference, were cost-effective to be applied, were appropriate for various poor and marginalized populations, and could be realistically applied within a time frame of the next 10 years. As a result of this process of evaluation, the Project organizers narrowed the field to eight advances, four in public health and four in healthcare.

“The project is a part of a futures organization, so we aim to help people understand the future better, and therefore better create it,” says Bezold. The effort to accelerate these advances meant taking a different approach from the traditional advocacy route. Although the project took on tasks such as facilitating research, publicizing results, encouraging pilots or trials in low-income populations, holding briefings for congressional staff, bringing together leaders on relevant topics, and creating maps of health outcomes and disparities (one depicted the income gradient and race gradient of various neighborhoods and illustrated how these relate to the community’s health), it has also recognized that there is a limit to what any one organization is capable of doing.

It takes a village

Rather than trying to work alone, the DRA Project began creating a network of partners who would commit to implementing and advocating the selected advances. Today, the project has a network of more than 60 committed partners, including the Center for Minority Health, Center for Information Therapy, the Institute for Community Health, the American Diabetes Association, The Intercultural Cancer Council, Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Alliance for Health Reform, and the Institute for Healthcare Improvement.

Among the advances selected by the DRA Project are researching and promoting the use of patient navigators, particularly in the cancer setting. Many underserved populations do not get tested early enough, or their cancers are not caught early enough or treated aggressively enough. Patient navigators are valuable because they help people through the system, which is often more a fragmented maze of doctors’ offices, hospitals, outpatient centers, clinics, support organizations, and payment systems. These navigators often take on the role of facilitating communication between the patients, family members, and care providers; arranging for financial support; aiding with paperwork; facilitating follow-up appointments; and arranging for transportation or child care. As some minority cancer patients have a language barrier as well, the navigators must possess the language and cultural skills needed to communicate with the patients from these underserved communities. These navigators are sometimes trained social workers, nurses, nurse practitioners, trained outreach volunteers, or even cancer survivors themselves. Visit for more information. The DRA Project is currently conducting a survey to see what some of the functions of patient navigators are, who they are, what kind of training they have, and where some of the patients are that they are seeing.

“We feel that this is one thing that would be a pretty important advance for reducing disparities, not only in cancer care, but other areas as well,” says Craig Beetles, futurist and researcher at the Institute for Alternative Futures.

Using biomonitoring to shape health behaviors

While patient navigators can have an immediate impact on reducing disparities for individual patients, the DRA Project is also taking the long view by studying the benefits and uses of biomonitoring. Two major aspects of biomonitoring have taken the project’s interest, as well as that of the Robert Wood Johnson Foundation, which has agreed to fund the research. “If we look longer term, it will be biomonitoring which shapes our behavior, a combination of the right kind of biomonitoring used inexpensively enough and together with culturally relevant and competent behavior coaching tools to shape our behaviors. The second will be biomonitoring that tells us years in advance that we’ve got pre-cancer or pre-diabetes or in the case of cancer, that we have early stage cancers, especially some of the more difficult ones like brain cancer, which usually we don’t catch until later on,” explains Bezold.

Much of this also involves creating technologies that will be available for all, not just for those who can afford them. In particular, the Project has

taken a keen interest in the use of cell phones as biomonitoring tools. Their affordability has made them quite common even in low-income communities where computer availability and literacy is often limited. Low-cost wireless is now also increasing in availability.

“Cell phones are improving in their capacity to offer, either in the device itself or as a conduit, the ability to link biomonitoring tools in a significant way to communicate the results of your medical testing to either your doctor’s electronic health record or your personal health record, for example. So cell phones will continue to grow in importance as a biomonitoring tool,” says Bezold. They could potentially be used to provide early warnings of diseases and real-time monitoring of conditions. Although the DRA Project has been looking at accelerating advances through alliances at the organizational level, Bezold says there is much that physicians can do to reduce healthcare disparities as well. Physicians can ensure that their marginalized patient populations receive continuous care without getting lost in a fragmented system. Physicians must also increasingly account for social determinants when providing medical care in lowincome and minority communities.

“The most important thing a physician can do is shape the lifestyle, particularly the diet and exercise, of many of their patients, given the role of that in chronic disease and obesity,” says Bezold. It is particularly important to understand the role of social determinants for patients. These determinants include the impact of education, employment, housing, nutrition and individual lifestyle choices regarding nutrition, exercise, and smoking choices on health outcomes. So if physicians are, for example, advocating that their patients eat fresh fruit and vegetables, they need to consider if the patients have grocery stores in their neighborhood, or only liquor stores. Can the patient even afford fresh vegetables? Rather than prescribing medications, physicians will also need to increasingly prescribe physical activity to improve health. Yet this requires sensitivity to the living conditions of the patient. Is the neighborhood safe for people to be outside?

“We have had the experience that the physicians in a practice said to their patients that they need to exercise. As it turns out, there was a boardwalk in Queens, but it was unsafe to walk there. So this community health center, the physicians, and the leaders in that community got together with the police department to announce when patrol cars would be patrolling the boardwalk,” says Bezold. By making the boardwalk safer, the physicians were able to provide a means for patients to complete the healthy activities they were prescribing and increase compliance.

Many Canadian physicians have been issued green prescription pads; on the front they can write prescriptions for medications, and on the backs they are able to check off various other prescriptions for healthy activities. In California, the Strategic Alliance is trying to get grocery stores to return to neighborhoods they have left. In Chicago, REACH US worked to get liquor and convenience stores to sell fruits and vegetables.

Creating change often requires breaking with convention, which is often a difficult task. Beetles and Bezold both agree that the DRA Project’s strength lies in its strong partner network. Promoting their disparity-reducing advances would not have been possible had they been working alone. In the same way, it would be very difficult for individual physicians to create changes in their community’s health by working singlehandedly. “It’s important for physicians to know what the resources are for changing the social determinants in their community,” concludes Bezold. “It’s not an easy task, but it’s not impossible, nor is it inappropriate for the physicians to do it, but they may need to have a sense that they are not alone.”