Social Determinants of Health: A Health Services/Policy Perspective Shoshanna Sofaer, Dr.P .H. Senior Scholar, School of Public Health & Health Policy, CUNY
A bit of history The idea of social, economic and political determinants of health goes back a long way: For example, people have for centuries recognized the link between poverty and ill health LaLonde report in Canada in the 1960’s first articulated a modern idea of SDOH My own training at UC Berkeley in the 1970’s built around Henrik Blum’s idea of “the football,” which identified in increasing order of impact the following determinants of health: Genetics Medical Care Behavior Social, Economic and Political Environment Internationally, SDOH have been inescapable In US, recent attention has been different in engaging health care delivery & insurance Shoshanna Sofaer, Dr.P.H. 6/2/2019 2
This panel: Emphasis on economics as a determinant of health I would argue that even the study of food insecurity is essentially about economics: difficulties in purchasing sufficient healthy food AND economic barriers to availability of healthy food in certain communities Berkowitz et al. study: Intervention on the surface is straightforward: provide food to food insecure people But working with low-income populations is NEVER simple and straightforward Interventions must be designed to suit the specific population, which means you have to learn about them and their “peculiarities” Actually attracting people to things they need can be harder than we think Is this because of issues with “trust?” Implications for choosing the people who will be the “face” of the intervention - Shoshanna Sofaer, Dr.P.H. 6/2/2019 3
But does trust always matter? Greene et al. study There are large differences in trust for institutions and systems as compared to a particular known physician Think about what that may mean for the influence of physicians over health care While there are differences in whether you have a personal physician by race/ethnicity, there do not appear to be differences in trust of physicians by race/ethnicity but there are differences in trust of the health care system by race On the other hand, there are significant differences in whether one has a personal physician and trust in that physician by INCOME And significant differences in trust across the board by INCOME The big question: WHY? Shoshanna Sofaer, Dr.P.H. 6/2/2019 4
Trust in another context Gallopyn and Iezzioni study: A worker-employer relationship that we need to know more about Please note potential discussant bias here: my husband gets personal care 24/7 from two caregivers and has for over five years These are difficult and charged relationships One issue not addressed: how present and active were family members Structurally, this is a set up for racial/ethnic based difficulties between those who serve and those who are served This is a serious human problem, but it also has enormous policy implications Unless these issues are addressed, we will not have enough caregivers for the emerging older generations of baby boomers Shoshanna Sofaer, Dr.P.H. 6/2/2019 5
Impact of Changes in Minimum Wage on Multiple Health-related outcomes Narain & Zimmerman study This is a complex study of one way to look at the relationship between income and health My questions: What does the minimum wage represent as an income? How does it differ from poverty level? How might it differ from an income level derived from different approach to figuring out how much people/families need to live a “good” life? My hope is that the researchers will continue this line of research! Shoshanna Sofaer, Dr.P.H. 6/2/2019 6
Ideas about how to improve the research in this area Explore other social determinants (obvious and being done) Try to “tell a story” of how it is that a given determinant or set of determinants come to have an impact on health In particular, try to get at specific behaviors Do more studies of interventions as well as studies of how the world works (or doesn’t) as it now is Try to include some qualitative work (interviews, focus groups) Note that this might be useful BEFORE major quantitative work is done, especially when using secondary data Shoshanna Sofaer, Dr.P.H. 6/2/2019 7
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