Social Determinants of Health: A Health Services/Policy Perspective - - PowerPoint PPT Presentation

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

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The idea of social, economic and political determinants of health goes back a long way:

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For example, people have for centuries recognized the link between poverty and ill health

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LaLonde report in Canada in the 1960’s first articulated a modern idea of SDOH

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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

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Internationally, SDOH have been inescapable

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In US, recent attention has been different in engaging health care delivery & insurance

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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-

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But does trust always matter?

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Greene et al. study

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There are large differences in trust for institutions and systems as compared to a particular known physician

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Think about what that may mean for the influence of physicians over health care

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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

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On the other hand, there are significant differences in whether one has a personal physician and trust in that physician by INCOME

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And significant differences in trust across the board by INCOME

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The big question: WHY?

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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

• lder generations of baby boomers

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Impact of Changes in Minimum Wage

• n 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!

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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

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