Christine Chim, PharmD, BCACP
Sharon Connor, PharmD
Miranda Law, PharmD, BCPS
Stephanie Lukas, PharmD, MPH
Jonathan Thigpen, PharmD
At the end of this case, students will be able to:
- Explain the definition of social determinants of health
- Identify the broad factors that influences an individual’s health status important to public health
- Compare and contrast determinants of health that impact overall health and well-being specific to unique patient populations
- Identify patient specific needs related to determinants of health using a holistic approach
Our health is determined by more than just our genetics and our physical well-being. In fact, according to the World Health Organization (WHO), health is not limited to the lack of disease but includes an individual’s physical, mental and social states.1 The leading causes of death worldwide include heart disease, pulmonary disease and diabetes,2 and these non-communicable diseases are impacted by our personal behavior and by larger factors such as where we live, our education level and our ability to access care. However, in the US and beyond, inequalities in these environments and social factors create health inequities.
According to the CDC, social determinants of health (SDH) are the conditions and circumstances surrounding an individual’s life that can affect their health outcomes.3 Healthy People, the US government’s agenda for improving health outcomes,4 defines these conditions as places in which people thrive or are adversely affected.5 Health disparities and health inequity exist when differences lie among these environments, particularly where obstacles to good health are many and great. Equity is “the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.”6 Thus, health equity exists when access to resources linked to good health is equitable and fair, regardless of social status.7 Health inequities result from differences in SDH and unequal distribution of resources. Health equality is achievable when health inequities are addressed accordingly. SDH impact health disparities, defined as the differences seen in health outcomes as a result of an individual’s disadvantages, whether social, economic, or environmentally.8 Such negative outcomes include increased illnesses, lower quality care, higher mortality rates, and greater health care costs.
In order for populations and individuals to achieve health, many factors must be considered. This is clear when looking at the many outcomes and objectives of Healthy People 2020. Healthy People 2020 provides a framework that helps to identify resources and tools to address SDH. The framework consists of five key determinants – economic stability, education, social and community context, health and health care, and neighborhood and built environment – all of which exhibit factors that can dictate an individual’s health-associated risks and outcomes.5 Globally, there is also a concerted effort to improve the lives, health and well-being; the Sustainable Development Goals (SDG) were developed to ensure a sustainable future and to assist in achieving health for all by fighting poverty and inequalities. Good health as a human right should be obtainable by all. Thus, SDG 3 addresses health and well-being at all ages.9 There are multiple factors for health care providers to consider when providing care. It is especially pertinent to consider how socioeconomic status (e.g., income, education, occupation) impacts health, particularly when considering how it influences the ways individuals interact with their environment. For example, how might income affect health care access and utilization? How might education influence health literacy and the ability of an individual to feel empowered and engaged in their own health? Furthermore, how might differences in SDH contribute and exacerbate health disparities? These are important considerations we, as practitioners, must understand in order to aid others in achieving their full health potential.
You are a clinical pharmacist at a family medicine ambulatory care clinic
CC: “I’m here for a follow-up appointment.”
HPI: AJ is a 45-year-old, Hispanic male (69 in, 82 kg) who comes into the clinic today for an appointment to manage his medications and ensure his disease states are controlled.
PMH: T2DM; hypertension; COPD; high cholesterol
- Mother: alive, with T2DM
- Father: alive, with T2DM and HF
- Brother with pre-diabetes
- One daughter
- Drinks alcohol socially
- Previous smoker (1.5 PPD), quit 2 years ago
- Denies illicit drug use
Surgical history: N/A
ROS: (+) Chronic cough with sputum production
- BP 144/88
- HR 60
- RR 16/min
- Temperature 37°C
- Pulse oximetry 93% on room air
Labs (drawn at last visit 1 month ago):
- Na 135 mEq/L
- K 4.2 mEq/L
- Cl 108 mEq/L
- CO2 26 mEq/L
- BUN 19 mg/dL
- SCr 1.1 mg/dL
- Glu 168 mg/dL
- Ca 9.6 mg/L
- Mg 3.6 mg/L
- A1c: 7.8%
- Metformin 500 mg – 2 tablets PO BID
- Hydrochlorothiazide 25 mg – 1 tablet PO daily
- Lisinopril 20 mg – 1 tablet PO daily
- Atorvastatin 40 mg – 1 tablet PO daily
- Fluticasone/salmeterol 100/50 mcg – 1 inhalation BID
- Albuterol 90 mcg HFA – 1-2 puffs every 4-6 hours as needed
SDH and additional context: AJ is married and has a five-year-old daughter. He was born in the US, and his parents are immigrants from Mexico and made barely enough to support him and his younger brother. He grew up in a relatively under-resourced neighborhood in a small apartment with 1 bedroom, 1 bathroom, and a shared living/eating space. He often likes to tell short stories about how he grew up when he comes for clinic visits, describing how they had to squeeze his whole family into one bedroom at night, and often, how his little brother would accidentally kick or punch him in his sleep. He talks about growing up eating fast food hamburgers because they were inexpensive and his parents didn’t have much time to cook for him and his brother. Additionally, there was only one grocery in his neighborhood that was over five miles away, and since his parents did not own a car, they rarely went. He remembers sometimes the water ran a little strange colored from the faucets, that streets were almost always covered in trash, and that many buildings were broken down and not maintained. He and his brother did not play outside often because it was not safe to be out after dark, there was barely any clean park space, and so he would be at home and either watch tv or play card games with his brother.
AJ works as a bank teller at a local bank. He finished high school with average grades, but decided to go work immediately because his parents were getting old and he had to make money to support their life and health care. He mentioned once that he considered applying for college but could not afford it, and therefore, never bothered. His wife is a stay at home mom, taking care of the apartment and their daughter. She previously worked as a bank teller (this is how they met), but had to quit her job to take care of their daughter because child care was not affordable.
As an adult and father, AJ has made enough money to move out of the neighborhood he grew up in. His family now lives in two-bedroom apartment in a neighborhood that has a fairly average income. There are two grocery stores within walking distance, and one decent school that his daughter will eventually be able to go to. AJ makes sure he provides everything he can for his daughter, giving most of his income to pay for healthy meals, saving up for school supplies and eventually college, and providing her with toys and clothes that she needs. They use the second bedroom for her so she can have her own bed and room. Additional income goes to his mother and father, who are now retired and living off very little. Because most of his money goes to his family, he has very little for himself, often still eating the fast food hamburgers that he grew up on to leave the healthy meals for his family. Additionally, AJ sometimes skips picking up his medications because they can cost a lot. He will take medications every other day to make them last longer. AJ is quite proud of what he has been able to provide for those he loves, especially because he was given so little as a child.
1. What aspects of AJ’s childhood may have influenced his current health status? Elaborate on each aspect and explain why it influences his current health status.
Aspects from AJ’s childhood that may have influenced AJ’s current health status could include, but not be limited to, his diet comprised of fast food, limited physical activity, crowded living environment, unsafe drinking water, living in a polluted area, and living in an unsafe community. It is important to remember that factors outside AJ’s control (e.g. unsafe communities) play a large role in AJ’s health status.
Factors related to his diet and physical activity could contribute to the development of chronic diseases such as diabetes, hypertension, and high cholesterol. AJ, as an adult, now has all three of these. A crowded living environment could impact aspects of mental health and well-being. Pollution and unsafe drinking water could either cause immediate more acute effects or accumulate later on impact respiratory or gastrointestinal systems.
2. Compare and contrast the childhood AJ had and the one his daughter now has. What does she have (that AJ didn’t) that might impact her health in the future?
AJ has worked really hard to provide his daughter with resources and an environment that he did not have when he was younger. She lives in a neighborhood that is safe, walkable, and provides good education. She is able to eat healthy meals and has what she needs for learning. Additionally, she has her own space and privacy if she wants or needs it. Because of the resources that AJ’s daughter has, her healthy diet can help prevent disease, her ability to have physical activity outside can also help prevent disease, and her education will empower her to ensure that her choices in the future can benefit her health.
3. How do AJ’s current responsibilities impact his health? What advice would you give him as his healthcare provider?
AJ currently spends most of his time working to support his family and minimal time taking care of himself. He gives everything to his family and sacrifices healthy eating so his loved ones can have it. His fast food habits could be contributing to the worsening of his chronic health problems (diabetes, hypertension, high cholesterol). Since he gives up most of his money for his family, he sometimes skips picking up his medications, which could also worsen his current conditions.
Advice for AJ could focus on the importance and value of his own health. By staying healthy, eating health home cooked meals, and adhering to his medication regimens, he can prevent the worsening of his current conditions. This will allow him to keep working so he can support his family rather than potentially worsening his condition and needing to go to the hospital.
4. Consider the neighborhood AJ grew up in and all those who lived in this neighborhood. How do you think this neighborhood’s poor resources and state may have impacted all of its residents?
Social determinants of health include the many environmental and community-related factors that have a significant impact on a patient’s ability to manage their health. The environment one lives in has an inordinately large influence on their resulting health. For example, life expectancy may vary up to 20 years depending on where a patient lives.a
Overcoming one’s environment to improve their life trajectory is an extremely difficult task, especially concerning those born into poverty. Why is this the case? Those who live in underserved neighborhoods often face multiple challenges, including but not limited to substandard housing, poor quality in education, unsafe communities, lack of healthy food and safe play areas, and limited health services.b,c
Accordingly, in AJ’s case, we can begin to understand how such external factors may have contributed to the health of AJ, his family, and community.
Recognizing the many external and internal factors that influence health and contribute to health disparities, it often makes sense to implement policies aimed to address issues at both the individual and community wide levels. For example, let’s say a particular community was experiencing an increase in obesity. Resulting policies may try to both educate community leaders about healthy eating habits and exercise (individual level) while also increasing fresh, healthy grocery options in local area (community level).
5. What can pharmacists do to help patients and communities with low-resources?
Pharmacists are uniquely positioned to connect with patients as one of the most accessible members of the healthcare team. We see many of our patients regularly as they pick up their prescriptions and the community doesn’t need an appointment to meet with us. As such, we are at the frontline of providing care. We are in a prime position to connect patients with resources and provide appropriate education. Interventions could include: counseling patients on healthy food and exercise options, running health fairs, inviting guest speakers in the pharmacy to cover health-related topics, providing educational brochures for patients to take, hanging a local resource bulletin board in the pharmacy with flyers for things like discounts at local gyms, working with local health departments to create a pharmacy resource binder so that if a patient comes in needing something specific such as the location of the closest federally qualified health center or foodbank the pharmacists knows how to connect them.
The role of the pharmacist as a patient and community advocate doesn’t end once they leave the walls of their pharmacy. As we know health disparities is a systematic issue, if we want to see real changes, we need to change the system. Pharmacists can help in many ways for example: involvement in policy development (connect with legislators through letters, calls or visits to educate them on an issue; join a pharmacy organizations’ advocacy group; run for political position), education (volunteer at a school, become a tutor or mentor, provide health resources), nutrition (volunteer with a local foodbank) or homelessness (volunteer with a shelter, a vocational training program or a mental health organization).
a. Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, Morozoff C, Mackenbach JP, van Lenthe FJ, Mokdad AH, Murray CJ. Inequalities in life expectancy among US counties, 1980 to 2014 temporal trends and key drivers. JAMA Intern Med. 2017;177(7):1003-1011.
b. Woods ER, Bhaumik U, Sommer SJ, Chan E, Tsopelas L, Fleegler EW, Lorenzi M, Klements EM, Dickerson DU, Nethersole S, Dulin R. Community asthma initiative to improve health outcomes and reduce disparities among children with asthma. MMWR Supplements / February 12, 2016 / 65(1);11–20.
c. Lamb AK, Ervice J, Lorenzen K, Prentice B, White S. Reducing asthma disparities by addressing environmental inequities: a case study of regional asthma management and prevention’s advocacy efforts. Fam Community Health 2011;34(Suppl 1):S54–62.
Health disparities and inequities drive negative health outcomes and have long-lasting impact on patients and entire communities. When communities are not healthy, it not only has negative implications for an individual’s health status, but it also has adverse effects on the community’s economy, safety and education. This creates a negative cycle as these same issues can further health disparities divides. As pharmacists, we must care for the patients in front of us, but in our ever-expanding roles as public health professionals, we must also begin advocating for our patients and communities. We must educate ourselves on the implications of subpar and disparate housing, food access, parks and recreation, safety and violence, and education, as we must use our knowledge for advocacy and policy change a local, regional, national and international levels.
Patient Approaches and Opportunities
As pharmacists, we can do our best to optimize medication therapy; however, it is critical to think about the larger picture and the social determinants of health that are influencing a patient’s lifestyle and environment. Before making lifestyle-change recommendations, it is vital to consider what is possible for the patient to accomplish. Pharmacists must remember to recommend culturally appropriate diet and lifestyle changes that are within the realm of possibility for a patient so they have the ability to follow them. Additionally, pharmacists have the potential to make an impact at the population-health level by utilizing their patient-care experiences to advocate for larger community or district-level policy changes.
Related chapters of interest:
- Saying what you mean doesn’t always mean what you say: cross-cultural communication
- Communicating health information: hidden barriers and practical approaches
- Plant now, harvest later: services for rural underserved patients
- The ‘state’ of things: epidemiologic comparisons across populations
- Healthy People 2020: https://www.healthypeople.gov/. Accessed February 20, 2019.
- Sustainable Development Goals: https://www.un.org/sustainabledevelopment/sustainable-development-goals/. Accessed February 20, 2019.
- Federally Qualified Health Center locator https://findahealthcenter.hrsa.gov/. Accessed February 20, 2019.
- Find a local foodbank with Feeding America https://www.feedingamerica.org/. Accessed February 20, 2019.
- Spent: http://playspent.org/. Accessed February 20, 2019.
- UNNATURAL CAUSES…is inequality making us sick? Place Matters. Ellie Lee, Producer and Director, Andrea Williams, Editor. California Newsreel 2008. https://www.unnaturalcauses.org/about_the_series.php. Accessed February 20, 2019.
- Constitution of WHO: principles. http://www.who.int/about/mission/en/. Accessed August 24, 2018.
- The top 10 causes of death. http://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death. Accessed August 24, 2018.
- Social Determinants of Health: Know What Affects Health. https://www.cdc.gov/socialdeterminants/. Accessed August 24, 2018.
- Healthy People 2020 https://www.healthypeople.gov/. Accessed August 24, 2018.
- Social Determinants of Health https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed August 24, 2018.
- Healthy Systems: Equity. https://www.who.int/healthsystems/topics/equity/en/. Accessed November 30, 2018.
- Klein R, Huang D. Defining and measuring disparities, inequities, and inequalities in the Healthy People initiative. CDC. https://www.cdc.gov/nchs/ppt/nchs2010/41_klein.pdf. Accessed November 30, 2018.
- Disparities https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities. Accessed August 24, 2018.
- Sustainable Knowledge Platform, Sustainable Development Goal 3. https://sustainabledevelopment.un.org/sdg3. Accessed August 24, 2018.