Challenging the Status Quo of Social Determinants
Healthbox Forum events bring together healthcare leaders and innovators in a small group setting to explore important industry topics and to think creatively about how to implement actionable change. This May, we invited a group of stakeholders from across the industry to examine the influence of social determinants on individual and community health and the opportunity for healthcare organizations to improve health outcomes and reduce the costs of care. We are excited to share insights from the Healthbox Social Determinants Forum to spur more discussion across the innovation community.
Social Determinants of Health: Definitions
Health happens where we live, learn, work, worship, and play, yet we often only think of health taking place in the doctor’s office or at the hospital, or even simply consider it the absence of illness. In reality, only 20% of our health is determined by the healthcare we receive; the remaining 80% is determined by socioeconomic factors, physical environment, and health behaviors. These root causes of health are preventable, avoidable, and actionable and include the following domains: economic stability, neighborhood & physical environment, education, food, community & social context, healthcare system, and policy. At the Healthbox Social Determinants Forum, stakeholders explored existing approaches and interventions, the responsibility they each have to impact the social determinants of health, and the role of data and technology in improving the health of our most vulnerable populations.
Zip Code and Race: Drivers of Health Disparities (or The Intersection of Health, Race, and Place)
When discussing social determinants of health and our diverse roles in addressing them, it is imperative that we acknowledge the existence of disparities that disproportionately affect the health of poor and minority populations. These populations have reduced access to prevention and intervention and receive differential treatment even after access barriers are overcome. Attendees engaged in conversations that examined how deep, underlying biases and prejudices at both the personal and policy level perpetuate these disparities and lead to an unfair distribution of resources.
A Chicago Department of Health (CDPH) Healthy Chicago 2.0 study unveiled how profoundly bias and prejudice impact resource distribution, and in turn, the health of our most vulnerable populations. For instance, the life expectancy for people living in two Chicago neighborhoods located merely three train stops apart differed by 14 years; an individual’s zip code, perhaps surprisingly, is a more accurate measurement of their health than genetic code. A CDPH and University of Chicago health equity study that measured how proximity to toxic waste centers, access to fruits & vegetables, educational attainment, and availability of safe and clean parks, among others, impacts community health revealed how closely health, race, and place are connected: 1 in 2 African American and Hispanic children were found to live in low child opportunity areas compared to 1 in 50 white children. Social determinants such as race, physical environment, and community play a tremendous role in determining the health of communities, yet these factors are often overlooked or left out of the healthcare conversation.
It’s challenging to look past individual privilege and experiences to uncover and understand the obstacles and needs of different communities, but we share a responsibility as health professionals to surface and address the “‘unvisible’—what we don’t see due to our biases” to truly improve health outcomes for all citizens. How can we, from positions of power, elevate social determinants of health and community perspective to the forefront of conversations to make decisions that better serve our most vulnerable populations? Until we build structures, systems, and policies that allow for people to live a healthy life, we cannot achieve health equity.
Above: Child Opportunity Mapping from Healthy Chicago 2.0 Report
Leveraging Data and Technology to Improve Health Outcomes and Equity
Community level data and technology are invaluable tools in helping stakeholders identify areas of greatest need and prioritize how to make efficient use of the resources that exist to improve health outcomes. Several stakeholders discussed using geo-mapping technology to inform where to build community assets that serve people with the highest need and which assets to prioritize. The CDPH, for example, used geo-mapping technology to create a public resource called Chicago Health Atlas, a central repository for data on 160+ indicators of health and well-being. The CDPH used this data repository to identify resource gaps across neighborhoods; results showed that while some affluent neighborhoods had sidewalks, access to public transport, and a plethora of public schools and parks, other low-income areas had half the public schools and parks, broken sidewalks, and more difficult access to transport. Not surprisingly, those living in poor, resource-deficient neighborhoods had significantly worse rates of housing and socioeconomic vulnerability. Access to this data not only gives stakeholders the ability to better understand the health opportunity landscape, but it also serves as incentive to build infrastructure in places with the highest need to impact health outcomes at the root level. Furthermore, CDPH uses data and technology to design predictive analytics and innovation models that mitigate environmental health hazards like lead paint, mold, and food borne illnesses. For example, computer models that rank food establishments based on likelihood to have food violations allows CDPH to send inspectors to those locations first to prevent illness before it occurs.
While data is a powerful tool for evaluating the health landscape, predicting outcomes, informing decision-making, and measuring the success of an intervention, we must be aware of confirmation bias. How can we ensure the data we’re using is accurate, valid, and complete in order to create objective, evidence-based predictions and solutions? Many community asset-mapping models rely on Google Maps as a primary source for assessing the state of affairs; however, this approach to gathering data can result in inaccurate information and creating an incomplete picture of a community. One Chicago-based nonprofit MAPScore, the data engine for NowPow, uses a community-engaged approach to gather accurate and complete data that community members and stakeholders can access to better promote health and economic vitality within their communities. MAPScore trains and employs high school students as community data scientists to capture data about all of the public facing businesses and organizations serving their community by applying scientific method and mobile technology. Integrating community members into the data collection process can help provide more meaningful and thorough community asset maps. Data is a powerful, descriptive tool for outlining the state of affairs; thus, our responsibility as stakeholders is to uncover the causal drivers of health care inequity that lie in data to promote public policy and economic strategies that create opportunity, unlock undiscovered abundance and build health equity.
Key Takeaways from the Healthbox Social Determinants Forum:
- Particular emphasis should be placed on levers that influence “upstream interventions” that support preventive and pre-emptive public health actions that are likely to be the most impactful upon health and wellbeing.
- The causal drivers of social inequity are often hidden in the unrecognized biases and prejudices that even socially conscious individuals bring to their everyday decisions. In addition, deficiencies in neighborhood structural assets, disparities in economic opportunity, challenges in education attainment, unavailability of healthy food choices, fragility of social support mechanisms and insufficient access to appropriate health and wellness services are the preconditions for poor health and lack of wellness.
- With the abundance of data at hand we can begin to describe and characterize the challenges of the social landscape with the purpose of forming testable hypotheses to define the highest priority opportunities and the most impactful solutions to improve community health and well-being. Ensure that the data being collected and used is accurate, valid, and complete.
The Forum generated a strong sense of optimism that the availability of relevant vetted data sources will shed new light on the path forward towards building health equity and healthier communities. Informed partnerships, empowered communities and a strong public voice have the power to drive collective benefit for the medical commons. Our goal is not to simply redistribute resources in a limited zero-sum game, but rather to create opportunity and equity as the foundation for community abundance, growth, wellness and productivity.
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 Healthy People 2020
 Booske, et. al. 2010. County Health Rankings Weighting Methodology
 Inspired by Ralph Ellison’s novel Invisible Man, Forum panelist and attendee Stacy Lindau, Founder of NowPow, used the term “unvisible” to describe the biases that we hold that lie beneath the surface