Comprehensive Study Guide on Social Determinants of Health and Racism in Public Health

Racism as a Public Health Imperative

• Why is racism considered a public health issue?   - Racism affects healthcare access, stress levels, illness rates, and life expectancy.   - It is a primary driver in the creation of health disparities.

• Defining Structural Racism:   - This refers to system-wide inequality across various sectors, including housing, healthcare, education, employment, and public policies.   - These systems disadvantage specific racial groups through established frameworks.

• Disparities in Black Maternal Mortality Rates:   - The higher rates associated with Black maternal mortality are not attributed to biology.   - Causes identified include bias, unequal treatment, chronic stress, and institutional racism present within the healthcare system.

• Public Health Leadership Recommendations from Bassett:   - Leaders must explicitly recognize racism as a determinant of health.   - They must advocate for substantive policy change.   - There is a requirement to address unequal healthcare treatment directly.   - Recognition that racism permeates housing, healthcare, income, neighborhoods, education, and stress levels.

• Examples of Institutional Racism:   - Hospital bias.   - Unequal provision of prenatal care.   - Discrimination during hiring processes.

• Impact of Community Conditions on Health:   - Pollution levels.   - Unsafe neighborhoods.   - Lack of accessible medical clinics.   - Food deserts (areas with limited access to affordable and nutritious food).

• Importance of Addressing Racism in Healthcare:   - Essential for the reduction of disparities.   - Necessary to improve health outcomes for marginalized communities.

Cultural and Linguistic Competence in Care

• Core Philosophy of Cultural Competence:   - "Understand culture to improve care."

• Rationales for Cultural Competence:   - Improves interpersonal communication.   - Builds trust between patients and providers.   - Reduces existing health disparities.   - Leads to improved health outcomes.   - Ensures patients feel respected during their care journey.

• Practical Examples of Culturally Competent Healthcare:   - Provision of interpreter services.   - Recruitment and hiring of minority staff members.   - Implementing cultural awareness training for all employees.   - Utilizing community health workers.   - Including family members in healthcare decisions.   - Placing clinics in accessible geographic areas.   - Expanding clinic hours to accommodate diverse schedules.

• Linguistic Competency:   - This involves providing healthcare communication in a patient’s native language.   - Coverage includes medical forms, appointment scheduling, billing statements, and medical advice lines.

• Importance of Interpreter Services:   - Critical for reducing misunderstandings.   - Improves the quality of communication between providers and patients.

• Biases Healthcare Workers Should Recognize:   - Racism.   - Sexism.   - Ageism.   - Homophobia.   - Classism.

• Role in Reducing Disparities:   - Improved access, trust, and quality of care for diverse populations.

The Social Ecological Model and Organizational Strategy

• Levels of Influence in the Social Ecological Model:   - Individual level.   - Interpersonal level: Influences such as family support, friends, and personal relationships.   - Community level: Factors including neighborhood safety, access to clinics, and food deserts.   - Organizational level.   - Policy/Society level.

• Strategies for Healthcare Organizations to Increase Competence:   - Offer comprehensive interpreter services.   - Train all staff members.   - Increase diversity within the workforce.   - Improve physical and economic accessibility.   - Respect and integrate cultural practices into care plans.

• Consequences of Incompetent Healthcare:   - Miscommunication.   - Lowered levels of trust.   - Worse health outcomes.   - Patients avoiding necessary healthcare services.   - Increased health disparities.

Social Determinants of Health (SDOH)

• Definitions of SDOH:   - Economic and social conditions that influence people’s health and quality of life.   - The conditions in which people are born, grow, live, work, and age that affect health outcomes.

• Core Factors Influencing Outcomes:   - Housing (stability and quality).   - Education (access and quality).   - Income and economic stability.   - Food access/security.   - Discrimination.   - Healthcare access and quality.   - Early childhood development.   - Employment.   - Social support and community context.

• The Five Determinants of Health:   1. Genes and biology.   2. Health behaviors.   3. Social environment.   4. Physical environment.   5. Health services/medical care.

• Percentage of Health Determined by Genes and Behaviors:   - Approximately $25\%$, meaning social and environmental factors account for the majority of health outcomes.

Intervention Frameworks: Upstream, Midstream, and Downstream

• Upstream Determinants:   - These are the root causes of health problems.   - Examples: Poverty, housing issues, lack of education, and racism.   - Importance: They prevent disease before it starts by addressing foundation issues.

• Midstream Interventions:   - Focused on changing behaviors before an illness worsens.   - Examples: Nutrition programs, physical activity initiatives, and smoking prevention campaigns.

• Downstream Determinants:   - Treating health problems after they have already manifested.   - Examples: Surgery, medication, and emergency care services.

Healthy People 2030 Initiative

• Overview:   - A national initiative setting data-driven goals to improve health and well-being in the U.S. over the next decade.   - Includes $358$ core measurable objectives.

• Major Goal Related to SDOH:   - Creating social, physical, and economic environments that help all people achieve health and well-being.

• Five Categories of SDOH in Healthy People 2030:   1. Economic Stability: Includes income, employment, and the ability to afford food or housing.   2. Education Access and Quality: Includes graduation rates.   3. Health Care Access and Quality: Includes insurance coverage.   4. Neighborhood and Built Environment: Includes pollution, safe housing, parks, transportation, and food access.   5. Social and Community Context: Includes community support.

• SDOH Workgroup Purpose:   - To focus specifically on social determinants and develop related health objectives.

Policy Impacts and State Resilience (The Butler Analysis)

• Examination of the Trump Administration:   - Butler examined how federal policy changes affected SDOH programs.   - Findings included reduced federal guidance for SDOH and limited Medicaid flexibility.   - Significant slowing of federal momentum for SDOH initiatives.

• Federal Setbacks Identified:   - Cuts and reorganization of community health programs.   - Increased instability in immigrant communities.   - Weakened trust in the public health system.

• Medicaid Section $1115$ Waivers:   - Special permissions allowing states to test new approaches under Medicaid.   - Historically used for housing assistance, nutrition support, transportation, and community-based care.   - Policy changes made approval more restrictive, creating barriers for states.

• State and Local Resilience:   - Despite weaker federal support, states, hospitals, and local organizations continued SDOH programs (e.g., food insecurity and housing support).

• Political Divergence in State Approaches:   - Republican-led states: Emphasized targeted assistance, personal responsibility, and smaller government programs.   - Democratic-led states: Emphasized Medicaid expansion, expanded social services, and larger public health investments.

Specific Economic and Social Determinants

• Income:   - Affects health directly through access to resources (nutritious food, healthcare, safe housing).   - Affects health indirectly through living conditions, stress levels, and health behaviors.   - Childhood poverty increases long-term disease risk later in life.   - Reducing disparities requires higher wages, affordable housing, and reducing medical debt.

• Education:   - Referred to as the "root to the tree" because it influences many other determinants both directly and indirectly.   - Increases earning potential and health knowledge.   - Higher educational attainment is linked to lower smoking rates.   - Lower education is associated with obesity, mental health issues, chronic illness, and early death.   - From $1997$ to $2017$, health declined and disparities increased among less-educated adults.

• Occupation:   - Influences health through income, benefits, and exposure to hazards (chemicals, dust, pollutants, heavy lifting).   - Psychosocial stress can be caused by job pressure, low control, and workplace hierarchy.   - Low-wage jobs often lack insurance and paid sick leave.   - Occupational Segregation: Systemic inequalities pushing certain racial or social groups into riskier or lower-paying jobs.   - CDC Definition: Work is a "driver, marker, and outcome of inequity."

References and Key Scholarly Works

• Belluz, J. ($2015$). This is why you shouldn’t believe that exciting new medical study. Vox.
• Braveman, P., Egerter, S., & Williams, D. R. ($2011$). The social determinants of health: coming of age. Annual Review of Public Health.
• Graham, H. ($2004$). Social determinants and their unequal distribution: clarifying policy understandings. Milbank Quarterly.
• Goodman, A. H. ($2000$). Why Genes Don't Count (for Racial Differences in Health). American Journal of Public Health.
• Williams, D. R. ($2012$). Miles to go before we Sleep: Racial Inequities in Health. Journal of Health and Social Behavior.
• Kawachi et al. ($2005$). Health Disparities by Race and Class: Why Both Matter. Health Affairs.
• Bassett, M. T. ($2015$). #BlackLivesMatter — A Challenge to the Medical and Public Health Communities. NEJM.
• Krieger, N. ($2003$). Genders, sexes, and health: what are the connections—and why does it matter? International Journal of Epidemiology.
• Gilmore, A. B., et al. ($2023$). Defining and conceptualising the commercial determinants of health. Lancet.