Rethorn ZD, Cook C, Reneker JC. Social Determinants of Health: If You Aren’t Measuring Them, You Aren’t Seeing the Big Picture. J Orthop Sports Phys Ther. 2019 Dec;49(12):872-874. doi: 10.2519/jospt.2019.0613. PMID: 31789121.
See the video version here.
Take 5 – 5 Critical Takeaways to Improve your Practice
- Social Determinants of Health (SDH) may be more influential over health outcomes for musculoskeletal (MSK) conditions compared to direct medical treatment.
- SDH also affects health behaviors and lifestyle choices, and are the most modifiable factor.
- If you are going to screen for SDH, then you better have resources available and ready for referral.
- “There is no cookbook for this work.” Asking the specific needs of each community is crucial when addressing SDH.
- We need more research on how SDH impacts health outcomes.
A patient comes into the ED after hurting their back lifting a mattress at work. They recently started working for a moving company so that they can try to save enough money for rent so they can move out of the motel they are staying in with their husband and two children. The patient and their family immigrated to the US a few years ago and got kicked out of their housing due to gentrification of their neighborhood, where their extended family also lives nearby. The motel doesn’t have a kitchen, so they either make microwave dinners or go to fast food restaurants to save time and money. Sometimes the water at the motel never gets warm and the heating is inconsistent. The patient is currently not ambulatory due to pain. Imaging is unremarkable and discharge orders are pending. What can you do and what does this patient need right now?
The study “Social Determinants of Health: If You Aren’t Measuring Them, You Aren’t Seeing the Big Picture” reviews and informs the reader on how SDH impacts outcomes for patients with MSK conditions (1). As PTs, sometimes we focus solely on our interventions and evidence based practice for treating MSK conditions. But what key elements are we missing? And what is our PT role in addressing community needs and the SDH? This article starts the conversation of how the SDH should be included in PT practice.
- Social Determinants of Health (SDH) may be more influential over health outcomes for musculoskeletal (MSK) conditions compared to direct medical treatment.
The report states that medical treatment may only contribute 20% to recovery, and that the SDH contributes to health outcomes more (social and economic circumstances 40%, environmental factors 10%, behavioral patterns 30%) (1). The figure in the article highlights economic stability, education, health care, neighborhood and built environment, and social and community context as the key factors that make up the SDH. I recommend looking at this figure to understand how each contributes to health outcomes and health behaviors.
- SDH also affects health behaviors and lifestyle choices, and are the most modifiable factor.
The SDH makes it more or less likely for someone to choose a healthier behavior over another. For example, poor urban planning makes it less desirable for a person to engage in outdoor physical activity. So how can we lighten the “SDH load?” The article suggests knowing resources outside of “traditional” clinical care, getting to know your community and their needs, and creating partnerships with local leaders and organizations. (see #4). When the SDH changes positively, people are more likely to make healthy behavioral choices, which may ultimately impact recovery after an MSK injury.
- If you are going to screen for SDH, then you better have resources available and ready for referral.
The article brings up an excellent point regarding if it’s ethical to inquire about a patient’s risk for SDH unless you have a readily available resource or referral to provide to a patient. For example, is it fair to recommend outpatient PT to a patient that already struggles with limitations in transportation unless you’re also connecting them to an affordable and sustainable transportation option? In my experience, collaboration with case management, social work, and familiarity with local organizations and resources has significantly helped patients get the resources they need in a timely fashion that support the patient beyond their chief complaint.
- “There is no cookbook for this work.” Asking the specific needs of each community is crucial when addressing SDH.
Every community has different challenges and it’s important to understand the unique problems of different neighborhoods and communities. For example, both urban and mountain communities in Colorado have challenges with affordable housing for low to middle income people and families. One additional challenge that people face in urban areas is exposures to different environmental pollutants that may be present in lower income neighborhoods. You can’t treat each community the same, so you have to know who you are seeing and the general population health information of the area. The report argues for a community needs assessment as a way to establish common goals and language regarding community health and the prospect for different health initiatives specific to a community’s needs.
- We need more research on how SDH impacts health outcomes.
Not only are the SDH hard to quantitatively study, there just isn’t any research out there about how it impacts outcomes for patients with MSK conditions specifically. The SDH impacts how well they can be studied. The report gives the example of transportation limitations for follow up during a study and difficulty with data collection. Also, the sample must be representative. And due to the nuances of community needs, this can be hard to study due to lack of generalizability. If we can measure the impact of the SDH more effectively, then we can understand health outcomes better and work diligently with the community, government officials, and policy makers to reduce its impact on our patients.
Summary
I hope this article is informative and helps look at the whole picture of what contributes to patient outcomes and health. The ED is America’s safety net, so the SDH will certainly show up in this setting and PTs need to know how it affects their patients and the role they can play in improving patient outcomes, and not just from a PT intervention standpoint. Knowing your patient population and local community and the challenges they face can and will make us better advocates.
More on SDH from the CDC found here.