Category Archives: Social Determinants of Health

The factors that influence and impact health including social/cultural structures.

Intimate Partner Violence

Recognize structural factors that contribute to IPV and IPV disparities, using this example of IPV among Indigenous women. 

There will be an in-class discussion of this reading.  Amnesty International “Maze of Injustice” Chapters 1, 2 and 8 (pp 1-18, 75-82)

Here is a brief (2min) frame of IPV and the importance to health & healthcare 

IPV introductory video:

 

Optional reference for students to have as they travel throughout WWAMI, to understand their responsibilities/requirements if they encounter a disclosure: 

Information on rules/requirements for mandatory reporting by state

Optional reference for students to have as they travel throughout WWAMI, to direct patients to appropriate resources ;

Information on state-specific DV/IPV/assault resources: state by state numbers and resources 2018

Optional printable reference for students who wish to use/give out the cards and/or lose the hard copy they were given:

“Is Your Relationship Affecting Your Health” safety card

Optional reading for students who wish to learn more about dating violence among teens/tweens:

Fact sheet on dating violence among adolescents

Intersectionality and Structural Competency

These three readings explore the complexities of identity and power in the clinical setting from the patient and physician perspectives.

  1. Manning, Kimberly D. “The nod.” JAMA 312.2 (2014): 133-134.
  2. Gridley, Samantha. “The Gold–Hope Tang, MD 2015 Humanism in Medicine Essay Contest: Third Place Gauze and Guns.” Academic Medicine 90.10 (2015): 1356-1357.
  3. Lynch, Katrina. “The Gold–Hope Tang, MD 2015 Humanism in Medicine Essay Contest: Second Place The Doctor Will See You Now.” Academic Medicine 90.11 (2015): 1530-1531.

Optional readings for students who want to explore more:

Introduction to Social Determinants of Health / What is Health?

Read What is Health by Fiona Godlee (2011), BMJ. The goal for this activity is to introduce students to two definitions of health. Students should take notes and reflect on the reading. Students can also research definitions of health.

Additional Optional resources – Review websites

The Medical Safety Net

After Class:

GOAL for this reading: Provide additional data regarding community health centers, populations served, and funding received.

Instructions: Read the “Executive Summary” of “Community Health Centers: Recent Growth and the Role of the ACA” after class in preparation for community experience.

Optional video:

Optional additional references:

Community Violence: ACEs, Resilience, and Trauma Informed Care

Watch Nadine Burke Harris’s TED talk that introduces key concepts about Adverse Childhood Experiences and how they impact health.

Read about how one community is addressing violence (PDF) and adverse childhood experiences.

Optional: For students who want to see how the idea was started – Read the original ACE Study, Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults.

Social Determinants of Health in US Populations

Required:

  • Link and Phelan. 1995. “Social Conditions as Fundamental Causes of Disease” Journal of Health and Social Behavior pp.80-94
    • In this foundational article, social epidemiologists Bruce Link and Jo Phelan argue three main points:
      1.  social conditions (e.g., SES, inequality, racism, segregation) have a causal effect on health and well-being,
      2. to understand patterns of disease prevalence and incidence, we need to contextualize risk factors and understand what conditions put people “at risks of risks” (i.e., people in poor neighborhoods have an elevated risk of exposure to crime which increases the risk of stress accumulation), and
      3. researchers need to acknowledge that social conditions are not just distal causes of disease, they are FUNDAMENTAL causes, meaning that the relationship between the social conditions (e.g., SES) and health is robust and will remain present even as the risk factors for disease and the leading causes of disease/death change.
    • This is because high SES individuals are afforded flexible resources that they can use to avoid risks and minimize the consequences of disease.
  • Frieda, Misha. 2016. “For Native Americans, Health Care Is a Long, Hard Road Away”.
    • NPR : https://www.npr.org/2016/04/13/473264076/for-native-americans-health-care-is-a-long-hard-road-away
  • Social Determinants of Health PPT

Stroke

Objectives

1. Work with the concepts of life course and exposure and susceptibility in relation to risk of having and surviving a cerebral vascular accident, with potentials for good or bad outcomes when there is class, racial, gender, or geographic inequality
2. Discuss potential stroke prevention interventions at different stages of the life course and different levels of the social-ecological model, taking into account class, racial, gender or geographic inequality

Why this topic:
It is important to recognize that over the course of one’s life there are exposures that can put someone at advantage or disadvantage regarding health risks. This is true for stroke. What are the upstream exposures? How can we explain these exposures and their health consequences to others including our patients?

Before class: (what is written below is also in a word doc version)

1. Review risk factors for stroke at link (Links to an external site.)Links to an external site..
2. Explore the CDC website: Interactive Atlas of Heart Disease and Stroke (Links to an external site.)Links to an external site.

  Think about the following questions:

  • How does the WWAMI compare to the rest of the country with regards to stroke prevalence and death from stroke?
  • What does the prevalence of stroke look like in your Foundations WWAMI state?
  • When looking at your WWAMI state, are there disparities among individual counties?
  • Are there risk factors, social and economic characteristics, health behaviors, or access to care measures that you find surprising for your Foundations state and its individual counties? Use data and filter options to see disparities within individual counties.

3. Read the “Future Directions” section (pages 887-888) pdf which is extracted from Harvanek et al. Social Determinants of Risk and Outcomes for Cardiovascular Disease: A Scientific Statement From the American Heart Association Circulation 2015  (Links to an external site.)Links to an external site.(link for those who want to read the entire article) about social determinants of health and their impact on cardiovascular disease. Cardiovascular disease risk is often used as a surrogate for stroke risk.

4. Come to class prepared to think about influences on a person’s risk of having a stroke (remember that the impact is multi-factorial) and be prepared to discuss the article. In particular, how might physicians communicate inequities within risk factors that lead to disparities for strokes and their outcomes.

5. Read Perzynski et al., Informing Policy for Reducing Stroke Health Disparities from the Experience of African American Male Stroke Survivors 2015 and think about how one can improve stroke health disparities as a society and as an individual physician.

In Class

Stroke SDH PowerPoint

During the session you will be divided into smaller groups. Each of small groups will be provided with a clinical vignette highlighting a patient diagnosed with a stroke. Keep the following concepts in mind.

1. Over a life course there are various pathways to health and disease.
2. There are effects of exposures, with cumulative interplay and effects.

Working as a groups and using the Social Ecological Model, give examples of the pathways and exposures that might have advantaged or disadvantaged the patient described in the clinical vignette. One member from your group will type out your group’s thoughts into a public Google spreadsheet. Specifics for using the spreadsheet will be given in class. Consider these questions:

  • What elements of the individual’s history suggest possible positive and negative pathways and exposures?
  • If you were to write the fictional (but realistic) story of the individual’s life, what other possible positive and negative pathways and exposures can you think of? Do NOT stereotype the individual. DO think of the complex interplay of factors throughout the life course, and the influence of factors at all levels of the social ecological model. Use the case as a sketch, and paint the rest of the picture.
  • What factors, if present in the case, or worth exploring, might have put this person at increased risk for stroke?
  • What factors might influence the likelihood of surviving the stroke?

 

Cultural Context of Pain

Objectives

  1. Recognize and discuss factors leading to pain treatment challenges, variability, and access due to race, gender, ethnic, social and economic disparity
  2. Describe unique pain assessment and management needs of special populations
  3. Describe the role of the clinician as an advocate in assisting patients to meet treatment goals
  4. Explain how health promotion and self-management strategies are important to the management of pain
  5. Describe patient, provider, and system factors that can facilitate or interfere with effective pain assessment and management
  6. Design an individualized pain management plan that integrates the perspectives of patients, their social support systems, and health care providers in the context of available resources
  7. Reflect on the wider role of the clinician, within and beyond the healthcare system, as an advocate for patients suffering from chronic pain
  8. Describe the impact of pain on society

Before Class

1. Required reading

After reading the articles, write a short reflection that includes the following, and upload it to the pre-class quiz on Canvas.
For each article:

What is one finding in each article which surprised you? Why?
What is one thing you have a question about?
How and where will you seek answers to your questions?
One of the studies noted in the first article mentioned that some Native patients have an ‘expectation of empathy.’ The Native patients “expressed the conviction that it was the provider’s role to perceive and experience the patient’s pain in order to treat it” without the patient having to describe their pain in detail. What do you think about this? Do you believe this is possible across cultural beliefs and practices? Why or why not?

2. Required videos

Some questions to ponder as you watch:

In the field of medicine you are particularly interested in, how might historical trauma express itself in a patient’s life? What would be some possible physical, psychological or emotional manifestations?
Do you think historical trauma is different or the same as social determinants of health?

  • Interview with Chaplain Joisky Caudill: An Indigenous Perspective on Health and Wellness (12 min) 

    Some questions to ponder as you watch:
    How did Chaplain Joisky negotiate her care with her physicians? As a provider, how might you offer opportunities for your patients to negotiate their treatment with you? What would you do, say or ask?

Some questions to ponder as you watch:
What are ‘positive’ stereotypes about Native Americans/Alaska Natives? Why are they harmful?
What is your reaction when you hear Chaplain JoiSky’s definitions of medicine and health?  How would you know if your patients defined these concepts differently than you do? Why might that be important to be aware of?

There is mention that some Native people may understand illness and pain as manifestations of sickness of soul or as something which happens as a result of something a person was meant to do but hasn’t done. How would you work with patients who hold beliefs such as these? Would their beliefs change how you would provide care for them?

‘Racial Disparities in Pain Medication Use’ (10 min)

Review from EHM Cultural Humility Film (first 12 of 15 min) 

Historical Trauma: Hozhonahaslíí: Stories of Healing the Soul Wound Part III (11 min)

In Class

Students will work in small groups to discuss the case story with a community consultant.
Small groups should designate a member to write up a brief summary of their discussion with guest consultant (please include in your summary who your guest was, and the names of the people in your group).

The summary should include
1. One thing which was surprising to hear or was a new perspective
2. Two points of information you will carry forward as a future physician

We will reconvene as a large group for report out.

Please sign in for attendance of small group.

After Class

Healing the Warrior’s Heart 

 

Social Ecological Model

Social Ecological Model

McLeroy, Bibeau, Steckler and Glanz are generally credited with creating the social ecological model of care.  A quick Google search for the social ecological model will reinforce how widely it has been adopted.  There are numerous community, state, national and international organizations that utilize this model in their programs.

Think back to your session in immersion on the social history.  How often do you think beyond the individual and interpersonal factors that influence you and your patients health?

Image result for social ecological model uw

 

From CDC Colorectal Cancer Control Program (CRCCP)