Category Archives: Social Determinants of Health

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

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)

What is Health?

The Oxford English Dictionary defines health as “the state of being free from illness or injury.”  

The constitution of The World Health Organization (WHO) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Fiona Goodlee, editor of the British Medical Journal and the editorial staff at The Lancet have both written editorials about the evolving definition of health.  Click on the below links to read the two articles.  Read the articles with the below questions in mind.

As you progress throughout your medical student career (and beyond) we would encourage you to return to this page to reflect upon:

  • How do you currently define health?
  • How has the definition of health changed over time?
  • Does the definition of health change by perspective?  Is health defined differently in the United States that it is in other countries?
  • Do patients define health differently than their physicians?
  • Does the public health system define health differently than hospitals?
  • How are medical schools accountable for health?

Lexicon

This is a partial list of some important terms. For a more complete list, see the Diversity and Inclusion Dictionary.

Diversity: Diversity means more than just acknowledging and/or tolerating difference. Diversity is a set of conscious practices that involve:

  • Understanding and appreciating interdependence of humanity, cultures, and the natural environment.
  • Practicing mutual respect for qualities and experiences that are different from our own.
  • Understanding that diversity includes not only ways of being but also ways of knowing;
  • Recognizing that personal, cultural and institutionalized discrimination creates and sustains privileges for some while creating and sustaining disadvantages for others;
  • Building alliances across differences so that we can work together to eradicate all forms of discrimination.

Diversity includes, therefore, knowing how to relate to those qualities and conditions that are different from our own and outside the groups to which we belong, yet are present in other individuals and groups. These include but are not limited to age, ethnicity, class, gender, physical abilities/qualities, race, sexual orientation, as well as religious status, gender expression, educational background, geographical location, income, marital status, parental status, and work experiences. Finally, categories of difference are not always fixed but also can be fluid. Diversity includes respecting an individual’s right to self-identification and recognizing that even though hierarchies based on identity are built into systems, no one culture or identity is intrinsically superior to another.

Identity:  the qualities, beliefs, etc., that make a particular person or group different from others. Some ways in which we identify are connected to groups which are socially ascribed such as gender, race, age, class, sexual orientation, ability, nationality and citizenship, etc.

 Implicit Bias:  Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.  These biases, which we all hold and which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or control.   The implicit associations we harbor in our subconscious cause us to have feelings and attitudes about and different responses to people based on characteristics such as race, gender, age, and appearance. These associations develop over the course of a lifetime beginning at a very early age through exposure to direct and indirect messages.  In addition to early life experiences, the media and news prograaming are often-cited origins of implicit associations. Implicit biases are malleable, and since they are learned, they can be gradually unlearned through a vareity of debiasing techniques.

Intersectionality:  Though theories related to intersectionality have been around since the 19th century, Kimberlé Crenshaw professor of law and an expert on critical race study first coined the term intersectionality in 1989 to describe how social and cultural identities/categories interrelate on concurrent and multiple levels to create interlocking systems of social inequality.  Intersectionality is a theory or standpoint that allows us to see and understand the ways in which social categoris of difference like gender, race, age, class etc are woven together.  For example, if a person is transmasculine, brown, and working class with no health insurance, they may have a much more difficult time accessing trans*affirming health care than a transmasculine, white, middle class person with health insurance.

Power: One definition of power that is both simple and useful is: “the ability to get what you want.” Power is a relational term. It can only be understood as a relationship between human beings in a specific historical, economic and social setting. It must be exercised to be visible.

It is worth noting here the difference between forms of power that are ‘power-over’ and ‘power-with’. Power-over is power that is used in a discriminatory and oppressive way: It means having power over others and therefore domination and control over others (e.g. through coercion and violence). Power-with is power that is shared with all people in struggles for liberation and equality. In other words, it means using or exercising one’s power to work with others equitably.

Privilege:  A special right, advantage, or immunity granted or available only to a particular person or group of people whether they want those privileges or not, and regardless of their stated intent.  Privilege is characteristically invisible to people who have it. People in dominant groups often believe that they have earned the privileges that they enjoy or that everyone could have access to these privileges if only they worked to earn them. In fact, privileges are unearned and they are granted to people in the dominant groups whether they want those privileges or not, and regardless of their stated intent.  Unlike targets of oppression, people in dominant groups are frequently unaware that they are members of the dominant group due to the privilege of being able to see themselves as persons rather than being constantly regulated to the level of stereotype. Privilege operates on personal, interpersonal, cultural, and institutional levels and gives advantages, favors, and benefits to members of dominant groups at the expense of members of target groups.

Oppression/Target Groups: Oppression is the combination of prejudice and institutional power, which creates a system that discriminates against some groups (often called “target groups”) and benefits other groups (often called “dominant groups”). Examples of these systems are racism, sexism, heterosexism, cis-sexism, ableism, classism, ageism, and anti-Semitism. These systems enable dominant groups to exert control over target groups by limiting their rights, freedom, and access to basic resources such as health care, education, employment, and housing.

Four Levels of Oppression/”isms”:

  • Internalized / Personal Oppression: Values, Beliefs, Feelings
  • Interpersonal Oppression: Actions, Behaviors, Language
  • Institutional and Structural Oppression: Rules, Policies, Procedures
  • Cultural Oppression: Beauty, Truth, Right

Oppression Internalized (inferiority and superiority): Internalized inferiority is the process whereby people in the target group make oppression internal and personal by coming to believe that the lies, prejudices, and stereotypes about them are true. Members of target groups exhibit internalized oppression when they alter their attitudes, behaviors, speech, and self-confidence to reflect the stereotypes and norms of the dominant group. Internalized oppression can create low self-esteem, self-doubt, and even self-loathing. It can also be projected outward as fear, criticism, and distrust of members of one’s target group.

Internalized superiority is the process whereby people in the privileged group make oppression internal and personal by coming to believe that the lies, prejudices, and stereotypes about people in a target group are true, which positions people in the privileged group as superior.  Members of privileged group often exhibit internalized superiority by assuming they are smarter and more deserving of decision making power, comfort, and authority than people in the associated target group.  This is often expressed through perfectly logical explanations that justify and normalize discriminatory behavior.

Race: Someone has said that “race is a pigment of our imagination”. That is a clever way of saying that race is actually an invention. It is a way of arbitrarily dividing humankind into different groups for the purpose of keeping some on top and some at the bottom; some in and some out.  Ant its invention has very clear historical roots; namely, colonialism. “Race is an arbitrary socio-biological classification created by Europeans during the time of worldwide colonial expansion, to assign human worth and social status, using themselves as the model of humanity, for the purpose of legitimizing white power and white skin privilege” (Crossroads-Interfaith Ministry for Social Justice).

To acknowledge that race is a historical arbitrary invention does not mean that it can be, thereby, easily dispensed with as a reality in people’s lives. To acknowledge race as an invention of colonialism is not the same as pretending to be color blind or declaring, “I don’t notice people’s race!”  For example, it has been demonstrated that health professionals are less likely to prescribe painkillers for people of color who are experiencing the same symptoms as white people. So, even though race is a social construct, when someone doesn’t get the pain medication that they need because of implicit bias, race and racism have real consequences.  Our world has been ordered and structured on the basis of skin color and that oppressive ordering and structuring is racism.

 Racism: Racism is a system in which one race maintains supremacy over another race through a set of attitudes, behaviors, social structures, and institutional power. Racism is a “system of structured dis-equality where the goods, services, rewards, privileges, and benefits of the society are available to individuals according to their presumed membership in” particular racial groups (Barbara Love, 1994. Understanding Internalized Oppression). A person of any race can have prejudices about people of other races, but only members of the dominant social group can exhibit racism because racism is prejudice plus the institutional power to enforce it.

Stereotype: An exaggerated or distorted belief that attributes characteristics to members of a particular group, simplistically lumping them together and refusing to acknowledge differences among members of the group.

Cultural Competency: Cultural competency is a common, well-intentioned approach to teaching (presumably) privileged people that cultural mastery of traits, beliefs, traditions, etc. of marginalized communities is possible.  While it is certainly important to be aware of cultural practices that are outside one’s own lived experiences and world view, this definition and concept is problematic because it harbors unstated assumptions that trainees are necessarily from a privileged cultural group, that patients of a particular background share homogeneous beliefs, that the complex nuances of difference can be “mastered”, and that ethnic similarity between clinician and patient mandates mutual understanding.  Most importantly, traditional cultural competency training, like traditional medical training, is externally focused, primarily concerned with mastering the Other, rather than examining the internal cultures, prejudices, fears, or identifications of the Self in relation to that Other.

Narrative Humility/ Narrative Competence: Craig Irvine describes humility as “The sense of humility toward that which we do not know—the face of the Other, the face we cannot know but to which we are responsible.”  Narrative humility acknowledges that patients’ stories are not objects that can be mastered, but rather dynamic entities that can be engaged with, while simultaneously remaining open to their ambiguity and contradiction.  Narrative humility means engaging in constant self-evaluation and self-critique about issues such as one’s own role in the story, one’s expectations of the story, one’s responsibilities to the story, and one’s identifications with the story.  Narrative humility allows clinicians to recognize that each story heard holds elements that are unfamiliar—be they cultural, socioeconomic, sexual, religious, or idiosyncratically personal.  Narrative competency, on the other hand, is not an end point—but rather a skill set that is developed through the practice of narrative humility, which needs to be exercised just like a muscle.

References:

AMSA website: http://www.amsa.org/advocacy/action-committees/gender-sexuality/lgbt-local-projects-in-a-box/

MSU Extension Multi-Cultural Awareness Workshop and http://www.amsa.org/advocacy/action-committees/gender-sexuality/lgbt-local-projects-in-a-box/

Ignite! A Toolkit for Anti-Racist Education: http://antiracist-toolkit.users.ecobytes.net/?page_id=124

Kirwan Institute for the Study or Race and Ethnicity: http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/

  Sayantani DasGupta:  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)60440-7/fulltext

Queensborough Community College: http://www.qcc.cuny.edu/Diversity/definition.html

Text adapted from CEDI Resources and References