Addressing structural and social determinants/drivers of health and health disparities

Watch video only
I Structural and social determinants of health influence health outcomes and contribute to health disparities. They are often called drivers of health because being in a disadvantaged situation doesn't guarantee or determine a bad outcome, but it does steer towards it, making it harder to achieve a good one.
Many of these factors exist outside of the healthcare system. However, healthcare professionals can still play an important role in addressing them, which helps reduce health disparities and improve health outcomes for both individuals and populations.
Healthcare professionals can act at multiple levels. They can address structural and social determinants of health at the individual patient level, community level, and through advocacy for policies that promote health equity.
Before we get into details, let's go over a case. Kazim is a 43-year-old Afghan refugee who has lived in the United States for 10 years.
He works long hours in construction, speaks limited English, has limited formal education, and has not routinely accessed healthcare since arriving in the United States.
He shares housing with several other Afghan men who provide much of his social support. His wife and children remain in Afghanistan, and he works long hours in hopes of eventually bringing them to the United States.
Kazim was recently hospitalized with an infected foot ulcer and was found to have previously undiagnosed diabetes with complications including peripheral neuropathy and peripheral artery disease.
After discharge, he was referred to a community clinic for follow-up, but has now missed two appointments. The members of his healthcare team, which includes a primary care physician, endocrinology nurse practitioner, and a community health worker, message each other through the electronic medical record system in an attempt to better support him.
It would be easy to label Kazim as not engaged in care and discharge him from the clinic, but that approach would only reinforce health inequities.
A better approach is to consider the barriers affecting his ability to engage in care. Several structural and social determinants of health may be influencing Kazim's situation.
His refugee status, education, income, available transportation, occupation, and language barriers may affect his ability to access healthcare and manage his diabetes.
He may have difficulty attending appointments because of work demands, costs, or a limited understanding of his condition.
He may also be experiencing stress related to separation from his family or trauma associated with his refugee experiences.
At the same time, Kazim's local Afghan community represents an important source of support and resilience. Understanding both the barriers and strengths in Kazim's life can help guide a more effective and equitable approach to care.
To understand how we can help Kazim, let's consider several strategies healthcare professionals can use to address structural and social determinants of health at the individual patient level.
These include identifying social needs, helping patients navigate services and resources, providing culturally responsive and trauma-informed care, and supporting health literacy through appropriate patient education and shared decision making.
Together, these approaches can help reduce barriers to care and improve health outcomes. First, healthcare professionals need to identify social needs.
This begins with taking a thorough social history and using validated screening tools to identify barriers related to housing, food access, transportation, financial strain, health literacy, and social support.
Recognizing these barriers helps clinicians connect patients with appropriate resources. Another important strategy is the use of warm referrals, care navigation, and flexible access to care.
Warm referrals involve directly connecting patients with needed services rather than simply providing information. Community health workers can also help build trust and improve engagement by serving as a bridge between patients and the healthcare team.
Flexible scheduling, including evening or weekend appointments, may help reduce barriers related to work and transportation.
Another important strategy is culturally responsive care. This approach recognizes that patients bring unique cultural backgrounds, values and experiences into healthcare encounters.
Cultural formulation interviewing is a structured approach that helps clinicians understand how patients view their illness, its causes, available support, and potential treatments.
By better understanding the patient's perspective, clinicians can improve communication, engagement, and outcomes across cultural contexts.
A related approach is trauma informed care. This recognizes that trauma, chronic stress, and structural discrimination may affect health behaviors, trust, and engagement with care.
Clinicians should respond with empathy, create a sense of safety, and avoid actions that may re-traumatize patients. Finally, healthcare professionals can promote shared decision making and improve health literacy.
Structural disadvantage may be associated with lower health literacy, but not lower intelligence or decision making capacity.
Clinicians should communicate using plain language, professional interpreters when needed, and the teachback method to confirm understanding.
In the teachback method, patients are asked to explain the plan in their own words so that misunderstandings can be identified and corrected.
To improve Kazim's engagement with care, the healthcare team could ask a community health worker with shared cultural or linguistic experience to reach out and help Kazim understand the diagnosis and the importance of treatment.
Flexible appointment scheduling could help accommodate his work responsibilities. Professional interpreter services should be used during visits to improve communication and understanding.
The team could also use culturally responsive and trauma informed approaches to better understand Kazim's experiences and priorities.
If needed, they could connect him with social or legal services that address barriers affecting his health. The strategies we've discussed can help Kazim as an individual patient.
However, many of the barriers affecting his health are likely shared by others in his community. Addressing determinants of health at the community level often focuses on building partnerships, understanding local needs, working with trusted community members, and promoting continuity of care.
Together, these approaches can improve access to services and help reduce health disparities across entire populations. First, healthcare professionals can develop strong partnerships with community organizations, cultural groups, faith-based organizations, schools, and local leaders.
These partnerships can improve health education, strengthen community relationships, and increase access to healthcare services.
Next, community needs assessments can help identify local priorities. These assessments combine health data with direct input from community members to guide interventions that are responsive to community needs.
Another important approach is working with community health workers and lay health advisors. Because they often share language, culture, or lived experiences with the communities they serve, they can help improve communication and connect people with needed services.
Finally, promoting care continuity and patient engagement is essential. Healthcare professionals should anticipate changing clinical and social needs and work with patients and communities to co-design programs and services that improve outcomes.
In Kazim's case, his community is an important source of support, so the healthcare team could partner with local Afghan community organizations or leaders to provide culturally appropriate diabetes education.
The community-based strategies we've discussed can help address barriers affecting Kazim and others in his community. However, many of the factors driving health disparities are shaped by larger systems and policies.
Let's look at how healthcare professionals can address determinants of health through advocacy for policies that promote health equity.
Many structural determinants of health are shaped by policies related to housing, education, transportation, employment, healthcare access, and discrimination.
By advocating for equitable policies, clinicians can help address the root causes of health disparities. Advocacy can occur at multiple levels.
Within healthcare organizations, clinicians can help shape policies and practices that promote health equity. At the local, state and national levels, healthcare professionals can work with community organizations, professional societies, and policymakers to support evidence-based reforms.
Healthcare professionals can also contribute through public education, community engagement, coalition building, and participation in policy discussions.
By sharing their clinical experiences and advocating for underserved populations, clinicians can help influence the systems that shape health outcomes.
Now, to help Kazim and individuals in a similar situation on a broader level, healthcare professionals could advocate for policies that improve healthcare access and chronic disease management for refugee and immigrant populations.
All right, as a quick recap, healthcare professionals can address structural and social determinants of health at multiple levels.
At the individual level, clinicians can identify social needs, provide culturally responsive and trauma informed care, improve health literacy, and connect patients with resources.
At the community level, partnerships with community organizations and community health workers can help reduce barriers to care.
Finally, healthcare professionals can serve as allies and advocates by supporting policies that improve health equity and address the structural conditions that contribute to health disparities.