Social Pathways to Health Vulnerability: Implications for Health Professionals

257 Pages·2019·4.26 MB·English

by  Dula F. Pacquiao

Social Pathways
to Health
Vulnerability
Implications for Health
Professionals
Dula F. Pacquiao
Marilyn “Marty” Douglas
Editors
123
Social Pathways to Health Vulnerability
Dula F. Pacquiao
Marilyn "Marty" Douglas
Editors
Social Pathways to
Health Vulnerability
Implications for Health Professionals
Editors
Dula F. Pacquiao Marilyn "Marty" Douglas
Schools of Nursing School of Nursing
University of Hawaii, Hilo, HI University of California San Francisco
Rutgers University San Francisco, CA
Newark, NJ USA
USA
ISBN 978-3-319-93325-2 ISBN 978-3-319-93326-9 (eBook)
https://doi.org/10.1007/978-3-319-93326-9
Library of Congress Control Number: 2018957083
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Foreword
Expensive health care is not unique to the USA; costs are rising around the
world as technological advances and an aging population have driven up the
price for everyone. But nowhere are costs rising as fast as in the USA where,
in 2016, health care consumed 18% of our national GDP, $3.3 trillion. That is
$10,348 of health care spending in a single year for every woman, man, and
child in the USA. Our medical industry is approximately the size of Brazil’s
economy, the seventh largest in the world.
Given the amount of money that the USA sinks into health care, one would
imagine that we would be the healthiest nation on earth. However, this is far
from true; in terms of health, the USA compares poorly to other developed
countries. A 2013 Organization for Economic Cooperation and Development
(OECD) study found that across 13 high-income countries, Americans had
worse outcomes than their peers. Of the countries studied, the USA had the
lowest life expectancy at birth (78.8 years compared to an OECD median of
81.2), the highest infant mortality rate (at 6.1 deaths per 1,000 live births in
comparison to an OECD median of 3.5). The prevalence of chronic disease
was higher in the USA: 68% of Americans age 65 or older had at least two
chronic conditions (in comparison to 33% in the UK and 56% in Canada).
And, more than 1/3 of Americans were obese in 2012: this was about 15%
higher than the next-highest country.
There are other reasons why our health care is more expensive: adminis-
trative costs, costs of drugs in the USA, waste, medical error, the practice of
defensive medicine (i.e., when a provider recommends testing or treatment
that may or may not be the best option for the patient, but protects the pro-
vider against potential legal action), and overspecialization of the provider
workforce. However, perhaps the biggest reason is the fact that as a nation we
predominantly invest in downstream factors—care for the individual once
they have experienced alterations in physiological and biological functioning.
While focusing primarily on acute care and disease-based care, we have
ignored the fact that wellness and prevention of disease occurs at the upstream
(policies and the determinants of health—environmental, social, economic)
and midstream levels—psychosocial factors, health-related behaviors, and
the role played by the healthcare system.1 To improve population health and
1 Bharmal, N., Derose, K.P., Felician, M., & Weden, M.M. Understanding the Upstream
Social Determinants of Health. Rand Health. May, 2015. https://www.rand.org/content/
dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf.
v
vi Foreword
prevent vulnerable populations from experiencing serious illness, we must
invest substantially more in understanding and overcoming social determi-
nants of health and the challenges vulnerable populations face.
We cannot improve population health outcomes or control the rising cost
of health care until we address these determinants of health—the conditions
in which people are born, grow, live, work, and age. The World Health
Organization reminds us that “these circumstances are shaped by the distribu-
tion of money, power and resources at global, national and local levels and
that these social determinants of health are mostly responsible for health
inequities—the unfair and avoidable differences in health status seen within
and between [neighborhoods, populations, and] countries.”2 Social disadvan-
tage, risk exposure, and social inequities are a central causal role in poor
health outcomes and thus represent important opportunities for improving
health and reducing health disparities.
The OECD study mentioned previously found that the USA—possibly as
a result of high health spending—crowds out other forms of social spending,
spends substantially less on social services than peer countries. According to
OECD, “A growing body of evidence suggests that social services aimed at
social determinants play an important role in shaping health trajectories and
mitigating health disparities.” Redressing this imbalance is a needed step
toward a population health approach.
Population health moves us from “reactive responses to an individual’s
health needs towards outcomes-based proactive approaches to a given popu-
lation with attention directed toward larger, socially grouped needs and pre-
vention efforts while reducing disparity and variation in care delivery.”3
Population health broadens the traditional medical delivery system by encom-
passing the wide range of factors that affect health that are not yet integrated
into our healthcare delivery model. These activities include not only preven-
tion, health education, and wellness but also care coordination, in-patient and
out-patient health risk assessment, patient engagement, greater use of pri-
mary care, and patient-centered care. But it also recognizes the role of the
healthcare provider as advocate in determining public policy that addresses
factors that affect health and access to health whether it is the cost of drugs,
advocating for policies that reduce administration or defensive medicine,
supporting patient access to information to make well-informed health-
related decisions, ensuring access to education and community safety, and
improving air and water quality and healthy housing.
This book provides a comprehensive look at the social determinants—
what they are, how they manifest, how they should be measured and studied,
and how they can be addressed to achieve equity. It highlights the link
between health and social disadvantage in which neighborhood conditions,
working conditions, education, income and wealth, and race/ethnicity and
racism all create stress, which is a causal factor of disease as brought to light
2 WHO. About Social Determinants of Health. http://www.who.int/social_determinants/
sdh_definition/en/.
3 Milken Institute School of Public Health, George Washington University. What Is
Population Health? April 27, 2015. https://mha.gwu.edu/what-is-population-health/.
Foreword vii
through the growing understanding of epigenetics. It provides an understand-
ing of the link between health and social inequities stemming from sociode-
mographic factors, such as class and immigration status, gender, and sexual
orientation. They remind the practitioner of the need for data to understand
health outcomes and disparity and provide approaches for monitoring and
measuring social determinants and programs addressing social determinants.
And significantly, they present broad frameworks of action for addressing
social determinants and disparities and in integrating these approaches into
clinical practice, education, research, and administration.
I applaud Drs. Pacquiao and Douglas’s approach of reinforcing the multi-
ple pathways to health vulnerability. My hope is that this book is more than a
reservoir of knowledge but a call to action. Achieving a culture of health and
overcoming health disparities requires our professional role to go beyond
direct patient care. We must actively support or participate in evaluation and
impact research that highlights the evidence base for interventions and mod-
els of care that address social determinants and ultimately improve health
outcomes and reduce healthcare costs. We must actively participate in policy
development to reimagine health care and improve health and in changing
broad socioeconomic public policies that make a difference for underserved
and vulnerable communities. We must be advocates so that social determi-
nants of health are reflected within national standards and within education
curricula. And we must be leaders in ensuring that in our approach to care we
engage our organizations, ourselves, and others to ensure the needed partner-
ing between health care, social services, private industry, nongovernmental
organizations, and civil society.
Susan W. Salmond, EdD, RN, ANEF, FAAN
School of Nursing
Rutgers, The State University
of New Jersey
Newark, NJ, USA
Preface
This book is intended for students, faculty, and professionals interested in
health and health promotion for communities and populations. This book
uses specific social determinants of health as its organizing framework. This
approach is in contrast to many books that are organized around different
vulnerable population groups and their specific illnesses (e.g., diabetes, HIV).
It promotes an in-depth understanding of the social and environmental repro-
duction of cumulative disadvantages that create poor health in vulnerable
populations. This presentation helps ground readers in the universal processes
contributing to population health inequities and shifts the focus to population
health promotion that goes beyond individual-level and disease-centered
interventions. This approach is critical to broadening the perspectives of
health by professionals whose practice is mostly limited to individual encoun-
ters with sick individuals within organizations.
The content is organized using specific social determinants of health and
their influence in creating health vulnerability in populations. By using this
approach, the authors attempt to explicate the root causes of poor health and
the mechanisms by which they produce differential health statuses across
population groups. Corrective remedies addressing health inequities must be
grounded in reducing or preventing the social structural factors and processes
contributing to poor health. By focusing on the social and environmental
explanations of the different patterns of disease distribution, readers are able
to direct their attention toward macrosocial, structural, and upstream forces
that have greater health impact. Addressing social determinants of health has
greater impact on population health compared to individual-level approaches
that are focused on disease conditions using the biomedical paradigm.
The book is informed by constructs, theories, and research from different
disciplines including the social sciences, environmental sciences, public
health, medicine, ethics, and nursing. Chapter authors have a multidisci-
plinary background with doctoral preparation and experience in population
health promotion. The book is organized in four units: (a) social, economic
and political determinants of health, (b) natural and built environmental fac-
tors influencing health, (c) methodological considerations in examining
health determinants, and (d) approaches to address social and environmental
determinants of health. We aim to provide a comprehensive single reference
for students, faculty, and practitioners in health. Each chapter presents
cutting- edge theories, research, and strategies drawn from the different disci-
plines. Each chapter is supplemented by selected seminal research pertinent
ix
x Preface
to the health determinants being presented. A list of additional resources is
provided in relevant chapters to obtain further information on the topic.
Reflective questions are designed to provoke readers to engage in further
examination of the critical issues presented.
The challenge of population health promotion is that it requires broad-
based social and political advocacy in order to achieve sustainable long-term
changes, particularly for the most vulnerable. The ethical principles of social
justice, human rights, and empowerment are integrated in each chapter to
sensitize readers toward actions that might achieve meaningful changes in
people’s lives, particularly for the disadvantaged and vulnerable.
Health promotion requires multisectoral and interdisciplinary collabora-
tion with active participation by the people and communities. The book’s
content is purposely enriched by the breadth of knowledge, research, and
experience from the various disciplines. This is critical as population health
necessitates broad-based efforts beyond a single discipline or specialty. It
requires a global perspective of problems that transcend individual-level con-
text because of their connections with societal, governmental, economic,
political, and institutional structures. A more global approach to the discus-
sion is used to expand the understanding of similar and diverse perspectives
as well as interventions to universal problems such as social inequalities, dis-
crimination, poverty, inadequate resources, and marginal environments.
We are deeply indebted to the contribution of our colleagues at Rutgers
University School of Nursing, especially the graduates of the PhD program in
urban systems, whose collaborative work with the editors have strengthened
the content and application of this book. We value their individual and collec-
tive expertise in making this project a reality. Together, we have gained a
greater understanding of health determinants—a must for all healthcare pro-
fessionals, academicians, researchers, and students. We hope to share our
journey toward a broader and deeper enlightenment of the social determi-
nants of population health with other health professionals, and we wish to
engage them in strategizing solutions to address the challenges of population
health promotion.
Newark, NJ; Hilo, HI Dula F. Pacquiao
San Francisco, CA Marilyn "Marty" Douglas
Contents
Part I S ocial, Economic and Political Determinants of Health
1 “Place” and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Dula F. Pacquiao
2 Poverty, Discrimination, and Health . . . . . . . . . . . . . . . . . . . . . . 23
Sharese N. Porter
3 Politics, Economics, and Health . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Dula F. Pacquiao
4 Disempowerment and Migrant Populations . . . . . . . . . . . . . . . . 73
Rubab I. Qureshi
Part II N atural and Built Environmental Determinants of Health
5 The Built World and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Phoebe Del Boccio
6 Epigenetics: The Process of Inheriting Health Disparities . . . . 143
Yuri T. Jadotte
Part III Methodological Considerations in the
Examination of Health Determinants
7 Social Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Peijia Zha
8 Program Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Peijia Zha
Part IV Approaches to Address Social and Environmental
Determinants of Health
9 Building Community Social Capital . . . . . . . . . . . . . . . . . . . . . . 207
Ellen S. Lieberman
10 Practices to Address the Social Determinants of Health . . . . . . 237
Dula F. Pacquiao and Marilyn "Marty" Douglas
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
xi