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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 © Springer International Publishing AG, part of Springer Nature 2019 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland 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

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