#4 - Beyond Medicine: How Social Determinants Shape Our Health

Explore how social factors like education, income, race, and neighborhoods impact our health. We discuss groundbreaking studies on the hidden forces shaping our well-being.  Whether it's the challenge of food deserts or the promise of technological innovations in healthcare, this episode is packed with insights and stories that will change the way you think about health. We also talk about addressing social determinants of health with solutions through community engagement, policy advocacy, and public-private partnerships.

Timestamps:
 (00:00:00) Channel Intro 
 (00:01:44) Introduction to Social Determinants of Health (SDOH)
 (00:10:03) What are SDOH
 (00:11:02) 5 Categories of SDOH
 (00:14:52) SDOH or Not
 (00:18:41) Global Perspective
 (00:21:32) Deep Dive Into 5 Categories
 (00:22:09) 1) Economic Stability
 (00:28:39) 2) Education
 (00:36:42) 3) Social and Community Context
 (00:42:30) 4) Health and Healthcare
 (00:45:28) 5) Neighborhood and the Built Environment
 (01:01:01) Addressing SDOH
 (01:02:01) 1) Community Engagement and Empowerment
 (01:06:12) 2) Technological Innovations
 (01:08:32) 3) Policy Changes and Advocacy
 (01:12:12) 4) Public-Private Partnerships
 (01:14:50) 5) Educational Initiatives
 (01:17:35) 6) Built Environment and Urban Planning
 (01:20:46) 7) Economic Interventions
 (01:23:52) 8) Cultural Competence in Healthcare
 (01:27:35) Conclusion
 (01:29:37) Outro

Linktree: linktr.ee/gustavofrancopod

Chapters

• 0:00 Channel Intro
• 1:44 Introduction to Social Determinants of Health (SDOH)
• 10:03 What are SDOH
• 11:02 5 Categories of SDOH
• 14:52 SDOH or Not
• 18:41 Global Perspective
• 21:32 Deep Dive Into the 5 Categories
• 22:09 1) Economic Stability
• 28:39 2) Education
• 36:42 3) Social and Community Context
• 42:30 4) Health and Healthcare
• 45:28 5) Neighborhood and the Built Environment
• 1:01:01 Addressing SDOH
• 1:02:01 1) Community Engagement and Empowerment
• 1:06:12 2) Technological Innovations
• 1:08:32 3) Policy Changes and Advocacy
• 1:12:12 4) Public-Private Partnerships
• 1:14:50 5) Educational Initiatives
• 1:17:35 6) Built Environment and Urban Planning
• 1:20:46 7) Economic Interventions
• 1:23:52 8) Cultural Competence in Healthcare
• 1:27:35 Conclusion
• 1:29:37 Outro

Transcript

Introduction

• Welcome to this month’s episode of the Gustavo Franco Podcast where we will discuss social determinants of health. Have you ever thought about what else besides your genetic code and lifestyles choices can help determine your health outcomes? Well, that is exactly what we will discuss in this episode. Social determinants of health are non-medical factors that we can’t directly directly control. They are often described as the wider set of forces that have an impact in our daily lives and health outcomes.
• Did you know that your ZIP code can be the strongest predictor of your health? Even more than your genetic code or lifestyle choices depending on where you live. According to county health rankings, if you born in Oglala Lakota County in South Dakota, you can expect to have a life expectancy of 62.8 years while if you are born in Mono County, California, you can expect to live to over 100 years old. That’s nearly a 40 year difference in life expectancy solely based on the ZIP code that you are born in. In this episode we’ll explore why this is. What besides lifestyle choices and genetics can be used the determine your health outcomes? The answer is social determinants of health. While both these counties may have significant genetics differences and lifestyle factors such as smoking rates, they also differ significantly in income, race, education level, and much more that we will discuss in this podcast.
• However, as we go through this episode, it's crucial to understand what we actually mean when we say that 'race' can be a social determinant. It's not a matter of biology; there are no inherent biological differences that predispose any race to poorer health outcomes. Instead, it's about the societal constructs and systemic inequalities that lead to disparities in health. Prejudices, discrimination, and unequal access to resources contribute to these health gaps. So, when we talk about race in this context, we're really talking about the social, economic, and environmental barriers that people of different racial and ethnic backgrounds face, not the color of their skin or any supposed biological differences. So please keep this in mind as we go through today's episode.
• When looking at income by itself, the richest man in the US can expect to live at least 15 years longer than the poorest man. While men in the top 1% live to 87.3 years old, men in the bottom 1% live to 72.7 years old. And that is only data looking at life expectancy from 2001 to 2014. These numbers are definitely even more extreme now, because this same study found was that there were massive inequalities in life expectancy increases over time. While life expectancy increased by 2.34 years for men in the top 1% from 2001 to 2014, it only increased by 0.32 years for men in the bottom 1%. So if the same trend continues as we saw from 2001 to 2014, even though the life expectancy gap was 14.6 years for men in the top and bottom 1%, we can expect that gap to be over 15 years now. The same trends follow for women, who had a life expectancy gap of 10.1 years between the top 1% and bottom 1% in 2014, but they saw an even greater disparity in life expectancy increase, with women in the top 1% seeing a 2.91 year increase from 2001 to 2014, while women in the bottom 1% only saw an increase of 0.04 years. Income is one of the most significant determinants of health in the US and globally, and we will explore more about this as we go through the podcast.
• Education also significantly determines your health outcomes. According to a study by Robert A. Hummer and Joseph T. Larisey in the International Book of Adult Mortality, relative to those with 17 or more years of education, those that only get between 9 and 11 years of education have a mortality rate that is 202% percent higher for the age group between 25 to 44 years old. That means that mortality rate is more than tripled for those with 9 to 11 years of education compared to those with 17 or more years of education. This difference is significant across all age groups based on age, however, it’s not as severe for older groups. This is likely a result of education having a more significant impact on the highly preventable causes of death such as lung cancer from smoking, respiratory distress, homicides, and accidents. The overall mortality rate in younger groups is not that high because younger people are less likely to have all of the debilitating conditions that come with old age, so if one of these groups is more likely to partake in high risk activities with terrible health outcomes such as smoking, then the difference will be more significant than at older ages where age catches on to everyone and all groups suffer from many more complications. Education attainment not only decreases mortality rates and increases life expectancy, it also improves overall quality of life, and that is something that we will discuss in detail.
• Lastly, before diving into the episode, I want to highlight a few statistics about race as a determinant of health because some of these are truly disheartening. Take maternal mortality in the US for example. In 2021, black women had a maternal mortality of 69.9 for every 100,000 births while white women had a maternal mortality of 26.6 for every 100,000 births, making black women 2.5 times more likely to die from birth than white women. Maternal health is a topic for its own episode with numerous social inequalities, and with truly disappointing outcomes in the US that pale in comparison to other developed countries. And worse of all, these outcomes have only been getting worse in the US in the past years.
• And that’s just a small glimpse of racial disparities in health. Race by itself was also a significant determinant of health during covid. Take life expectancy for example, it’s well known that overall life expectancy decreased in the US because of COVID, but many people forget to look at how different this decrease was by race. Overall life expectancy went from 78.8 years in 2019 to 76.1 years in 2021, a 2.7 years decrease in life expectancy. But while whites and Asians saw a 2.4 and 2.1 year decrease in lifespan, Blacks had a 4 year decrease in life expectancy and Hispanics had an even more significant 4.2 year decrease. And then we have Alaskan natives, who were affected the most with a mind blowing 6.6 year decline in life expectancy due to covid. These numbers show that social determinants of health are a real thing and something that we should all be aware of. As we move into the main part of the episode we will dive further into each of these social determinants of health and how we can pull them apart and analyze them individually. We will also talk about a key aspect of social determinants of health, and that is how we can actually improve them. So lean back and enjoy this ride into the world of social determinants of health.

Transition Music

Segment 1: Defining Social Determinants of Health

Definition: Explain what SDOH are and why they matter.

• First of, you might be wondering, what exactly are Social Determinants of Health? The World Health Organization defines them as the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.
• To put it simply, it's not just about our genes or our personal choices. It's about the environment around us, the opportunities available to us, and the societal structures that influence our lives.
• Vicente Navarro, in his paper 'What We Mean by Social Determinants of Health,' emphasizes the distinction between individual determinants and social determinants. While our personal behaviors, like diet or exercise, play a role in our health, there are broader societal and economic structures that influence those behaviors. It's these structures that we're focusing on today.
• And here's an interesting fact: The U.S. Department of Health and Human Services, the CDC, and the Healthy People initiative 2030 have categorized these determinants into five key areas: Economic Stability, Education Access and Quality, Social and Community Context, Healthcare Access and Quality, and Neighborhood and Built Environment. We'll be diving deep into each of these buckets throughout the episode.
• But before we delve further, it's essential to understand that while the healthcare system plays a crucial role in our health, broader societal interventions are necessary to truly make a difference. As Navarro poignantly states in his paper, 'Medicine is a social science, and politics is nothing more than medicine on a large scale.
• So, as we navigate today's episode, let's remember that health isn't just about medicine. It's about the world we live in, the opportunities we have, and the societal structures that shape our lives.

Five Key Areas (based on the World Health Organization's framework):

• As we delve deeper into the world of Social Determinants of Health, it's crucial to understand the five key areas that shape our health outcomes. These areas, as recognized by the U.S. Department of Health and Human Services, the CDC, and the Healthy People initiative 2030, provide a comprehensive framework for understanding the myriad factors that influence our health.
• Let's break them down one by one.
• First up, Economic Stability. This area encompasses factors like income, employment, job security, and debt. The Kaiser Family Foundation highlights the significance of socioeconomic status in determining health outcomes. Simply put, financial stability, or the lack thereof, can have profound effects on one's health, from stress-related illnesses to limited access to nutritious food or safe housing.
• Next, we have Education Access and Quality. It's not just about the degrees you hold but also about health literacy, early childhood education, and vocational training. A well-educated individual is more likely to make informed health decisions, have better access to healthcare, and even live longer.
• The third area is Social and Community Context. This dives into the essence of our human interactions - our social integration, support systems, and community engagement. But it also touches on the darker aspects of society, like discrimination and racism. Our sense of belonging, the support we receive, and the societal biases we face can all play pivotal roles in our mental and physical well-being.
• Of course, we can't discuss health without addressing Healthcare Access and Quality. While we often think of this in terms of having a good doctor or hospital nearby, it's also about health coverage, provider availability, and health literacy. As highlighted in the Kaiser Family Foundation's paper, access to quality healthcare is a cornerstone of good health.
• Lastly, we have the Neighborhood and Built Environment. This is where we live, the safety of our communities, the parks we relax in, and the walkability of our streets. It also touches on the concept of 'food deserts' – areas where access to fresh, healthy food options is limited. Our surroundings, from the air we breathe to the safety of our streets, play a crucial role in our health.
• These five areas provide a holistic view of the myriad factors that shape our health. It's not just about individual choices but the environment and society we're a part of. As we navigate today's episode, we'll delve deeper into each of these areas, shedding light on their significance and the ways we can address the challenges they present.

Differentiating What Counts as a Social Determinant

• Having explored the five key areas of Social Determinants of Health, a natural question arises: How do we differentiate between what counts as a social determinant and what doesn't? This distinction is crucial for understanding the depth and breadth of the topic
• Vicente Navarro's paper, 'What We Mean by Social Determinants of Health,' offers a deeper dive into this. He distinguishes between the conditions we might control, like our personal diet or exercise routine, and the broader societal conditions that influence these choices.
• Imagine two individuals: One has the means to buy fresh produce, has time to cook, and lives in a neighborhood with safe walking paths. The other lives in a 'food desert' where fresh food is scarce, works two jobs, and has no safe recreational spaces nearby. While both have a choice in their diet, the societal conditions heavily influence these choices.
• Navarro provides a striking example from East Baltimore. The vast difference in lifespan between a black unemployed youth and a white corporate lawyer isn't just about personal choices. It's a reflection of broader societal structures, from economic disparities to systemic discrimination.
• This example brings forth an essential aspect of social determinants: their interconnectedness. Social determinants of health aren't isolated silos; they often overlap and intersect in complex ways. The black unemployed youth in East Baltimore doesn't just face economic challenges. He might also be grappling with limited access to quality education, inadequate healthcare facilities, and a neighborhood environment that's not conducive to good health. Each of these determinants compounds the other, creating a web of challenges that can be daunting to navigate.
• Similarly, the white corporate lawyer, while enjoying economic stability, might still face challenges in other areas, such as mental health pressures from a high-stress job or limited social support. It's crucial to understand that individuals often experience multiple social determinants simultaneously, and these determinants can either amplify each other's effects or provide a counterbalance.
• The Kaiser Family Foundation's insights resonate with this. Socioeconomic status isn't just about one's bank balance. It's about societal structures that determine access to resources, education, and opportunities.
• In essence, our lives are a mosaic of these determinants. Recognizing their interconnected nature helps us appreciate the complexity of the challenges many face and underscores the need for holistic solutions that address multiple determinants simultaneously.
• Navarro's emphasis on the role of politics in medicine is also thought-provoking. If we consider 'politics as medicine on a large scale,' it underscores the profound impact of policy decisions on our collective health. It's not just about healthcare policies but about housing, education, labor rights, and more.
• In essence, while our individual choices play a role in our health, they are often a product of the societal structures we're embedded in. Recognizing and addressing these structures is pivotal for holistic health improvements
• As we continue our journey today, we'll delve deeper into these societal structures, understanding their intricacies and the profound impact they have on our health.

Global Perspective on SDOH

• Having delved into the intricacies of Social Determinants of Health within the U.S., it's essential to zoom out and understand the global landscape. The challenges and opportunities presented by SDOH are not unique to any one country; they are a shared human experience, albeit with regional variations.
• Consider this: A family in the top 1% in Tanzania might enjoy relative affluence in their local context, with access to private education, healthcare, and a comfortable home. Contrast this with a family in the bottom 1% in the U.S., who might face challenges accessing basic healthcare, nutritious food, or safe housing. Yet, both families, despite their economic disparities, might face similar challenges in terms of social integration, community support, or facing systemic biases.
• Michael Marmot and Richard Wilkinson, in their book 'Social Determinants of Health: The Solid Facts,' emphasize the universality of these determinants. Whether in Europe, Africa, or the Americas, the societal structures that influence health outcomes remain consistent. The manifestations might differ, but the underlying principles remain the same.
• A stark example of this is the disparity in health outcomes globally. A girl born in Sweden can expect a long, healthy life, with access to world-class healthcare, education, and social support. Contrast this with a girl born in Sierra Leone, where the challenges of infectious diseases, limited healthcare infrastructure, and socio-economic challenges might significantly reduce her expected lifespan.
• These disparities aren't just statistics; they represent a moral imperative. As global citizens, understanding and addressing these disparities is our shared responsibility. It's not just about charity or aid; it's about creating a world where every individual, regardless of their birthplace, has an equal opportunity to lead a healthy, fulfilling life.
• In the words of Marmot and Wilkinson, 'Health inequalities are not just a matter of personal choice or bad luck; they are a matter of social justice.' As we continue our exploration of SDOH, let's keep this global perspective in mind, recognizing the shared challenges and opportunities that bind us all.

Segment 2: Deep Dive into Key Areas

• In this next segment, we will break the 5 key buckets of social determinants of health that we discussed earlier. And once again, this a mutually exclusive and collectively exhaustive model used by the Healthy People Initiative with the Department of Human Services and it is also used by the World Health Organization. The model includes 1. Economic Stability 2. Education Access and Quality 3. Social and Community Context 4. Healthcare Access and Quality 5. Neighborhood and Built Environment. So let’s really five deep into what each of these mean and how they impact our health.

Economic Stability:

• Economic Stability is a true cornerstone of well-being. But it’s important to know that economic stability isn't just about dollars and cents; it's about employment, income, and stress, and how each of these are intricately linked to our health and longevity.
• Let's start with Income's Role in Health. A comprehensive study published in Journal of the American Medical Association, conducted by researchers including Chetty and colleagues, sheds light on this relationship. The paper, titled 'The Association Between Income and Life Expectancy in the United States, 2001-2014,' provides a detailed analysis of how income affects life expectancy.
• The findings are stark. In the U.S. between 2001 and 2014, higher income was consistently associated with greater longevity. This wasn't just a minor difference. The disparities in life expectancy across income groups have been increasing. But what's even more intriguing is that this association varies across different geographic areas.
• Moving on to Employment and Health. Stable employment does more than just provide a paycheck. It offers a sense of purpose, social connections, and, importantly, access to health benefits. Conversely, unemployment or underemployment can lead to stress, mental health issues, and deferred healthcare.
• The same JAMA study found correlations between life expectancy and local area characteristics. For instance, areas with a higher fraction of college graduates and higher median house values were associated with increased life expectancy, especially for those in the bottom income quartile.
• Lastly, let's delve into Financial Stress and Chronic Diseases. Financial stress isn't just about feeling anxious at the end of the month. It has tangible, physiological effects. Chronic financial stress can lead to conditions like hypertension, diabetes, and mental health disorders. The stress of deciding between paying a medical bill or rent, for instance, can exacerbate health conditions.
• The JAMA paper also highlighted the negative correlation between life expectancy and rates of smoking and obesity, especially among individuals in the bottom income quartile. These health behaviors, often influenced by financial stress and socio-economic conditions, play a significant role in determining life expectancy.
• In conclusion, economic stability is a multifaceted determinant of health. It's not just about the money in our bank accounts but about the broader societal structures that determine our access to resources, opportunities, and ultimately, our health outcomes.
• But before leaving economic stability behind, and to further underscore the profound relationship between economic stability and health, let's turn our attention to East Asia, specifically Indonesia, Malaysia, and Thailand. A research paper titled 'Economic stability and health status: Evidence from East Asia before and after the 1990s economic crisis,' authored by Sandra Hopkins and published in the journal Health Policy, provides invaluable insights into this relationship.
• The late 1990s were tumultuous for the East Asian economies. Their growth rates, which had been soaring in the early 1990s, took a sharp downturn. The Asian financial crisis began with the depreciation of regional currencies against the US dollar, leading to capital outflows, widespread bankruptcy, and unemployment.
• Let's delve into some specifics. In Indonesia, the GDP declined by a staggering 13.1% in 1998. This economic downturn was accompanied by a massive decline in the value of the rupiah, leading to an 83.6% increase in the food price index. It's estimated that 13.4 million workers lost their jobs by June 1998, and the percentage of the population living in poverty surged from 17% to 40%.
• Thailand, too, faced economic challenges. In 1998, its real GDP growth rate declined by 10.5%. However, by the following year, it rebounded with a growth rate of 4.4%. Despite the significant depreciation of the baht, Thailand's currency, the impact on prices was relatively modest, with the Consumer Price Index (CPI) increasing by 8.5% in 1998.
• These economic fluctuations had direct implications for health. As household incomes declined, families were forced to cut back on essential expenditures, including food and healthcare. This led to health challenges such as malnutrition and low birth weight. Moreover, with reduced tax revenue, governments found it challenging to maintain health and education expenditures. This decline in public health spending limited the ability to provide essential health services, such as universal immunization.
• The Thai Ministry of Health reported that the suicide rate for men jumped from 5.01 per 100,000 population in 1996 to 8.05 in 1999
• The paper's findings emphasize the importance of social safety nets and the need to maintain government expenditure during economic downturns to minimize the impact on health. It's a stark reminder that economic policies and health outcomes are deeply intertwined.
• Drawing parallels with our earlier discussion on the U.S., it becomes evident that whether in developed nations like the U.S. or developing economies like those in East Asia, economic downturns can have profound implications for health outcomes. The East Asian experience shows the need for robust economic policies and safety nets to ensure the well-being of populations during economic challenges.

Education:

• Now, let's turn our attention to another crucial determinant of health: Education. Education plays a pivotal role in shaping our health outcomes, and today, we'll explore this intricate relationship.
• Firstly, let's discuss the direct link between education levels and health outcomes. Numerous studies have shown that individuals with higher education levels tend to have better health outcomes. For instance, a child born to parents who haven't completed high school is more likely to live in an environment with barriers to health, such as lack of safety, exposed garbage, and substandard housing. They might also lack access to essential amenities like sidewalks, parks, or libraries.
• This brings us to the concept of health literacy. Health literacy is the ability to obtain, read, understand, and use healthcare information to make appropriate health decisions and follow instructions for treatment. Higher education levels often correlate with better health literacy, enabling individuals to make informed decisions about their health. This, in turn, can lead to better health outcomes. I’ve recorded a full one-hour episode on just health literacy so make sure to check that out since it goes a lot more in depth into this issue.
• But I also want this to serve as an examples as to how deep these concepts within the Social Determinants of Health really are. Within the bucket of education, we talk about health literacy here for a couple of minutes, but this is just these topics are way more complicated so if any of the topics that we discuss today really interest you, make sure to do your own research on it since there is a lot more to learn. Or just let me know if there is a specific topic that you would like me to go into more detail, and I can do another episode on that.
• Now, going back to education, let's delve into the realm of early childhood education. Early childhood education plays a pivotal role in shaping the future health of individuals. Providing quality early childhood education to children in low-income families and communities of color helps reduce achievement gaps, improve the health of these students, and promote health equity. It's not just about academic achievements; it's about laying the foundation for a healthier future.
• To further emphasize the importance of education in determining health outcomes, let's delve into a research paper titled 'Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity.' This paper, published in the journal Health Policy, provides a comprehensive analysis of the relationship between various social determinants, including education, and health outcomes.
• The paper highlights that while healthcare is essential, it's a relatively weak health determinant. Health behaviors, such as diet and exercise, are significant determinants of premature death. However, there's growing recognition that social and economic factors shape individuals' ability to engage in these healthy behaviors. For instance, the availability and accessibility of public transportation can affect access to employment, affordable healthy foods, healthcare, and other crucial drivers of health and wellness.
• In conclusion, education is not just about academic achievements. It plays a pivotal role in shaping our health outcomes and overall well-being. Ensuring access to quality education, especially in the early years, can lay the foundation for a healthier future.
• But before moving on to Social and Community Context, I want to discuss two papers from scientific journals on the topic of Education as a social determinant of health.
• Our first paper is titled "Education: A Missed Opportunity for Public Health Intervention" by Alison Klebanoff Cohen and S. Leonard Syme, published in the American Journal of Public Health. This paper delves into how educational attainment, a well-established social determinant of health, affects health through various mechanisms such as neural development, biological aging, health literacy, and more.
• The authors emphasize that education, ranging from preschool to higher education, is a social determinant of health with clear policy pathways for intervention. They reviewed various educational stages to identify which components are essential for good health outcomes. This is great because it encompasses the whole spectrum of education that we just covered. It also discusses key metrics that have been shown affect education and therefore health outcomes.
• Let's start with early childhood education. Researchers from diverse fields, including economics and neurobiology, have identified early childhood as a pivotal time in human development. High-quality early childhood programs, such as the Perry Preschool and the Carolina Abecedarian Project, have shown to produce better health outcomes and behaviors in adulthood. Key markers of high-quality programs include small classes, well-trained teachers, school-family partnerships, and methods consistent with elementary school experiences.
• Moving on to kindergarten through 12th-grade education, transformative policies like desegregation have been linked to improved school quality for non-White students, leading to better self-rated health. State policies that raise the dropout age have shown to increase students' educational attainment, subsequently boosting their earnings in adulthood. Additionally, smaller class sizes in elementary schools have been associated with positive cognitive and academic outcomes.
• In the realm of higher education, the relationship between educational attainment and health appears to be nonlinear. A bachelor's degree, in particular, is associated with a myriad of health benefits, possibly due to its contribution to social and economic stratification. As more people attend college, the quality and reputation of the institution become increasingly significant sources of differentiation.
• This paper underscores the importance of high-quality education across an individual's academic journey and how every aspect of education has an impact in health outcomes.
• Our next paper that we’ll discuss related to education and health outcomes is titled "Education and Health: Evaluating Theories and Evidence" this paper is authored by David M. Cutler and Adriana Lleras-Muney and was published in the National Bureau of Economic Research.
• Cutler and Lleras-Muney's research provides a robust examination of the various theories that attempt to explain the connection between education and health. They delve into the mechanisms that might underlie this relationship, exploring factors such as income, health behaviors, and social networks.
• One of the standout findings from this research is the strong correlation between educational attainment and health outcomes. The authors highlight that individuals with more education tend to have better health outcomes, and this isn't just about income. Even after accounting for income differences, the health benefits of education remain evident.
• The paper also delves into the role of health behaviors. It's found that those with more education are less likely to smoke, more likely to exercise, and have healthier diets. These behaviors, in turn, have a direct impact on health outcomes, emphasizing the importance of education in shaping health-related behaviors.
• Another fascinating aspect the authors touch upon is the social and psychological benefits of education. Those with higher educational attainment often have better social networks, a greater sense of control over their lives, and higher levels of psychological well-being. These factors, while not directly health-related, play a significant role in influencing overall health and well-being.
• Cutler and Lleras-Muney also discuss the potential policy implications of their findings. They suggest that interventions aimed at increasing educational attainment could have significant health benefits. By understanding the pathways through which education affects health, policymakers can design more effective interventions that target the root causes of health disparities.

Social and Community Context:

• As we delve deeper into the social determinants of health, we now turn to the intricate realm of social and community context. This determinant is a mosaic of our relationships, interactions, and the broader societal structures that influence them. And I will be honest from the beginning, this is a rather broad bucket of health determinants, and it is sometimes hard to determine wether or not a certain principle fits into this category. I will do my best to keep everything plain and simple.
• According to Healthy People 2030, our interactions with family, friends, co-workers, and community members can profoundly shape our health. But it's not just about these direct interactions; it's also about the societal and systemic factors that influence them.
• One such factor is race. Race, and the associated experiences of discrimination and systemic racism, plays a pivotal role in our health and well-being. For instance, communities of color often face systemic barriers that can lead to health disparities. These barriers can range from limited access to quality healthcare and education to living in neighborhoods with limited resources and higher levels of pollution.
• Discrimination, whether based on race, gender, sexual orientation, or other factors, can have detrimental effects on mental and physical health. Chronic stress from facing discrimination can lead to conditions like hypertension, anxiety, and depression.
• But the social and community context isn't just about the challenges. It's also about resilience, support, and community cohesion. Positive relationships, whether at home, work, or within the community, can act as protective factors, buffering against the negative impacts of discrimination and other challenges.
• Imagine living in a neighborhood where you don't feel safe walking outside, or facing discrimination daily because of your race, gender, or beliefs. These challenges, which many people face, can have detrimental effects on health and safety throughout life.
• On the flip side, positive relationships, whether at home, work, or within the community, can act as a buffer against these negative impacts. A supportive friend or a caring neighbor can make all the difference in someone's life, especially during challenging times.
• However, not everyone is fortunate enough to have this support system. Consider children whose parents might be incarcerated or adolescents who face bullying. These individuals often lack the social and community support that is so crucial for mental and physical well-being.
• Here, it’s also essential to understand that not all experiences fit neatly into this category. For instance, while race and experiences of discrimination are part of the social and community context, individual health behaviors, like diet and exercise, might not directly fit into this category. They are influenced by it but are often considered separate determinants of health.
• Building on our discussion about the social and community context of health, I'd like to delve deeper into a seminal research paper that provides a comprehensive look at the intersection of race, discrimination, and health outcomes among African Americans.
• The paper we're discussing today is titled 'Race, Race-Based Discrimination, and Health Outcomes Among African Americans.' It's authored by Vickie M. Mays, Susan D. Cochran, and Namdi W. Barnes, and was published in the esteemed Annual Review of Psychology.
• This research is particularly significant as it delves into the persistent health disadvantages faced by African Americans, a topic that is intricately tied to the broader social and community context we've been discussing.
• One of the most startling revelations from this study is the profound health disparities that exist. To put it into perspective, in the 1990s, an African American male residing in Harlem had a lower likelihood of reaching the age of 65 than the average male in Bangladesh. This is a stark reminder of the deep-seated health disparities that can exist even within developed nations.
• The paper doesn't just stop at presenting these disparities. It delves into the why. Why do such profound health disparities exist? The researchers hypothesize that continuous experiences of racism and discrimination may be at the root of many of these health disparities.
• For instance, the overall death rate for African Americans today is equivalent to that of Whites in America three decades ago. This is evident in diseases like diabetes, cardiovascular heart disease, hypertension, and obesity.
• But how does discrimination translate to these health outcomes? The paper provides some insights. Chronic experiences with race-based discrimination, both actual and perceived, can trigger physiological responses. Think elevated blood pressure and heart rate. Over time, these physiological responses can lead to diseases and, ultimately, mortality.
• The study also underscores the importance of understanding the external influences of social space and the internal effects of body and brain functioning. With the advancements in neuroscience and biology, there's a growing body of evidence that shows the intricate relationships between discrimination, brain function, and health outcomes.
• In wrapping up our discussion on this paper, it's evident that while strides have been made in addressing race-based civil rights, the health disparities rooted in discrimination remain a significant concern. As we continue our journey into understanding the social determinants of health, it's crucial to recognize these disparities and work towards creating a more inclusive and supportive environment for all.

Health and Health Care:

• As we continue our exploration of the social determinants of health, we now turn our attention to a critical pillar: Health and Health Care. Access to quality healthcare is a fundamental right, yet disparities persist, affecting the health outcomes of countless individuals.
• According to Healthy People 2030, the National Academies of Sciences, Engineering, and Medicine define access to health care as the 'timely use of personal health services to achieve the best possible health outcomes.' Yet, many face barriers that limit or even prevent them from accessing these essential services, leading to poorer health outcomes and pronounced health disparities.
• Across the U.S., disparities in healthcare access are evident. Whether it's due to geographical constraints, socio-economic factors, or other barriers, these disparities can have profound implications. For instance, a person living in a rural area might have to travel hours to see a specialist, while someone in an urban setting might have multiple specialists within a few miles.
• Health insurance is a significant factor in healthcare access. Inadequate health insurance is one of the largest barriers. The unequal distribution of coverage contributes to health disparities. Out-of-pocket medical costs can lead individuals to delay or even forgo essential care. Medical debt is a reality for many, both insured and uninsured. And here's a startling fact: minority groups account for over half of the uninsured population.
• The implications? Uninsured adults are less likely to receive preventive services for chronic conditions. Children without health insurance are less likely to receive treatments or preventive services, such as dental care or immunizations.
• Primary care is the frontline in health. It's where early detection and prevention of diseases often occur. Studies have shown that having health insurance improves access to health services and better health monitoring. For instance, when previously uninsured adults become eligible for Medicare, their use of basic clinical services increases.
• However, health insurance isn't the only barrier. Limited availability of healthcare resources, like physician shortages, can lead to longer wait times and delayed care. And let's not forget about transportation. Inconvenient or unreliable transportation can interfere with consistent access to healthcare. Research has shown that individuals from racial/ethnic minority groups, especially those at increased risk for severe illness from COVID-19, were more likely to lack transportation to healthcare services.
• In wrapping up, while affordable health insurance is part of the solution, we must also consider economic, social, cultural, and geographic barriers. New strategies are needed to increase the efficiency of healthcare delivery. As we continue our journey into understanding the social determinants of health, it's crucial to recognize these disparities and work towards creating a more inclusive and supportive environment for all.

Neighborhood and Built Environment:

• As we continue our exploration into the social determinants of health, we now turn our attention to a critical area that often goes unnoticed: the neighborhood and the built environment. This encompasses everything from the houses we live in, the streets we walk on, to the air we breathe. Let's dive in.
• Starting with Housing and Health. The place we call home plays a pivotal role in our well-being. Living in substandard housing, which might have mold, pests, or inadequate heating, can lead to a range of health problems, from respiratory conditions to mental health issues. Moreover, housing insecurity, such as the threat of eviction or homelessness, can lead to chronic stress, which, as we know, has a myriad of negative health implications.
• Going a little more in depth, let’s talk about the design and structure of our homes. These elements significantly influence housing quality and can affect both our mental and physical health. Poor housing conditions, such as the presence of lead, mold, or asbestos, can lead to chronic diseases and injuries. For instance, lead exposure, which can come from paint, pipes, and faucets, can have irreversible adverse health effects. Even at low levels, lead exposure can severely affect a child's nervous system and cognitive development.
• The temperature inside our homes also plays a role. Cold indoor conditions have been linked to high blood pressure, respiratory conditions, and even depression. On the flip side, homes that lack proper insulation or air conditioning can become unbearably hot, leading to heat-related illnesses.
• Water leaks in homes can lead to mold growth, which has been shown to affect respiratory health, increasing the likelihood of conditions like asthma. And let's not forget about safety features. The absence of smoke alarms or carbon monoxide detectors can be fatal.
• Overcrowding is another issue. Residents of overcrowded homes may face mental health challenges, food insecurity, and even infectious diseases. And these physical and structural conditions of housing disproportionately impact vulnerable groups, including children, older adults, individuals with physical disabilities, and those with lower incomes.
• Addressing housing quality as a public health issue can lead to better health outcomes. Housing codes and laws, such as those banning the use of lead paint, have already made a difference. Local building codes and state statutes have set basic standards for housing. Programs like the federal government’s Housing Choice Voucher program assist vulnerable populations in securing quality housing by requiring landlord’s to pass housing standards when renting the place out.
• Moving on to Transportation and Safety. Safe and accessible transportation is more than just a convenience; it's a lifeline. It's how we access healthcare, buy nutritious food, and engage in physical and social activities. A lack of reliable transportation can mean missed doctor's appointments or the inability to pick up necessary medications. Furthermore, living in areas with high crime rates can deter outdoor physical activities and contribute to chronic stress.
• Historically, transportation policies have emphasized roads over public and active transportation. This has not only contributed to health hazards but also segregated communities. However, introducing or expanding public transportation options can lead to improved health outcomes. This is achieved by promoting better air quality, increasing physical activity, reducing motor vehicle crashes, and improving mental health.
• Public transportation encompasses a wide range of options, from buses and streetcars to ferries and subways. But the history of public transportation in the U.S. has been shaped by various factors. Notably, the Federal Aid Highway Act of 1956 emphasized building national highway networks. This, combined with the rise of cars, led to a decline in public transportation infrastructure. And these highways often cut through communities of color, furthering racial and economic segregation.
• So, who relies on public transportation? In 2019, about 5% of all U.S. workers commuted by public transportation. This number is higher in major cities like New York and San Francisco. Some groups, such as women, young adults, Black workers, and low-income workers, rely more on public transportation. And a lack of access can disproportionately harm older people, people with disabilities, and communities of color.
• The health benefits of public transportation are numerous. Reduced vehicle miles lead to fewer motor vehicle crashes and less air pollution. And we know that air pollution can increase the risk of cancer, neurological issues, and damage to the cardiovascular, respiratory, reproductive, and immune systems. Moreover, public transportation provides access to health-promoting services, including healthcare itself. In fact, research has shown that lack of transportation can result in missed health care appointments, leading to poorer health outcomes.
• But it's not just about the direct health benefits. Public transportation promotes physical activity when people walk to and from transit stops. Regular physical activity helps reduce the risk of developing chronic diseases, which disproportionately affect low-income communities and communities of color.
• Now I want to talk a little bit more about safety because the mode of transportation you take and the places you go to are highly affected by the level of safety you feel. When people feel safe in their environment, they're more likely to walk or bike to their destinations. This not only promotes physical activity but also ensures that they can access essential services, like healthcare or grocery shopping.
• A study published in the esteemed journal "Social Science & Medicine" in 2016 sheds light on this very topic. Authored by J. Won, S. Lee, J. Forjuoh, and S. Ory, the paper is titled "Neighborhood safety factors associated with older adults' health-related outcomes: A systematic literature review.”
• So, what did this study uncover about the intricate relationship between neighborhood safety and health?
• The study emphasizes that neighborhood safety isn't just about crime rates. It's multifaceted, encompassing overall perceptions of safety, crime-related concerns, traffic-related issues, and even visible signs of disorder like vandalism or graffiti.
• And how does this perception of safety, or lack thereof, affect the health of older adults?
• Great question. The research found that the general feeling of safety in a neighborhood was most relevant to mental health and physical function. Traffic-related safety, on the other hand, was closely tied to physical activity. Think about it: if you're worried about speeding cars or lack of pedestrian crossings, you're less likely to take that evening walk or visit the local park. And when it comes to crime-related safety, it was consistently associated with mental health and walking habits.
• That's quite insightful. It's not just about one's physical safety but also the mental toll that a perceived lack of safety can take.
• Absolutely. And the paper also highlights that while many studies have delved into neighborhood safety and its impact on older adults' health, there's still a need for more empirical evidence to solidify these links. But it is pretty evident that feeling safe in your neighborhood can only be positive to your health. The overall feeling of safety reduces stress which is highly related to health outcomes. And we can’t forget once again that safety allows people to walk more freely in their neighborhoods, which increases physical activity and improves health outcomes.
• Now, let's talk about the Environment's Role in Health. The quality of our environment directly impacts our health. Living in areas with high pollution levels can exacerbate respiratory conditions like asthma and even lead to cardiovascular problems. On the flip side, access to green spaces not only promotes physical activity but also has mental health benefits, providing a space for relaxation and recreation.
• This all influences the amount of time we spend outdoors. And we're going to explore a fascinating study that delves into this topic. That's right! The study we're discussing today is titled "The Association between Time Spent Outdoors and Myopia in Children and Adolescents: A Systematic Review and Meta-analysis." It was authored by Justin C. Sherwin, Mark H. Reacher, Ruth H. Keogh, Anthony P. Khawaja, David A. Mackey, and Paul J. Foster and was published in the journal Ophthalmology in 2012.
• Myopia, commonly known as nearsightedness, is a condition where distant objects appear blurry while close objects can be seen clearly. The prevalence of myopia varies worldwide, exceeding 80% in some East Asian populations. It's not just about blurry vision; high myopia can lead to severe visual impairment and even blindness.
• And while genetics play a role in the development of myopia, environmental factors have been believed to significantly influence its onset and progression. One such factor that has gained attention over the past decade is the amount of time children and adolescents spend outdoors.
• The study we're discussing today aimed to summarize and combine evidence from various studies to understand the association between time spent outdoors and the development of myopia. The researchers analyzed results from seven cross-sectional studies, pooling their findings in a meta-analysis.
• And the results? Quite intriguing! The pooled analysis indicated that for every additional hour spent outdoors per week, there was a 2% reduced odds of developing myopia. To put it in simpler terms, an extra hour outdoors each day could reduce the odds of myopia by about 14%.
• That's significant! The study also highlighted that increasing time outdoors could be a simple strategy to reduce the risk of developing myopia and even its progression in children and adolescents.
• It's fascinating to think that something as simple as spending more time outdoors can have such a profound impact on our eye health. It emphasizes the importance of outdoor play and activities for children, not just for physical health but also for their vision. And you might be asking why this happens, and the answer really lies in the cones of your eyes. When you are inside all of the time and looking at screens, your eyes adapt to that because they don’t have to see things far away so the cones in the back of your eye get longer and so does your eyeball and myopia develops and your far away vision becomes blurry. And what was found is that children that are outside don’t let their eyes adapt to inside environments as well because they are looking at the sky and other things far away but they are also quickly switching the distance of things they are looking at. For example, they might be looking at the sky and then see a bug on the ground right next to them, and this shift in level of focus is good for eye health and preventing myopia. But keep in mind that this is just one aspect of health that benefits from spending more time outdoors.
• Lastly, the concept of Food Deserts. A food desert is an area where residents have limited access to affordable and nutritious food. This isn't about the absence of food but the absence of healthy food options. According to the USDA, 23.5 million people live in food deserts in the U.S. The implications? Higher rates of nutrition-related diseases like obesity and diabetes. When the nearest grocery store is miles away, and the corner store doesn't stock fresh produce, it becomes a challenge to maintain a healthy diet.
• But I want to dive a little deeper into this interesting concept, because I think there are many misconceptions around it. To shed light on this, we're drawing from a comprehensive review titled "Disparities and access to healthy food in the United States: A review of food deserts literature" authored by Renee E. Walker, Christopher R. Keane, and Jessica G. Burke.
• Now, what's startling is that even when there's access to nutritious food, it doesn't always mean increased consumption, especially for low-income households[^6,7^]. This could be due to various factors, including personal preferences and the actual presence or absence of a supermarket nearby.
• Interestingly, many residents feel a strong sense of loyalty to their local convenience stores. The introduction of a supermarket can sometimes be seen as a threat to these smaller businesses, which play a pivotal role in the community[^6,7^].
• But here's where it gets concerning. In many neighborhoods that lack supermarkets, residents face a higher prevalence of health challenges where diet plays a significant role. We're talking about conditions like diabetes, heart disease, and even cancer[^3^].
• And when we talk about food choices, it's often influenced by what's available in the immediate vicinity. In many low-income urban areas, there's a higher density of fast-food joints and corner stores offering prepared foods than in more affluent areas. This means more processed foods, more "empty calories," and ultimately, poorer health outcomes.
• And the economics of this topic is pretty interesting too, because if you think about it, the reason this happens is that it is more profitable for supermarkets to be in these more affluent areas since people are likely to spend more.

Summary

• But that’s enough about describing most social determinants of health. We have broken them down into 5 main buckets being: 1. Economic Stability 2. Education 3. Social and Community Context 4. Health and Healthcare and lastly, 5. Neighborhood and the Built Environment. And keep in mind that these buckets aren’t just one social determinant of health, they are categories of social determinants of health with many social determinants within them. This was a very surface level introduction to each of these social determinants of health, and the truth is that you can take on an entire career looking at just a single one of them. There is so much depth to all of it, and I hope to go more in depth into race as a social determinant of health in next month’s podcast episode with Dr. Christopher King, whose work has been monumental within the world of race and racism in healthcare.

Segment 4: Addressing Social Determinants – Solutions and Innovations

• But now, I want us to think about what can be done about these issues. We talked about all these factors that impact a person’s health, but how can we actually address them and what has been already been done already to address them and ensure health equity and access. This is a topic that I felt has always been missing from lectures and presentations I have seen on social determinants of health, so I will try to present most of the ways that I’ve found that social determinants of health can be addressed. And here I break them down again, into, 1. Community Engagement and Empowerment 2. Technological Innovations 3. Policy Changes and Advocacy 4. Public-Private Partnerships 5. Education Initiatives 6. Built Environment and Urban Planning 7. Economic Interventions and 8. Cultural Competence in Healthcare

1. Community Engagement and Empowerment
   • At the forefront of addressing these unique needs are the voices of the community members themselves. Communities are not just clusters of homes or groups of people; they're living, breathing entities with unique needs, strengths, and challenges. And who knows them better than themselves. This idea actually brings me back to a story one of my professors told me, she gave us the example of how a group from the US went into a very small rural town in South Sudan to build them a water well. The thing is, this group never really took time to survey the community and or asked for their input on what they wanted. So turns out, after the water well was built, many women in the area were discontent because going to the nearby river with their friends to get water was their social activity and a way to have fun. Every time I hear about the importance of community voices I remember that story, which truly underscores the importance of tailoring interventions for the community. No one intervention will look the same in different communities, and that is specially true when it comes to interventions addressing social determinants of health.
   • But let’s take a step back. When we talk about 'community voices,' what do we really mean? It's the collective insights, experiences, and aspirations of the people living in a particular area. These voices are the most authentic indicators of what a community truly needs. They provide a firsthand account of the challenges faced and the solutions that might work best.
   • Let's consider another example. Imagine a neighborhood with a high rate of childhood obesity. While external experts might suggest building a new gym or introducing a health program in schools, community voices might reveal that the real issue is the lack of safe playgrounds or the prevalence of fast-food outlets. By listening, we get to the root of the problem.
   • Across the nation, we've seen numerous community-led initiatives making waves. Let's spotlight a few.
   • In Detroit, Michigan, a city known for its resilience, the 'Detroit Community-Academic Urban Research Center' has been working hand-in-hand with local residents. Together, they've identified pressing health issues and developed strategies tailored to the community's needs. Their initiatives range from promoting physical activity to improving access to healthy foods.
   • Moving to the West Coast, in Los Angeles, the 'Community Coalition' has been empowering residents to transform the social and economic conditions that foster addiction, crime, and violence. Through grassroots leadership, they've successfully advocated for better housing, improved schools, and safer neighborhoods.
   • These are just a couple of examples, but they highlight a crucial point: solutions are most effective when they're rooted in the lived experiences of those they aim to serve. And I’ve been very happy to see this taking place here in Washington D.C. I’ve been helping to gather data and community voices to write the 2024 Community Health Needs Assessment for the Medstar hospital, and it’s truly fantastic to see everything that goes behind the report. Different neighborhoods, or wards as we call it in DC, have extremely different community health needs. And although these are highlighted by hard data like the prevalence of heart disease or child obesity in different areas, I learned the most about what community really needed by attending meetings with community members to hear their voices. One critical thing I learned from these meetings was that community members love community health programs, but they will never be effective if there is no safety in the area and people don’t feel safe walking around the street and going to and from these programs.
   • As we move forward in our series, remember this: every community holds within it the seeds of its own transformation. It's by nurturing these seeds, by listening and collaborating, that we can cultivate lasting change.
2. Technological Innovations
   • Now I want to turn our focus to technological innovations, a rapidly growing field. First and foremost, let's talk about the digital tools and platforms that are making waves in the realm of public health. From AI-driven diagnostic tools to platforms that connect patients with resources, technology is playing a pivotal role in leveling the playing field.
   • One of the most significant breakthroughs in recent years has been the rise of telemedicine. According to the CDC, in 2021 alone, a staggering 37.0% of adults reported using telemedicine in the past 12 months. Think about that for a moment. Over a third of adults turned to digital consultations, breaking down barriers of distance, mobility, and even time.
   • Telemedicine isn't just about convenience. For those living in remote areas, or for those who might not have easy access to specialist care, it's a lifeline. It bridges the gap between patients and providers, ensuring that quality care isn't just a privilege for those in urban centers or affluent neighborhoods.
   • But the digital revolution doesn't stop there. Mobile apps and platforms are emerging as powerful tools in promoting health behaviors. Whether it's an app that reminds you to take your medication, a platform that connects you with mental health professionals, or even a game that encourages physical activity, technology is finding innovative ways to nudge us towards healthier choices.
   • Consider this: there are apps today that can help manage chronic conditions, track nutrition, or even teach meditation and mindfulness. These tools, often right at our fingertips, empower individuals to take charge of their health, regardless of their socioeconomic status.
   • As we look to the future, it's clear that technology will play an ever-increasing role in addressing the social determinants of health. By making healthcare more accessible, personalized, and proactive, we're not just improving individual lives; we're transforming communities. However, it’s also important to note the limitations of these innovations, for example, many lack the access to devices or wifi to have telemedicine visits. But as these technologies evolve and new ideas come to market, I believe that accessibility and convenience will grow.
3. Policy Changes and Advocacy
   • Now let’s consider how the government addresses social determinants, and to do that, we are going to discuss the policies and advocacy efforts that shape our health outcomes.
   • Let's start by understanding the intricate web of health departments in the U.S. At the top, we have the national health department, which sets broad health objectives and strategies for the country. Then, at the state level, health departments tailor these national guidelines to the specific needs and challenges of their populations. And finally, at the grassroots, local health departments work on the front lines, implementing these strategies in our communities.
   • While they operate at different levels, these departments are interconnected. National initiatives often rely on state and local departments for execution, while local departments look to the state and national levels for guidance, resources, and support. It's a symbiotic relationship, with each level playing a crucial role in shaping our health outcomes.
   • Now, let's delve into the role of policies. Policies, whether they're set at the local, state, or federal level, have a profound impact on our health. Think about it: from the quality of the air we breathe to the safety of our neighborhoods, policies shape the world around us.
   • Take, for instance, the Clean Air Act, a federal policy that has significantly reduced air pollution across the U.S. By setting emission standards, this policy has not only improved our environment but has also led to fewer cases of respiratory illnesses and heart diseases.
   • On a state level, consider the policies around tobacco control. Many states have implemented higher taxes on tobacco products, leading to reduced consumption and, consequently, fewer tobacco-related diseases. And at the local level, policies like zoning laws can determine where businesses, like liquor stores or fast-food chains, can operate, influencing community health.
   • But policies don't change in a vacuum. This is where advocacy and grassroots movements come into play. These are the voices that push for change, that highlight disparities, and that demand better health outcomes for all.
   • Think about the grassroots movements that have pushed for healthier school lunches or the advocates who have lobbied for more green spaces in urban areas. Their efforts, often starting at a community level, can ripple outwards, influencing local, state, and even national policies.
   • In essence, advocacy bridges the gap between the lived experiences of individuals and the policies that affect them. It's a powerful tool, one that can drive meaningful, lasting change in our health outcomes.
   • However, we can’t go without discussing how policies vary by counties. The truth is that while at the national level, entities like the CDC and the Department of Health and Human services set broad, overarching goals and missions to tackle these determinants, there is a lot of leeway for states to tackle these goals in different ways. So different states have different programs and health standards, and local health departments play a very significant role all of the health initiatives by county. For instance, you could have two neighboring counties, one that just merely meets the state’s health standards, and the other that goes above and beyond with local health department initiatives. And in these two counties, the difference in health outcomes is evident. So the takeaway here is that local health departments go a long way in addressing social determinants of health through local policies and grassroot movements.
4. Public-Private Partnerships
   • As we continue our exploration into the ways we can address the social determinants of health, we're turning our attention to a powerful tool: Public-Private Partnerships.
   • Now, you might be wondering, what exactly are Public-Private Partnerships? Simply put, they're collaborations between governments, non-profit organizations, and private corporations. These partnerships harness the strengths of each sector to address complex health challenges.
   • Imagine the scale and reach of a government initiative, combined with the innovation and efficiency of the private sector, and the community focus of non-profits. That's the potential of Public-Private Partnerships.
   • Let's delve into some real-world examples to understand the impact of these collaborations. One of the most notable partnerships in recent years has been between governments and tech companies to address health crises. Think about the collaborations during the COVID-19 pandemic, where tech giants partnered with health organizations to develop contact tracing apps, ensuring a swift response to outbreaks.
   • But it's not just about responding to crises. These partnerships play a crucial role in preventive health too. Take, for instance, the collaboration between local governments and fitness companies to set up community fitness centers or outdoor gyms. These initiatives make it easier for communities to engage in physical activity, addressing the social determinant of health related to physical environments.
   • Now, let's talk about advocacy within these partnerships. Private organizations, especially those with a health focus, often lobby for health policies. A prime example is the American Heart Association, or AHA. They've been involved in numerous coalitions at both state and national levels.
   • The AHA's advocacy efforts have led to significant policy changes, from regulations around tobacco and vaping to ensuring better nutrition in school meals. Their partnerships with both public entities and private corporations amplify their impact, driving change at a scale that would be challenging for any single entity to achieve.
   • In essence, Public-Private Partnerships represent the power of collaboration. By bringing together diverse stakeholders, these partnerships can address the root causes of health disparities, from the environments we live in to the policies that shape our lives.
   • As we conclude this segment, it's clear that addressing social determinants of health requires a multi-faceted approach. Public-Private Partnerships offer a promising path forward, leveraging the strengths of each sector to drive meaningful change.
5. Educational Initiatives
   • Now let’s turn our focus to education, which remember, was one of the five big pillars of social determinants of health. So let’s dive deep into educational initiatives, specifically those aimed at increasing health literacy. Health literacy, once again, is the ability to understand and use information to make decisions about one's health. And in today's complex healthcare landscape, it's more important than ever. If you would like to learn more about it, be sure to check out my episode on health literacy.
   • Across the nation, there are numerous programs dedicated to this cause. One standout example is the 'Health Literacy Program for Elementary School Students'. This initiative uses interactive lessons, games, and activities to teach children about nutrition, physical activity, and mental well-being.
   • But it's not just about the individual. These programs recognize the importance of the community. By educating parents and caregivers alongside their children, we ensure that healthy behaviors learned in school are reinforced at home. After all, parents play a pivotal role in shaping their children's health choices.
   • Moving on to school-based initiatives, there's a growing emphasis on creating environments that promote health from an early age. Schools are not just places of academic learning; they're hubs where children form lifelong habits.
   • Take, for instance, the 'Farm to School' program. This initiative connects schools with local farmers to provide fresh, nutritious meals in cafeterias. But it goes beyond just food. The program incorporates lessons on nutrition, cooking classes, and even school gardens where students get hands-on experience growing their food.
   • Another transformative initiative is the 'Whole School, Whole Community, Whole Child' model. This comprehensive approach integrates health into every aspect of the school experience, from physical education to mental health resources. It's a testament to the power of holistic education.
   • As we reflect on the potential of educational initiatives, it's clear that they offer a multi-pronged approach to addressing social determinants of health. By instilling individuals with knowledge, we foster healthy environments and communities. And this way, we can pave the way for a healthier future.
   • A key aspect that we can’t forget here is that education isn’t just something we should have in childhood, it’s a life long commitment, and so, there should be health education efforts tackled for all age groups. Innovative ways of education, through say, mobile apps or required health courses for corporations, I truly believe that we can change the mindset of many and help them care for their health and the health of those around them.
6. Built Environment and Urban Planning
   • Another big bucket of social determinants of health that we discussed was the built environment. So I would like to talk a bit about initiatives for improving the built environment along with urban planning.
   • As we discussed, the cities and neighborhoods we inhabit play a pivotal role in our health and well-being. From the air we breathe to the streets we walk, every aspect of our environment influences our daily choices and, in turn, our health.
   • Let's start with a fundamental question: How can we design cities and neighborhoods for health? The answer lies in integrating health considerations right from the inception of urban planning. Think of cities like Copenhagen or Amsterdam, where cycling lanes are as integral as the roads themselves, promoting physical activity and reducing vehicular pollution.
   • But it's not just about transportation. The very layout of a city can promote health. Consider the concept of '15-minute cities'. This urban planning initiative, piloted in cities like Paris, aims to ensure that residents can access most of their daily needs within a 15-minute walk or bike ride from their homes. This not only reduces the reliance on cars but also fosters local businesses and community interactions.
   • Now, let's talk about green spaces. Parks, gardens, and even urban forests are the lungs of our cities. They provide a respite from the concrete jungle, offering spaces for recreation, relaxation, and connection with nature. Studies have shown that proximity to green spaces is linked to reduced stress, increased physical activity, and even improved mental well-being.
   • But green spaces are just one piece of the puzzle. Walkability is another crucial aspect. Cities like Portland, Oregon, have invested heavily in pedestrian-friendly infrastructure. Wide sidewalks, safe crosswalks, and pedestrian zones not only make walking a pleasure but also encourage residents to choose walking over driving for short distances.
   • Access to essential services is the cornerstone of a healthy urban environment. Imagine living in a neighborhood where healthcare facilities, grocery stores, schools, and recreational centers are all within easy reach. This not only reduces travel time and costs but also ensures that residents have everything they need for a healthy life right at their doorstep.
   • Before we wrap up, let's touch on the importance of clean air policies. Take the example of London's Ultra Low Emission Zone (ULEZ). Introduced in 2019, this policy restricts the most polluting vehicles from entering the city center. Since its implementation, there's been a significant reduction in nitrogen dioxide levels, making the air cleaner and safer for residents. Such policies not only protect the environment but also directly impact public health by reducing respiratory and cardiovascular diseases.
   • The built environment and urban planning are powerful tools in addressing social determinants of health. By designing cities that prioritize health, we can create environments that nurture well-being, foster community, and pave the way for a brighter, healthier future.
7. Economic Interventions
   • Now we’ll go into the world of economic interventions, the first bucket of social determinants that we talked about. Money might not buy happiness, but economic stability can certainly pave the way for better health.
   • Economic stability is a cornerstone of well-being. It affects where we live, what we eat, our stress levels, and even our access to healthcare. But how can we ensure that everyone has a fair shot at economic prosperity? Let's explore.
   • First on our list: job training and employment programs. These initiatives are designed to equip individuals with the skills they need to secure stable employment. Think of programs like Job Corps in the U.S., which offers free vocational training to young adults. By providing training in sectors like healthcare, manufacturing, and IT, such programs not only boost individual incomes but also fill critical gaps in the workforce.
   • But it's not just about job skills. Employment programs often go hand-in-hand with soft skills training, teaching participants everything from resume writing to interview techniques. For instance, the 'Year Up' program connects urban young adults with companies in need of talent, ensuring they're job-ready from day one.”
   • Now, while employment is crucial, it's just one piece of the economic puzzle. Financial stability also hinges on how we manage, save, and invest our money. And that's where microloan and financial literacy programs come into play.
   • Microloan programs, popularized in countries like Bangladesh by the Grameen Bank, provide small loans to entrepreneurs who might not have access to traditional banking. These loans, often given to women, enable them to start or expand small businesses, from handicrafts to livestock farming. The beauty of these programs? They not only boost individual incomes but also uplift entire communities.
   • But loans are just the beginning. Financial literacy is the key to long-term economic stability. Programs like 'Operation HOPE' in the U.S. offer financial dignity and literacy training, teaching participants the basics of budgeting, saving, and investing. By empowering individuals with the knowledge to make informed financial decisions, we're laying the groundwork for a future free from economic disparities.
   • It's clear that economic interventions have the power to transform lives. By providing individuals with the tools, skills, and knowledge they need, we're not just boosting incomes; we're paving the way for healthier, more prosperous communities.
   • Economic interventions are a vital tool in our quest to address social determinants of health. Whether it's through job training, microloans, or financial literacy, these initiatives are reshaping the economic landscape, one individual at a time. While some of these ideas such as giving loans and money to support those in economic distress cost everyone a lot of money, others, like offering financial literature class or even free courses on healthcare spending, we can lead to incredible change.
8. Cultural Competence in Healthcare
   • Last but definitely not least, I would like to discuss the role of cultural competence in healthcare to address social determinants.
   • Imagine walking into a doctor's office and feeling misunderstood, not because of your symptoms, but because of your cultural background. This is a reality for many, and it's why cultural competence is so essential.
   • First and foremost, what is cultural competence? It's the ability of healthcare providers to recognize and respect patients from diverse backgrounds and tailor care to meet their unique needs. It's not just about language, but understanding cultural nuances, beliefs, and values.
   • Let's start with training. It's essential for healthcare providers to understand cultural differences. Think about a scenario where a patient from a conservative background feels uncomfortable discussing certain health issues with a doctor of the opposite gender. Recognizing such nuances can make a world of difference in patient care.
   • Institutions like the University of California, San Francisco, have pioneered programs that immerse medical students in diverse communities. This hands-on experience helps future doctors understand the cultural and social challenges their patients might face.
   • But training isn't just about exposure. It's about equipping healthcare providers with the tools to communicate effectively. This might mean using interpreters or understanding non-verbal cues specific to certain cultures.
   • Now, let's talk about tailoring healthcare services. It's not a one-size-fits-all scenario. Different communities have different health needs, beliefs, and practices. For instance, traditional medicine plays a significant role in many cultures. A culturally competent healthcare provider would recognize this and find ways to integrate or acknowledge these practices in their treatment plans.
   • Consider the success of the 'I SPEAK' initiative in Seattle. This program ensures that patients receive medical information in their preferred language, making healthcare more accessible and understandable.
   • Or think about clinics that adjust their hours to accommodate cultural or religious practices. A simple change, like being open after sunset during Ramadan, can make healthcare more accessible to Muslim patients.
   • Cultural competence is more than just a buzzword. It's a commitment to understanding, respect, and individualized care. It's about seeing the person behind the patient and ensuring that everyone, regardless of their background, receives the best possible care.
   • In wrapping up, cultural competence is a journey, not a destination. As our world becomes more interconnected and diverse, the need for culturally competent care will only grow. It's up to us, whether we're healthcare providers or patients, to champion and demand this level of care.
9. Summary
   • And this brings me to the end of my list of possible ways to address social determinants of health. I’m sure that there are many more out there and innovation is what’s truly going to move us forward, so if you have any ideas that you think are really good, take them into action. It’s never too early to drive change, and if you think about most change and disruptive innovations came from young people, so don’t think that you have to wait until you are deep into your career to make change because that is never true. But to wrap up, I would like to repeat all of these ways to address social determinants of health that I talked about. They are 1. Community Engagement and Empowerment 2. Technological Innovations 3. Policy Changes and Advocacy 4. Public-Private Partnerships 5. Education Initiatives 6. Built Environment and Urban Planning 7. Economic Interventions and 8. Cultural Competence in Healthcare

Conclusion

• Ladies and gentlemen, as we draw this enlightening episode to a close, let's take a moment to reflect on the intricate web of factors that shape our health outcomes. From the economic stability of our households to the quality of education we receive; from the neighborhoods we grow up in to the very air we breathe – every facet of our lives plays a role in determining our health.
• We've delved deep into the pressing issues of housing, transportation, access to nutritious food, and the undeniable influence of our built environment. We've explored the transformative power of technology in bridging healthcare gaps and the pivotal role of policies at every level. We've celebrated the successes of community-led initiatives and the promise of public-private partnerships. And we've underscored the importance of cultural competence in healthcare, ensuring that every individual, regardless of their background, receives care that respects and understands their unique experiences.
• But here's the thing: while it's crucial to be informed, knowledge alone isn't enough. Change – real, lasting change – requires action. And that's where each one of us comes in. Whether it's advocating for better policies, supporting community initiatives, or simply being more understanding and inclusive in our daily interactions, every small step counts. Because improving the social determinants of health isn't just the responsibility of policymakers or healthcare professionals – it's a collective effort.
• So, as you go about your day, remember: you have the power to make a difference. Whether it's by supporting local initiatives, advocating for better policies, or simply educating others about the importance of these determinants, every effort counts. Together, we can create communities where everyone has the opportunity to lead healthier, more fulfilling lives.
• Thank you for joining us on this journey today. Let's not just be listeners; let's be doers. Let's champion a world where health isn't just a privilege for the few but a right for all. Until next time, stay informed, stay active, and stay healthy.