Using Social Determinants to Identify Dangers to Health

Over the years I have seen many people question the quantifiable effects of social determinants of health. I used to be one of them. I remember a colleague evangelizing the importance of understanding and considering factors such as income, geographical location and cultural norms in understanding health outcomes. I thought it was “nice to know” but not something we could actually fix. After all, where do you start? How does a health professional begin to understand and account for all the factors that could be impacting a person’s health?

Public health professionals play a significant role in this area. They have the ability to break society into smaller, more manageable bites and delve deeper into what is happening. A great example of this was documented in the a study published in the August 2012 Pediatrics about the increased rate of children admitted to hospitals for child abuse and its link to the housing mortgage crisis.

According to the New York Times report of the study, the rate of hospitalization for children suffering from physical abuse increased an average of 0.79 percent a year from 2000 to 2009. The researchers then linked the data to unemployment rates, mortgage delinquency and foreclosure statistics and found a correlation. For every 1 percent increase in the 90-day mortgage delinquency rate in a metropolitan area, there was a 3.09 percent increase in hospital admission rates for children and a 4.8 percent increase in high-risk brain injuries among children.

Clearly, the economic crisis has increased stress levels across the board. Research by the American Psychological Association (APA) shows work, money and the economy are the most frequently cited sources of stress, the same issues that have topped the list for the past five years.  And while we know that stress has a strong influence on our own health, we may not realize how it is impacting our children. This new research paints a picture. We get stressed. We lose our patience, and we inadvertently take it out on innocent victims in our lives.

As parents, we have all been guilty to some degree of letting stress impact our home lives. What parent has not scolded a child too quickly for doing something wrong simply because we had other things on our mind? If you are worried about how you are going to pay the mortgage next month, you may have less patience for a child who is jumping on the furniture pretending to fly. After all, the noise may be contributing to your headache, and you may worry that he or she may break something you can’t afford to replace.

There are no clear answers on how to fix the problem. But acute awareness is a good first step. Social determinants are the economic and social conditions that influence differences in health. It is most often associated with inequities in health, but – as in this case – it also helps shed a light on potential dangers to a population. Identifying and acknowledging issues like this will help us better address the health of the nation.

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Why is Fixing Access So Hard?

An article in The Atlantic earlier this month discussed the New York City Department of Health’s Healthy Bodegas Initiative to increase nutritional offerings in at-risk neighborhoods. The logic is that low income neighborhoods have less access to quality food and that contributes to high levels of obesity.

Studies around the country have shown that less affluent communities tend to have high levels of obese and overweight residents. And New York City is no exception. According to the data, 60 percent of adults in East Harlem and Central Harlem are either overweight or obese. And less than 10 percent of Harlem residents eat the recommended servings of fruits and vegetables.

This concept of low access to healthy food options in low socio-economic communities led to the term “food desert.” A food dessert is defined by the U.S. government as “a low-income census tract where a substantial number or share of residents has low access to a supermarket or large grocery store.” There are more than 6,500 food deserts in the continental U.S. (food desserts are not yet defined for Hawaii and Alaska) and 75 percent of them are in urban areas. Some studies have correlated low access to healthy food options to higher obesity rates.

So the solution should be simple. Let’s work with grocery store and supermarket chains to open more retail locations in these food deserts. Once residents of food deserts have healthier options, they will surely eat better. Right?

Again, the solution is not that easy. According to the New York Times two new studies are challenging the notion of lack of access to fresh food in low-income neighborhoods.  The studies show that while poor, urban neighborhoods have a higher concentration of fast-food restaurants and convenience stores, they also have more grocery stores, supermarkets and full-serve restaurants. They don’t lack access to healthy options. The study concludes there is no relationship between the type of food available in a neighborhood and obesity rates among its children and adolescents.

So what does it all mean? Like an economic model, we need to look at the supply and demand side of the equation. In this case, the Field of Dreams approach of “build it and they will come” isn’t the solution. Building fresh food stores only addresses the supply portion of the equation – and the recent studies are calling into question whether supply is even an issue. We need to look closely at the demand side.  If it were a matter of supply only, the New York bodegas wouldn’t be able to keep their small supply of fruits and vegetables in stock. Instead, they are throwing out half their stock. Why aren’t consumers in poor, urban neighborhoods buying produce when it is available? Is it too expensive? Is it difficult or time-consuming to prepare? Are the fruits and vegetables available not part of a community’s culinary culture? For example, communities whose heritage comes from warm weather climates (such as the Caribbean) may be less familiar with fruits and vegetables grown and consumed in more temperate climates (such as North America and Europe). What factors are impacting the demand side of the equation?

There are many variables impacting eating behaviors that we need to consider in the fight for healthier eating habits. Prescriptive supply-side solutions won’t fix the obesity crisis.  Shaming the food industry or overweight people won’t do it either.  The answer lies on the demand side of the equation. And that’s the hard part of the equation. If the demand is there, the supply will follow. The overweight and obesity issue in this country requires comprehensive, societal change, one that impacts body, mind, soul and environment. It’s pretty daunting to think about it that way, but then again, so is the problem.

Inspiration Comes From Many Places

I have a confession to make. It was Fall 2008 and I couldn’t run to the corner of my street without getting winded. I was in my 30s, the mother of two, with a successful career. I wasn’t particularly out of shape. I have been in good health most of my life. But I couldn’t run to the corner. And that bugged me.

Fast forward to 2012 and I am in the best shape of my life. I have run a few half-marathons. I lift weights regularly and I crave physical activity like never before.

But this is not the story of how I received devastating health news and fought my way back through exercise. This is not the story of how a life-changing experience drew me to running. This is a story of finding inspiration in unlikely places. It is about overcoming mental barriers and reaching new heights.

It all started with my work. I was a marketing and communications director at a large company. And I had just signed my company up to be the sponsor of a marathon/half marathon/5k weekend event. It was a great match for our company, and many employees, including senior people, were excited to participate.

I flew to the race city to meet with the event team to start working through our activation plans. I met with many people over the course of a few days, including the race directors, a married couple who have made a career out of their passion for running. Over dinner, I listened to their stories and got caught up in their enthusiasm. They challenged me to run, and by dessert, I agreed to run my first 5k at the event weekend, only a few months away.

I am goal-driven and competitive. But I knew I couldn’t run 3.1 miles. I panicked. How do I get out of this?  I didn’t have an elegant way out, so I enlisted the help of  a trainer I knew. I told him I need to make a decent showing at this 5k for professional reasons. It had nothing to do with my personal well-being. My credibility was at stake. I can’t be the face and champion of this event within the company and be the last one to finish the 5k? The trainer got me ready. Most importantly, he gave me confidence. He convinced me that I was an athlete. I believed him when he said I was ready.

In January 2009, I ran the 5k. As I crossed the finish line, I made two phone calls. The first was to my husband to say I had done it. The second was to my trainer to thank him. He had believed in me and he showed me how to believe in myself. The next day, as I watched thousands of people complete the half-marathon, I told the race directors, I’d be back next year — and I would run the half.

Guess what I did in January 2010?

The benefits of running are many, and my physical well-being has improved immensely since I started to run. But the most significant lesson I learned from running is that our biggest barrier to accomplishment is ourself. We limit ourselves with our fears and insecurities. We often think more in terms of what we can’t do instead of what we can do. I was never an athlete. Growing up, I had always been the intellectual one, not the athlete. But the experience of watching runners challenged me to wonder why I couldn’t be both.  Imagine if we could apply that learning to bigger problems? Imagine if people who struggle with health challenges, depression and other co-morbidities could overcome the deep sense of defeat and find the strength to believe they can overcome — and more importantly, thrive. Physical challenges always remain, but the old saying of putting your mind to something holds true. We need courage to reach new heights.

I have applied that lesson to other aspects of my life and it has made me braver than I ever was. And I have had the honor of trying to help others believe they can overcome challenges with success. I recently came across a quote from George Sheehan, an American physician, author, and runner who said,  “Success means having the courage, the determination, and the will to become the person you believe you were meant to be.”  I think that sums it up! So what’s next for me? I’m not sure, but I’m considering running a mud-crawling, fire-leaping extreme 5K this summer. Stay tuned…