Chapter 3: Social Determinants of Health
Katie Baker
The Centers for Disease Control and prevention Foundation (CDCF) defines public health as “the science of protecting and improving the health of people and their communities” (What Is Public Health?, n.d.). When you think of Public Health, you may consider mobile units that screen for breast cancer, hearing screenings in local elementary schools, vaccination initiatives, or county and state health departments that support local doctors in preventative care and the promotion of health through community outreach. These, and many more programs, fall under the umbrella of public health and prevention.
In the 19th century, local public health agencies were created in the U.S. and given the task of addressing communicable diseases. Since then, public health has addressed workplace safety, environmental exposures, health education and access to clinical care (What Is Public Health?, n.d.). The history of public health is one of heartbreak and triumph as agencies have fought to provide clean water and air, immunizations and contraceptive access for individuals and families in our country.
Public health-funded immunization drives helped to provide and encourage polio vaccination in the 1950s by providing immunization clinics in public school gymnasiums, addressing a deadly virus that could be transmitted via contaminated food and water. Prior to the creation of the vaccine by Dr. Jonas Salk, the polio virus killed or paralyzed over 500,000 people annually (WHO, n.d.).
During the recent COVID-19 pandemic, public health took center stage as government funding provided for public testing, providing masks and at home tests, research into vaccine programs and support for families whose children were no longer in school in the form of free meals. COVID’s effects shone a spotlight on how intertwined the world’s physical and financial health is as well as showing how integral public health is to a functioning society.
In addition to undertaking these projects, public health organizations were also integral in addressing the disparities seen between urban and rural health. Rural areas tend to have populations who live with higher risk of COVID-19. For example, individuals in these areas tend to be older and of lower socioeconomic status, and to lack access to quality healthcare (Melvin et al., 2020).
Funding for Public Health Programs
Public health is funded through local, state and federal funds, as well as through revenue streams, such as the marijuana tax in Washington State that pays for Medicaid, as well as substance abuse education and treatment programs. Private grant money is also an important source of Public Health funding.
In Washington state, the state Department of Health system is divided into 35 public health districts and local health departments to serve its 39 counties. Other states may divide public healthcare by city or county. In addition, many public partners, such as universities, collaborate with state and local health departments to provide care and research opportunities. In addition, Washington state has with federally-recognized tribal organizations for public health service delivery for over a decade.
On the federal level, public health organizations include the CDC, the Department of Health and Human Services (DHHS) and the National Institutes of Health (NIH), among other agencies. They work together and with state and local agencies to acquire funds and provide care to communities across the country.
Many decisions about public health funding are based on politics surrounding specific programs and conditions. For example, in the 1980s, it was not popular to support funding for HIV/AIDS research, due to stigmas surrounding HIV/AIDS and its role in the gay community. As a result, tens of thousands of patients died before drug cocktails could be developed. Public Health safer sex initiatives face similar uphill battles for funding in areas that are more socially conservative, even though school districts that teach abstinence-only sex education have higher teen pregnancy and teen STI rates than those that teach about contraception. In the U.S., the Congressional budget for abstinence-only education is currently 85 million/year, with prohibitions against teaching about contraception, except for failure rates, imposed upon all states receiving this funding. Due to this, the rate of formal instruction in birth control methods dropped from 81% (men) and 87% (women) in 1995 to 55% (men) and 65% (women) in 2011-2013. At the same time, the gap between first sexual intercourse and marriage is at 11 years for men and 8 years for women (Columbia University, 2017). Due to these limitations on funding, over half the states reject federal money for human sexuality education. Despite the funding limitations, research shows significant benefit from comprehensive sexuality education in the areas of teen pregnancy, HIV status and all STI transmission rates and shows no benefit in these areas from abstinence-only education (Chin et. al., 2012).
In another example, the Dickey Amendment which was passed in 1996 as an attachment to the congressional omnibus spending bill, prohibited the use of federal funding for ”advocating or promoting gun control” (Omnibus Consolidated Appropriations Act, 1997) and the funds were reallocated to research on traumatic brain injuries. In 2018, a report was added to the amendment, clarifying that gun research was not addressed by the amendment and the congressional budget now allows the Centers for Disease Control to study and compile statistics about gun violence in the United States, provided they have the funding for such research.
As we can see, public health can be funded publicly or privately at the local, state or federal level. Funding through the government can come with a number of strings attached or prohibitions. Popular public health projects can provide many benefits for generations to come and can have a profound impact.
Public Health and Epidemiology
The COVID-19 pandemic catapulted public health into the center of the discussion regarding infectious disease prevention, but many individuals are still unclear about the role of public health in healthcare.
Public health is a field that promotes and protects the health of people and the communities where they live, learn and play. The leading professional organization in the United States is the American Public Health Association, which has more information on what is public health, as well as how to get involved.
Public health utilizes a population-focused approach to addressing health interventions, as opposed to an individual or patient-focused approach as seen predominantly in medicine, nursing, pharmacy and other healthcare professions. There are many fields in public health, including public health nurses and physicians, social workers, first responders, restaurant inspectors, health educators, scientists and researchers, epidemiologists, community planners, nutritionists, public policy makers, sanitarians and occupational and safety professionals.
While there are many government employment opportunities in public health at the national level, including the Centers for Disease Control and Prevention, the Commissioned Corps of the U.S. Public Health Service, there are also state and local public health departments that employ public health professionals. Beyond government employment, public health careers can include professionals that are involved in anything from identifying diseases, to creating policy and interventions to address health and wellness at the population level.
There are 10 Essential Public Health Services (EPHS) that describe the public health activities that all communities should undertake to address health and wellness. Those were revised in 2020, and include:
- Assess and monitor population health status, factors that influence health, and community needs and assets
- Investigate, diagnose, and address health problems and hazards affecting the population
- Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it
- Strengthen, support, and mobilize communities and partnerships to improve health
- Create, champion, and implement policies, plans, and laws that impact health
- Utilize legal and regulatory actions designed to improve and protect the public’s health
- Assure an effective system that enables equitable access to the individual services and care needed to be healthy
- Build and support a diverse and skilled public health workforce
- Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement
- Build and maintain a strong organizational infrastructure for public health
The science of public health relies heavily on epidemiology, defined by the Dictionary of Epidemiology as the study of distribution and determinants of health-related states among specific populations and the application of that study to the control of health problems. The distribution includes the frequency or pattern of disease, and the determinants are the causes or risk factors of disease or events that are not only diseases. Some examples of investigations in public health are in the below table by the CDC.
epidemiologists are sometimes called “disease detectives” in that they search for the cause of a disease, identify people who are most at risk, and determine how to stop the spread or prevent further disease from happening. They often work hand-in-hand with other “disease detectives” trained in public health principles such as veterinarians, nurses, physicians, scientists, nutritionists and other health professionals.
In public health, disease detectives will investigate the causes and spread of both communicable and noncommunicable diseases, as well as other events that are not diseases that can have an impact on health. Examples of non-disease hazards are often environmental and include noise pollution, sun exposure, smoke inhalation, etc., or even legal, socioeconomic (such as poverty and access to healthcare) and structural.
Public Health and Disease Prevention
Prevention can be categorized into primary, secondary or tertiary interventions. primary interventions involve avoiding disease and maintaining good health. Secondary prevention is when a provider diagnoses and treats a disease as early as possible to prevent more serious complications or sequelae. Tertiary prevention is when healthcare providers attempt to manage chronic illnesses in such a way as to enhance quality of life and improve longevity.
Primary interventions require the evaluation of individual risk factors, such as smoking, a high-risk job or risky behaviors, and other diet and lifestyle factors. After evaluating risk factors, decisions can be made about preventive programs that address those specific diseases or conditions for which people with those risk factors are more likely to develop. For example, smoking cessation programs may be instituted to prevent lung cancer and other possible effects from smoking tobacco. They may be advertised in primary care clinics and high schools in communities where tobacco use is elevated in adolescents. Additional examples include community vaccination drives such as those instituted for polio, flu, and COVID-19 vaccines. Next time you are watching television or using social media, pay close attention to any public service announcements in those spaces. Many of them may be directed towards primary disease prevention.
secondary intervention, which prevents diseases from becoming more serious, can be seen in the many cancer screening programs instituted at free clinics and in provider offices around the country. Mobile clinics, such as those for mammograms, can provide secondary preventive services in rural and low-income urban areas that are otherwise underserved. Contact tracing, which has become more common since COVID-19 but was previously used for sexually transmitted and other infectious diseases, is another example of secondary prevention, allowing providers in public health to notify individuals who have been exposed to a disease so they can get tested and treated.
Finally, tertiary interventions focus on improving the quality of life and longevity of people with chronic illnesses. For example, blood sugar maintenance and diabetic foot care programs in individuals with type 1 and type 2 diabetes, can have positive effects on their condition and its progression. Individuals who participate in diabetic foot care programs through their senior center or long term care facility, for example, are less likely to have ulcers go unnoticed that would otherwise lead to gangrenous wounds that require amputation.
Primary, secondary, and tertiary prevention programs are all in the field of public health. Programs may be funded at the city, county, state, regional or federal levels, either through existing programs or through grant funding for new projects (CDC, 2013).
Skill Stitch: Advocating for Your Patient
Healthcare is a polarizing topic in the United States. So are protests. Protests are one way in which healthcare providers can advocate for their patients on a large scale. There are many other ways in which providers can advocate for their patients.
In your own place of work, you can advocate for patients by making sure they are being heard and any safety risks at work are understood by decision makers such as managers, providers, a patient ombudsman and social workers. Practicing before speaking to a supervising physician or another person in a position of authority can help you to feel more confident and be a more powerful advocate for patients and their safety. Another key point to remember is that providing solutions when addressing your concerns can help them to be successfully addressed more easily.
Outside of your work, you can advocate for patients in the community as well. As a healthcare professional, your professional reputation can lend weight to your opinion on health-related matters such as public health efforts, climate change and climate change, voting access and drug policy.
If large protests are not your style, you can participate in voter registration efforts, phone banking for local nonprofits in support or opposition to current legislation, or even letter-writing or texting campaigns to elected officials.
For more involved efforts, you can consider volunteering or working for nonprofits with healthcare goals that align with your own or even working with your coworkers to create research and collect data to support patient-centered changes at your work or in your community.
In this section, you will practice writing out what you want to say to advocate with the office manager for a patient who has difficulty with her healthcare. After reading the scenario, write in your notes the concerns that you have and how you would like to see them changed. Include a suggestion for how to prevent this situation from happening in the future.
Cleo is an 86 year old transgender female patient who is being seen in your clinic as a primary care patient. She has been a patient for decades and is always very polite and friendly to the staff. Lately, you have noticed with some concern that she appears worried when she comes in to see the new provider assigned to her care. Although she does not complain, she seems less enthusiastic about seeing this new provider than her previous one, who has retired. She has been struggling to comply with her provider’s directions and often seems on the edge of tears when leaving the clinic. She frequently pays her outstanding balance with small bills and change, promising to bring more money at the next visit.
What are some possible concerns around Cleo’s medical care and daily life? What allies [GL: persons who support the rights of another group or individual] might you find in your office to help support her? What might be some barriers to advocating for Cleo? How do you feel about advocating for support for a patient whose needs may lie outside of their medical care? How could you address this situation and prevent similar ones in the future?
Attributions
- Figure 3.3: CloseTheCamps_30Days_Day18_IMG_2861-1 by Peg Hunter is released under CC BY-NC 2.0
Organizations and processes focused on protecting the health of a community
The study of distribution and determinants of health-related states among specific populations and the application of that study to the control of health problems.
Individuals who study epidimiology, searching for the cause of a disease, identifying people who are most at risk, and determining how to stop the spread or prevent further disease from happening.
Actions to prevent a disease or injury before it occurs.
The length of a person’s life.
When a provider diagnoses and treats a disease as early as possible to prevent more serious complications.
Screening x-rays of breast tissue, looking for densities that suggest cancerous tumors
When healthcare providers attempt to manage chronic illnesses in such a way as to enhance quality of life and improve longevity.
Full of gangrene, localized death and decomposition of tissues due to lack of blood flow.
An official within an organization who investigates consumer/patient complaints against that organization’s administration, a neutral party who helps mediate conflicts between a patient and the healthcare organization.