Healthy habits lead to a healthy life, but how is our life affected by factors outside of our control? According to the Centers for Disease Control and Prevention (CDC), “your zip code can be more important than your genetic code.”1 In Philadelphia, two babies born just 5 miles apart face up to a 20-year difference in life expectancy.2 We don’t control where we are born but, as a community, we can counteract and prevent known healthcare inequities based on circumstances. An individual’s health is affected by several factors beyond the clinical measures, including neighborhood and built area, economic stability, education, and social and community context.3 Together these factors make up Social Determinants of Health: the conditions in which we grow, learn, work, and play.
Take Tracy for example. Tracy is a 34-year-old woman from rural Kentucky. She is a high school dropout working at the diner walking distance from her home. She has not seen her primary care physician for over 3 years and is morbidly obese. Living in a food desert, with no nutritional, fresh, and healthy food, and without access to her primary care physician, how can Tracy successfully manage her obesity and other risk factors? Clinical care affects only 20% of health1 according to the CDC. Limited or no access to a grocery store, stable housing, education, a safe place to exercise, air quality, etc. play an active role in a person’s health.
As in the case for Tracy, timely notification to a care team member can guide her to food pantries that are covered under her insurance. She can get healthy and wholesome food delivered to her, allowing her to get her health back on track. Proper utilization of analytics can alert a physician to a patient’s Social Determinants of Health to address these issues. For those babies in Philadelphia, a simple alert to the pediatrician would make sure that the child from the underserved neighborhood gets extra care to make sure he does not fall behind, physically, mentally, or socially compared to his peers. Educational data about an underserved population may help providers with a more effective strategy to reach their patients. A patient with no high school education may not be able to read the pamphlets given by their doctor, instead the patient would benefit much greater from a conversation.
Tracking Social Determinants of Health and analyzing subsets of the population help identify those at higher risk for chronic conditions. Using state-of-the-art clinical assessments, the providers can mitigate these health risks and reduce the costs for these patients, leading to a healthier population and health system. Opportunities for better health begin with our homes, neighborhoods, jobs, and schools, and the ability to pursue a better health outcome. An all-inclusive health strategy – focused on social, economic, environmental, clinical and preventative measures – allows people to shift their focus from regaining health to maintaining it.
- Invest in Your Community [PDF file]. (2015 March). Retrieved from (https://www.cdc.gov/chinav/docs/chi_nav_infographic.pdf
- Mapping Life Expectancy: Philadelphia. (2016, April 6). Retrieved from https://societyhealth.vcu.edu/work/the-projects/mapsphiladelphia.html
- Social Determinants of Health. (n.d.). Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health