Updated February 2019
The powerful influence of social and environmental factors on health outcomes has long been acknowledged by health care practitioners and epidemiologists since the times of Hippocrates, Galen and Snow. Interest in investigating and addressing social determinants of health (SDOH) continues to grow within health care organizations, and for Medicaid providers in particular. Healthy People 2020 has provided an brief definition for social determinants of health:
“conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. (Healthy People 2020, 2018)
Multiple clinical, biomedical, research and professional organizations have elaborated on this definition and embraced social determinants in multiple domains to a varied degree of breadth and specificity. For example, Healthy People 2020 further organizes social determinants into five areas: Economic Stability, Education, Social and Community Context, Health and Health Care, and the Neighborhood or Built Environment (Healthy People 2020, 2018). In this executive summary, we provide a concise summary of the current and future implications of research, best practices and ongoing work on social determinants of health as related to cardiovascular health and--in particular--high blood pressure in Ohio.
Social Determinants Concepts
A wide array of concepts can be described as social determinants of health. While a complete review of these concepts is beyond the scope of an executive summary, the CARDI-OH Social Determinants Working Group has created a glossary of core SDOH concepts that is now available here. In recent months, multiple professional and scientific associations and some provider organizations have sought to create, promote and distribute brief social determinants screening tools for use in clinical settings. These include the National Academy of Medicine, the American Association of Family Physicians, Kaiser Permanente and several others. These tools share a common set of “core” social determinants concepts. While each organization’s list might vary slightly, a core set of concepts should minimally include: Housing, Food, Transportation, Income, Education, Interpersonal Violence, and Social Support.
Social Determinants and Cardiovascular Health in Ohio
Ohio consists of 88 counties that are a combination of urban, rural and suburban areas. The 5 main urban areas are located in Cuyahoga (Cleveland), Franklin (Columbus), Hamilton (Cincinnati), Lucas (Toledo) and Summit (Akron/Canton) counties. The other 83 counties are smaller metropolitan areas, with the majority consisting of a mix of suburban, rural and rural/Appalachian areas. The State of Ohio Health Assessment conducted in 2016 reviewed demographics of Ohio by gender, race and age together with health outcomes such as length of life, quality of life, health behaviors, social and economic factors and physical environment (Reem et al, 2016). A snapshot of that report shows that cardiovascular disease, hypertension, obesity, diabetes and related risk factors (such as tobacco use, sedentary lifestyle and poor nutrition) are salient concerns for Ohio. According to the report:
Obesity and hypertension, for example, are highly-prevalent conditions reported by nearly one-third of Ohio’s adult population. Over 11 percent of adults had diabetes in 2014, an increase from 2013. All three of these conditions were more common among middle-aged Ohioans than younger Ohioans, indicating that chronic disease will be a significant challenge for Ohio’s growing aging population in the coming years. (p.3) The prevalence of diabetes and hypertension increased with age. By age 55-64, nearly one-fifth of Ohioans reported having diabetes and almost half reported hypertension (p. 20)
Maps of Ohio by county indicate that urban counties and counties located along the south and southwest borders of the Ohio River experience the highest rates of avoidable cardiovascular death. Maps of social and economic factors, such as the poverty rate similarly indicate that high poverty counties tend to be the same counties with higher levels of avoidable cardiovascular death. Data on health at the county level are completed approximately every 2-3 years and are available for all counties or clusters of counties in Ohio. They show a high burden of hypertension and diabetes. (See County Reports in References).
Counties at the bottom of the rankings for health outcomes are primarily rural counties and the largest cluster is considered rural/Appalachian.
Health factors in the County Health Rankings represent the focus areas that drive how long and how well we live, including health behaviors (tobacco use, diet & exercise, alcohol & drug use, sexual activity), clinical care (access to care, quality of care), social and economic factors (education, employment, income, family & social support, community safety), and the physical environment (air & water quality, & housing). Counties clustered along the southern border of Ohio and in urban counties have the lowest rankings.
Addressing Social Determinants of Health
Efforts to address SDOH will need to extend far beyond the walls of health care clinics, hospitals and emergency rooms. The long term and sustainable pathway to improved health is one that involves creating healthier communities through a combination of public policy, institutional change, and fundamental reworking of the ways in which people relate to one another and to their environments, as well as healthcare facilities. However, insurers, providers and policy makers are currently more focused on identifying high value pathways to improved health that can be initiated quickly at the level of individual patients and within current processes of care. In order to respond to these SDOH, CARDI-OH also seeks to highlight emerging strategies with potential for ameliorating social needs among Medicaid patients in Ohio. Screen and refer models to address SDOH are being tested by several organizations (e.g. the Ohio Comprehensive Primary Care initiative, the Accountable Health Communities initiatives, United Way 211) and are underway at practices across the state. New evidence and best practices continue to emerge. Projects across the state are seeking to implement innovations like Food Pharmacy onsite at health clinics to address food insecurity, health centric ride-sharing apps to address transportation challenges, novel health clinic and novel cash assistance programs. In addition, the 2018 Ohio Community Health Worker Statewide assessment provides a clear and feasible pathway toward improving the health and social conditions that shape outcomes for Ohio communities, “CHWs are well-suited to act as a bridge between community members and the health system to help ensure access to care at the right time and adherence to treatment plans.” By bring together efforts to address patients’ social needs with appropriate clinical best practices, these initiatives hold the promise for markedly advancing healthcare delivery and improving the cardiovascular health of the Medicaid population.
Crawford C (2018) The EveryONE Project Unveils Social Determinants of Health Tools. American Association of Family Physicians. https://www.aafp.org/news/health-of-the-public/20180109sdohtools.html. Accessed August 31, 2018
Healthy People 2020 (2018) Disparities. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities. Accessed August 31, 2018
Healthy People 2020 (2018) Social Determinants of Health. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health. Accessed August 31, 2018
Julia, C., & Valleron, A. J. (2009). Louis-René Villermé (1782-1863), a pioneer in social epidemiology: re-analysis of his data on comparative mortality in Paris in the early 19th century. Journal of Epidemiology & Community Health, jech-2009.
Orgera K, Artiga S (2018) Disparities in Health and Health Care: Five Key Questions and Answers. Kaiser Family Foundation https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/. Accessed August 31, 2018
Olsen, M. H., Angell, S. Y., Asma, S., Boutouyrie, P., Burger, D., Chirinos, J. A., ... & López-Jaramillo, P. (2016). A call to action and a lifecourse strategy to address the global burden of raised blood pressure on current and future generations: the Lancet Commission on hypertension. The Lancet, 388(10060), 2665-2712.
Reem Aly, JD, MHA; Sarah Bollig Dorn, MPA; Amy Rohling McGee, MSW; Amy Bush Stevens, MSW, MPH; and Rebecca Sustersic, MPA. (2016). State of Ohio Health Assessment 2016. Health Policy Institute of Ohio (HPIO). https://www.odh.ohio.gov/en/odhprograms/chss/HealthPolicy/ship/State-Health-Assessment
University of Wisconsin Population Health Institute. County Health Rankings 2018 commissioned by Robert Wood Johnson.
Whalen Smith CN, Reed Robinson H, Carter N & Kirkland C (2018) The 2018 Ohio Community Health Worker Statewide Assessment. Ohio Colleges of Medicine Government Resource Center, Ohio Department of Health.