September, 2013

Addressing the Social Determinants of Health

Many academic health centers like Penn State Hershey have enjoyed enormous success through a focus on cutting-edge health care, advancing the science of medicine through research, and training the next generation of health care professionals - yet if we really want to maximally improve the health and well-being of the people we serve, we must think more broadly. We must address the social determinants of health as well as the biological basis of disease.

The United States spends more money on health care, in total and on a per capita basis, than any other country, but by almost every measure, we are far from being the healthiest nation in the world. Health status indicators such as life expectancy at birth, infant mortality rates, and prevalence of chronic disease place us far from the top of the list of healthiest countries. There are many reasons for this, but one is especially important: medical care is not the most important factor determining overall health status. In fact, when we look at premature mortality, it has been estimated that health care accounts for only about 10% of the total years of potential life lost. The remaining 90% of premature deaths are accounted for by behavioral, social, environmental, and genetic factors. We can have the best medical care in the world, but if we don't act to address the factors that account for 90% of premature death and preventable disease, we won't make much progress in becoming healthier as a nation.

The Centers for Disease Control and the World Health Organization define the social determinants of health as "the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness." As this definition suggests, the social determinants of health - factors such as poverty and wealth, education, family relationships, access to or lack of health insurance - affect every aspect of people's lives and are a major contributor to health status. Indeed, they also frequently do much to shape the behavioral factors that are the largest single contributor to premature death, namely, health behaviors such as tobacco use and obesity. These and other behavioral factors - including alcohol and drug use, sexual behavior, guns, and motor vehicles - represent the largest single contributor to premature death. Genetic predisposition to disease accounts for about a third of premature deaths, with environmental factors - such as exposure to pollution, lead paint, and unsafe neighborhoods - also contributing.

More and more, the lines between these categories are becoming blurred. With the sequencing of the human genome and the advent of personalized medicine, it is quickly becoming possible to identify genetic underpinnings of a growing number of health problems, and to use that knowledge to treat and even prevent a wide range of diseases and conditions. The science of genomics is teaching us that the interaction between genes, health behaviors, and environmental factors is tremendously important in shaping how genes are expressed and, ultimately, how they impact our health. It is equally clear that social factors often have a profound effect on health behaviors; the decisions individuals make that impact their health - such as whether to avoid tobacco use, how often to eat fruits and vegetables, or whether to exercise regularly - are not made in a vacuum, but are shaped by the social environments in which they live. The line between environmental and social factors is far from clear, especially since environmental factors such as polluted air and water, lead paint, and dangerous neighborhoods disproportionately affect people with lower socioeconomic status.

The boundaries may be blurred, but it is clear that addressing the social and environmental determinants of health we need to think beyond the lab, the hospital and the clinic. And we can't simply ignore behavioral factors or dismiss them as individual health choices. Behavioral factors are not just about individual decisions; they are connected to social determinants of health, such as socioeconomic status, and as such can be addressed not just by individuals, but by society. As Dr. Steven Schroeder, former president of the Robert Wood Johnson Foundation, argued in his influential 2007 Shattuck Lecture, addressing health behaviors such as tobacco use and obesity requires that we, as a nation, tackle these issues by putting in place policies and by changing cultural norms to support and encourage healthy behaviors. Academic health centers such as ours can lead the way by engaging with the broader community to develop innovative solutions to address all these health determinants and thereby improve public health and well-being.

The Community Health Needs Assessment in which we participated last year, in partnership with Holy Spirit Health System and Pinnacle Health, confirmed the need to address these issues in our region. The assessment found that for many people throughout our region, access - or a lack thereof - is a central problem: not just access to health care, but also lack of access to fresh produce, to needed social services, and for some, lack of access to safe places for recreation and physical activity. A high percentage of those surveyed in our Community Health Needs Assessment reported that they did not have a primary care physician, and for many of those, lack of insurance was a deciding factor. Access to health care is essential to keeping people healthy, helping them to manage chronic conditions, and caring for them when they are sick. But we need to look beyond expanding access to care, and also expand access to the resources people need to live healthy lives.

These are issues that we can't tackle on our own, but we can work in partnership with other organizations and communities to come up with solutions that break down barriers to good health. Our Farmers Market in Hershey has been recognized for its innovative approach to integrating health and wellness activities into a weekly market featuring a wide variety of fresh, local agricultural products. In addition to making a wide array of healthy foods readily available, the Farmers Market features health education and screenings. We received the Modern Healthcare Spirit of Health Award for this innovative approach to promoting health and wellness. This fall, we are taking our efforts to increase access to fresh produce and promote healthy nutritional choices a step farther with the opening of the new Community Garden on our Penn State Hershey campus. The garden, a collaborative effort involving support from other major Hershey businesses, will generate additional benefits by providing opportunities for increased physical activity, nutrition education, as well as therapeutic uses for patients.

Encouraging healthy food choices and good nutrition is an important part of addressing one of the biggest behavioral determinants of health, the problem of obesity. Making it easier for people to eat healthy diets is only one part of the equation; it is equally important to encourage regular physical activity and exercise. For many people, there are social barriers to exercise, ranging from living in areas where it is not safe to play or exercise outside, to a lack of sidewalks and safe crosswalks. As we prepare for additional growth on our campus with the new strategic facilities master plan, improving the walkability and bike-ability of our campus is a priority. We hope that as we lead by example, we will help build momentum for walkability and encourage similar efforts throughout our community. Creating a culture that supports healthy behavior is also essential, and the new Penn State Hershey Shape Up program introduced earlier this year provides all employees with an opportunity to challenge themselves, and one another, to be more physically active.

The good news is that health behaviors can and do change in response to public health initiatives. In recent decades, smoke-free policies and stricter regulation of tobacco products, coupled with effective educational and counter-marketing campaigns, have dramatically reduced rates of tobacco use in the United States. Maintaining and enforcing policies to keep our campus tobacco-free is an important step toward reducing the harmful effects of tobacco use and second hand smoke and creating an environment that makes it easier for tobacco users to quit. But reducing the damaging health effects of tobacco also requires finding more effective ways to help smokers quit, which is where research can advance this important public health effort. Some of the same strategies that have been used to promote tobacco control can also be applied to other behavioral determinants of health, such as physical activity and nutrition.

Our efforts to improve health and well-being extend into the broader community. Our outreach programs are bringing health screenings and education to communities where access is limited. Working with the Lebanon school district, an area identified by the Community Health Needs Assessment (CHNA) as having a particularly high percentage of families lacking access to health care, our Penn State Hershey nurses and Penn State Hershey PRO Wellness Center (formerly the Center for Nutrition and Activity Promotion) conducted health screenings in schools throughout the district, screening for healthy weight as well as testing vision and hearing. Health education and wellness programs are important for everyone, but especially valuable for children and youth. Addressing health issues and developing healthy habits early in life prepares children to succeed in school and lead healthy lives as adults.

Our commitment to improving public health extends to our educational and research missions. The new Penn State College of Medicine graduate program in public health just awarded Master of Public Health (MPH) degrees to the first cohort of graduating students. The program prepares students for careers in public health, where they can address the social, environmental and behavioral factors that influence health. Because access to primary care plays such a vital role in maintaining health - particularly since primary care clinicians often help patients to address behaviors that impact health - our new physician assistant (PA) master's degree program, which is on schedule to enroll students in 2014, will have a strong focus on primary care.

Research can also play an important part in identifying the most effective ways to address the determinants of health. For example, the Penn State Clinical and Translational Science Institute (CTSI) is focusing efforts on some of the critical health needs revealed by the Community Health Needs Assessment - such as access to primary care, physical activity and nutrition, and health education - not simply to deliver programs that meet these needs, but also to engage the community in research to develop effective programs and interventions and to evaluate and further refine them based on results and feedback from the community.

Some of the social factors that impinge upon health - such as poverty - demand solutions that are much too complex for any individual academic health center to deal with on its own. Nonetheless, we can still play a role by advocating for the importance of addressing these social determinants of health. For those of us who are clinicians, it can be humbling to recognize that the health care we provide is in fact only a relatively small part of what keeps people healthy. Rather than be discouraged by this fact, we must broaden our sights and champion other ways of improving public health, creating healthy communities, and making health and well-being a priority, not just for individuals, but for society as a whole.


Harold L. Paz, M.D.
Chief Executive Officer, Penn State Hershey Medical Center
Senior Vice President for Health Affairs, Penn State
Dean, Penn State College of Medicine