Community Engagement as a Social Determinant of Health in Surgery

Identification of Social Determinants of Health

Access to healthcare varies across countries, communities, and individuals, oftentimes influenced by health policies as well as social and economic conditions. The interplay of differing factors, such as insurance coverage, low income, transportation costs, geographical barriers, and sociocultural expectations, must be taken into consideration when analyzing healthcare access. Limitations in access to healthcare not only lead to negative ramifications in the use of medical services but also affect treatment efficacy and overall health outcomes and quality of life. As value-based models are increasingly serving as guides for healthcare systems, the social determinants of health (SDOH) have emerged as key elements to consider when constructing healthcare systems. Many different communities play a role in improving or worsening SDOH, and in this section, we will overview what comprises SDOH, with a particular focus on the role the surgical community plays in addressing SDOH.

The World Health Organization (WHO) defines SDOH as “the conditions in which people are born, grow, live, work, and age” that are “shaped by the distribution of money, power, and resources at global, national and local levels.” This phenomenon inevitably leads to social stratification that creates health inequities among differing groups of people based on socioeconomics. Due to the complex relationships and feedback loops that characterize SDOH, SDOH are integral in shaping major health epidemics plaguing society today, such as diabetes, cancer, obesity, heart disease, and mental illness. Examples of SDOH include income/economic stability, access to educational opportunities, employment status, racial/ethnic disparities, gender inequity, access to housing and safe drinking water, availability of transportation, neighborhood conditions, and social support/inclusivity.

Several different community factors can positively or negatively affect SDOH, such as healthcare systems, national governments, local neighborhoods, and schools. Within healthcare systems, notable elements that can affect SDOH include physicians and other healthcare providers, nurses, social workers or case managers, and hospital administration. The surgical community is poised to impact SDOH through pre-, peri-, and postoperative screening and monitoring. National governments are also pivotal in influencing SDOH through public policy, healthcare access, funding, and research. On a more local scale, neighborhoods can affect SDOH, particularly through access to safe housing, adequate nutrition, recreation or exercise, reliable transportation, and community support, especially for the elderly. Furthermore, schools can create an early foundation that may impact SDOH through access to technology, supplies, or safe spaces, such as libraries ( Fig. 9.1 ).

The importance of SDOH in healthcare is evidenced in disparities in survival and treatment access seen in certain patient populations. For instance, Haider et al. reported that both race/ethnicity and insurance status were associated with disparate outcomes following trauma, such that uninsured trauma patients are twice as likely to die from their injuries as insured trauma patients, and black trauma patients are 20% more likely to die from their injuries as white patients. Moreover, despite attempts at standardization of trauma care with protocols in place for treatment at urban trauma centers, racial minority patients, specifically African American and Hispanic patients, with severe blunt traumatic brain injury, continue to receive worse initial management of trauma injuries and are 15% less likely to be placed in rehabilitation facilities, even after accounting for insurance status.

However, there are local and national responses in place to address the systematic inequalities in healthcare access to ameliorate the disproportionate impact these inequalities have on long-term functional outcomes and quality of life in patients from certain population groups. Urban safety net hospitals are critical in providing care to underserved populations, but unfortunately face the risk of closure due to various factors. In a retrospective study of all US hospitals with trauma centers in urban regions, Shen et al. found that hospitals in areas with a greater proportion of minorities face a higher risk of trauma center closure (hazard ratio 1.69, P < .01). This serves to further exacerbate healthcare access difficulties, thus resulting in worse health outcomes for minorities.

Government Response to Addressing Social Determinants of Health

The US annual health expenditures are upward of $3 trillion, but the United States continues to have the lowest life expectancy at birth, highest infant mortality rate, and significant prevalence of chronic diseases in comparison with other countries. Additionally, the United States allots a significantly lower percentage of its gross domestic product toward the maintenance and delivery of social services when compared with other countries with better health outcomes. The Health Resources and Services Administration's Office of Health Equity and the Centers for Medicaid and Medicare Services (CMS) have recognized SDOH as vital to population health and controlling healthcare costs, as social determinants now represent 40%–50% of the cost structure in Medicare and Medicaid. In response to this and the growing importance of addressing SDOH, the US government introduced the Affordable Care Act (ACA) with the goal of expanding healthcare access in a committed shift toward increasing health equity. Under the ACA, the Prevention and Public Health Fund was established to expand national investments in prevention and public health and to improve health outcomes. Starting in 2016, CMS regulations modernized the Medicaid Managed Care Operations (MCOs) as the “health care only” model has become increasingly antiquated, now empowering states to cover nonmedical interventions and to allot resources at the community level to address activities focused on SDOH and to promote preventative care and population health. A 2016 study by the Yale School of Public Health examined the association between variation in state-level health outcomes and the allocation of state spending between social services and healthcare and found that states with greater allocation of resources toward social services as opposed to medical expenditures demonstrated better health outcomes in various medical conditions, such as obesity, asthma, mental illness, lung cancer, myocardial infarction, and type 2 diabetes mellitus, compared with states that did not. By 2018, approximately 40% of US states had mandated screenings for social services and/or referrals to social services, with the number of additional states with social services screening requirements increasing annually.