What is the state of the evidence linking social determinants of health and interventions that address social determinants. To improving racial and ethnic health disparities or socioeconomic health disparities and getting us closer to that vision of achieving health equity. My colleagues and I wrote a paper in Health Affairs that describes several domains in which interventions show promise for addressing health disparities. In order to understand the importance of these types of interventions, I like to reference the health impact pyramid described by Frieden. Which shows that the potential impact of an intervention on population health can increase as we go from the more health specific interventions to more fundamental interventions that address social determinants of health such as socioeconomic conditions. So four of the domains that my colleagues and I have discussed in our work are education and early childhood, income supplements, housing, urban planning and community development. In general, there is a relatively strong body of evidence that suggests that interventions to improve access to high quality education and early childhood programs for children can have positive impacts on the health of those children. And on the health and well-being of their parents and the family overall. In particular, interventions including the Perry Preschool Project and the Abecedarian Project suggest that education and an emphasis on early childhood education for socioeconomically disadvantaged families. And racial ethnic minority families can yield increases in socioeconomic status for the children who received those early childhood interventions in adulthood. It has been associated with decreased health risk taking behaviors, increased educational attainment, decreased risk of incarceration. And many other outcomes that are likely to have positive impacts on health. These types of interventions, including interventions that involve home visiting, such as the Nurse-Family Partnership and parental support has also been linked to improved mental and physical health outcomes for the children who participate. And associated with decreased intimate partner violence and incarceration and child maltreatment for the parents of those children. Many of these benefits extend into adulthood. Both the Perry Preschool Project and the Abecedarian Project have shown benefits to health, health behaviors, educational attainment, and social economic status for participants 30 years later. Further more, there is a significant return on investment for such programs. An analysis of the economic returns of the Nurse-Family Partnership program suggest that this program not only produces returns on investment to the extent that it improves the educational outcomes of children who are enrolled in their program. But it has larger returns to society that are manifest and reduced engagement and criminal justice. Reduce child maltreatment and improved employment outcomes and parenting outcomes for the parents of those children in the program. Unlike some other these experimental programs or smaller scale programs, the data for national programs such as Head Start is more equivocal. Yet this body of evidence suggests that these early investments are important. And given what we know about how disadvantage can produce cumulative impact on health over time. This area of investment is likely to produce improvements in health disparities. Shifting gears to income supplements, there are a variety of different ways that income supplements can be received. Some of this occurs through federal benefit programs such as social security income, earned income tax credits, supplemental nutrition program for women infants and children, and the food stamp program. Looking at the WIC program, the Supplemental Nutrition Program for Women, Infants, and Children. Some analyses have shown that this program actually produces disproportionately positive benefits in birth outcomes for women who are poorer among the women receiving those benefits and also for African American women. As such it gives us some window into the notion that income supplement programs. And any type of social determinants intervention that produces a disproportionate positive benefit on those at greatest risks for health disparities would be likely to narrow the size of those disparities. And thus be important for decreasing disparities at the population level. Social Security income has been associated with increased life expectancy among the elderly. And again, the poorer that someone is who receives these benefits, the greater the benefit of the income supplement and improving their health. Which gives us another suggestion of the importance of such programs for decreasing disparate outcomes for marginalized and disadvantaged populations. Shifting gears a bit to something called conditional cash transfers. The data and science around conditional cash transfers is better developed in developing countries, but there are examples in the United States. The idea behind a conditional cash transfer is that someone receives a cash benefit as a condition of a particular behavior. One example taken from one of the Center for Health Equity research studies is an example from the Five Plus Nuts and Beans trial that was led by Dr. Miller and conducted as part of the Hopkins Center for Health Equity. This randomized control trial found that pairing a cash transfer in the form of a cash benefit for purchase of groceries with health education regarding healthy dietary choices was successful in producing improvements in the diet of participants. These types of programs can be designed to have a particular impact on people who are in need of additional economic resources. And can tie that access to economic resources with specific behaviors that are known to be health promoting. What about housing? There is a consistent body of evidence around the importance of housing quality and safety for the health of particular populations. Perhaps the most well known of these have to do with exposure to toxins within the home, and access to a safe environment that decreases risk of injuries. When thinking about exposure to toxins, some of the patient populations that are especially affected by these toxins include children and people with respiratory conditions. So, for example, there's clear evidence that led paint and led exposure in the home is associated with deleterious neurocognitive outcomes for children. And that abating lead decreases the risk of lead poisoning and the risk of permanent neurocognitive deficits for children. There's also relatively good evidence to suggest that methods in the home to improve the air quality indoors can improve outcomes for people with respiratory diseases such as asthma. Similarly, living in a home that is safe, structurally sound, and appropriately designed to support safety can be a very important intervention. And a very important condition of housing for elderly populations who are at risk for injury and falls in the home. And newer body of evidence has interrogated more about the nature of housing both its affordability and its location within communities. And the extent to which those characteristics of not just the quality of the housing stock per se. But the quality of the environment and the financial accessibility of housing for everyone on health. For example, there is a body of evidence regarding the use of housing mobility programs like section 8 vouchers. That suggests that when people have opportunities to move to housing that's affordable. That's located in neighborhoods with lower crime and higher socioeconomic status overall, their exposure to violence decreases. A landmark randomized control trial conducted by the Department of Housing and Urban Development known as the Moving to Opportunity for Fair Housing demonstration or MTO. Demonstrated through an experimental design that moving people out of concentrated poverty into lower poverty neighborhoods was associated with mental health improvements for female heads of household. Decreases in diabetes and extreme obesity risk for those women as well. And also was shown to have some positive impacts on the health of girls in those homes, particularly with regard to mental health outcomes. Additional research building on the findings of moving to opportunity done by Rudge Teddy and others. Further suggests that while the economic benefits of that mobility are not experienced necessarily by the parents, that moving out of concentrated poverty likely has economic benefits on children. And that those economic benefits for children increase, the younger the children are at the time of the move. One can imagine again because of how fundamental socioeconomic conditions are to health that this may be an important mechanism for decreasing disparities among populations that are marginalized, disadvantages. And experienced concentrated disadvantage in their neighborhoods. Some of these impacts have been demonstrated to be differential for males versus females, particularly related to mental health outcomes. So there's more work to be done this area. And I think it is worth mentioning that housing mobility cannot be considered as a standalone approach. From an experimental standpoint, it is helpful in allowing us to demonstrate that something about neighborhood conditions beyond the conditions of the housing units themselves may be important for health. But everyone can't move out of neighborhoods that are currently distressed. Rather, it should suggest to us a two prong strategy both providing opportunities for mobility and identifying strategies that actually improve the conditions within neighborhoods that currently experience concentrated disadvantage and excess violence. What about urban planning and community development? My own work has focused a bit on zoning policy as another mechanism for producing neighborhood level change. I think it is also important to note that there are historical context that have exacerbated inequalities and neighborhood conditions for racial ethnic minority groups and people living in poverty. Baltimore is actually the home of redlining. It is one of the first places in the United States where this practice which produced racial segregation and economic disadvantage and housing for African American populations. First took hold and later became a fundamental mechanism for maintaining segregation and maintaining economic disadvantage for minority communities in the United States. Similarly, the concept of liquor lining which has been promoted by a group called the Woodstock Institute in Chicago. Demonstrates that liquor stores are also not equally distributed among neighborhoods of all racial, ethnic, and socioeconomic Elks in the United States. They have demonstrated in Chicago and work by and colleagues has demonstrated in Baltimore. That liquor stores are disproportionately over concentrated, and low SES African American communities. There's also a very strong literature linking liquor stores to crime in such a way that such stores are known to be crime generators. That is they are not just a place where crime is potentially more likely to occur, but their existence may, in fact, actually produce crime in their immediate vicinity. Other types of neighborhood resources that are not necessarily equitably distributed across all neighborhoods include healthy food access, and opportunities for physical activity. You can look at the pictures here, and imagine back to the family I mentioned earlier, that a child living in either of these neighborhoods might be less likely to have opportunities for safe physical activity outdoors. Than a child living in a more socioeconomically advantaged neighborhood with more greenery and where crime is potentially less of a concern. So I've tried to lay out a case for you why the social determinants of health and interventions that fundamentally address social determinants of health should be a critical focus of health disparities research and interventions. But where do our current approaches fall in terms of addressing these fundamental drivers of inequity? Generally speaking, health disparities research tends to focus on disease specific interventions. Current approaches to disparities research tend to focus on addressing diseases one at a time. Identifying a disparity in a particular condition and developing interventions to address disparities in that particular condition. Yet, the pattern of disparity is highly consistent across a wide variety of disease conditions. And in fact, interventions that address fundamental social determinants may have impacts that transcend specific diseases. Meaning they could impact injury and cardiovascular disease through the same fundamental intervention. Yet this is a much less widely disseminated strategy within health disparities research. Furthermore, many of the interventions to address health disparities focus on the individual that is identifying mechanisms by which we can encourage individual level behavior change or focus on health systems. That is ensuring that we provide equitable access to treatment once conditions develop. In order to make a progress on the fundamental drivers that produce and sustain disparities across in multitude of conditions. Future research needs to focus more on the upstream determinants that I have already discussed. And while the evidence is not perfect, it seems probable that many of these strategies could produce positive impacts on health that are transmitted from one generation to the next. The other fundamental change in the way we address social determinants is that we should place more emphasis on a life-course perspective. As a pediatrician, I think about families and I watch children go from a healthy trajectory, to an unhealthy trajectory as life's challenges confront them. When we think about a life-course perspective, we're thinking about the fact that at every stage of development at every stage of life, the social determinants have an impact. And at any point when we intervene to improve the conditions in which someone lives, learns, work, place or worships, we can have a cumulative effect on their health over time. So that if that intervention happens early and is sustained, we can produce health improvements in adulthood. The argument and the pushback I often get is that the social determinants are just too big to tackle. Sure, many in health care and public health recognize that they are fundamental drivers of inequity, that they represent the root causes for health disparities. But they're difficult to impact, and many of them primarily operate outside of the health system. Furthermore, it's difficult to disentangle the benefits on education or employment or economic conditions from the impacts on health. And they require other sectors at the table besides the healthcare sector. One of the ways that I tend to argue against this sort of nihilistic perspective on addressing social determinants and fundamental drivers of health inequities. Is that somehow health needs to be part of the broader conversation we have around social policies that impact fundamental drivers like socioeconomic conditions, educational conditions, etc. [MUSIC]
