A growing number of psychologists are working to tackle the "social determinants of health"—how poverty, family discord, community violence, barriers to care and other environmental and developmental stressors undermine physical and mental health.
"Current efforts to improve our health-care system have reinvigorated the discussion around the critical role of social determinants in improving health and well-being," says psychologist Sandra Wilkniss, PhD, program director for the National Governors Association (NGA) Center for Best Practices Health Division.
In one of the most significant federal investments to address social determinants, this year the Centers for Medicare and Medicaid Services is providing more than $8 million to 32 social service, health-care and business organizations that will serve as community hubs to test service-delivery approaches related to these factors. Known as the Accountable Health Communities Model, the effort aims to improve coordination between clinical and community services so they better serve the health-related social needs of Medicare and Medicaid recipients in such areas as housing, food security, utility payments and transportation.
On the state level, the NGA—the group that gives state governors a broad forum for sharing best practices and coordinating initiatives—has launched several programs to address various social determinants of health, including housing. Psychologists' work in the area includes:
Creating innovative programs
Research shows that securing good housing for homeless people on Medicaid can catalyze other positive outcomes, including better health. "The notion is that the best way to help someone in high need is to first get them a house, a roof over their head," says Wilkniss.
In her position at the NGA, Wilkniss has had a major hand in developing "Housing as Health Care: A Road Map for States," that helps states develop, implement and evaluate programs that provide access to housing, job assistance, and mental health and substance abuse care. To date, the NGA has worked with 10 states and one territory to implement the plan.
Wilkniss says that while all of the program's services help this population, the main ingredient for their success has been securing housing. "Many people actually do very well comprehensively in their lives after getting housing first," she says.
In Philadelphia, Arthur C. Evans Jr., PhD, now APA's chief executive officer, enacted a range of successful programs using a social determinants framework when he served as commissioner of Philadelphia's Department of Behavioral Health and Intellectual disAbility Services between 2005 and 2017. One program used large-scale art projects, storytelling and mental health training to educate community members about how community-based trauma can affect people's mental health and substance use. Another program secured housing for 800 previously homeless people. Once in those new environments, these individuals' clinical status improved and their behavioral health costs dropped dramatically, Evans says.
"If we want to help people, it's really important to understand them within their social contexts," says Evans. "We can treat people over and over again, but unless we can get them into stable housing or address other environmental needs they may have, treatment alone doesn't help improve their health outcomes."
Offering practical help
Another effort is applying a social determinants model in work with patients who have HIV/AIDS, many of them poor, minority or both. University of Virginia assistant professor Amit Shahane, PhD, and his team first assess the challenges of these clients, asking them about their ability to pay medical bills, their levels of community support, and their degree of knowledge and comfort with medical terminology, for example. The team then uses this information to tailor treatment and identify solutions for patients' practical treatment challenges, such as hiring community health workers to bring patients who lack transportation to health-care appointments. Interventions like this are critical because they boost patient adherence to HIV/AIDS treatments. "Addressing social determinants of health, such as lack of transportation, increases these patients' access to health services and contributes to overall better health outcomes," Shahane says.
Pursuing new research
Psychologists are also incorporating more questions related to social determinants into their research. Fuller Theological Seminary associate professor Lisseth Rojas-Flores, PhD, for example, is examining how parents' immigration status and immigration enforcement may affect children's psychological well-being. In her research, she found significantly higher rates of post-traumatic stress symptoms among children of detained and deported parents than in youngsters whose parents were either legal permanent residents or were undocumented but hadn't been contacted by immigration enforcement (Psychological Trauma: Theory, Research, Practice, and Policy, Vol. 9, No. 3, 2017).
Other psychologists are developing tools to better capture the social and environmental stressors in clients' lives. Researchers at Tufts University School of Medicine, for example, have developed a screening instrument for pediatricians that assesses children's developmental milestones and social and emotional functioning, as well as parental problems such as depression, substance abuse, discord, hunger and more. The "Survey of Well-being of Young Children," or SWYC, is available for free online.
The tool is meant to assess the whole child in his or her environment and is intended for use with children of any socioeconomic class, since many social determinants—such as maternal depression, substance use and domestic violence—are not class-specific.
Such technological advances promise to make social determinants data more useful, says Chris Sheldrick, PhD, who created the tool with developmental behavioral pediatrician Ellen Perrin, MD. Once data from the SWYC are incorporated into pediatricians' electronic medical records, for instance, it will be easier to aggregate large sets of patient data related to these factors.
"We'll be able to generate data that can be used for public health research, population health monitoring and other information that can help improve public health and mental health," he says. "And that is going to be a game changer."
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