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Center for Rural Health Policy AnalysisUnderstanding the Social Determinants of HealthA Self-Guided Learning Module for Rural Health Care TeamsGOALSThis tool is designed with two goals in mind:1. Learning: To help people who work in (or are concerned with) rural health learn more about theconcept of social determinants of health.2. Acting: To enable rural health leaders and care teams to act to improve health outcomes in theircommunities by addressing factors that contribute to the social determinants of health.INTENDED AUDIENCEWe use the term care teams in the title to indicate that this tool is appropriate for a very broad group—essentially anyone who cares for patients (including patients themselves and their families), or who works incare coordination, social work, or other patient/family support fields, including all those who work on or areconcerned with the health of people in rural communities. The module is primarily designed to be used by agroup, but individuals will find it useful as well.HOW TO USEThis learning module is designed to be interactive. To get the most out of the learning experience, we suggestyou follow the instructions provided and use the opportunity to research health information about ruralAmerica and your local county. You can then compare this information to other U. S. counties or regions.Cooperative Agreement funded by theFederal Office of Rural Health Policy:1 UB7 RH25011-01On the go? Use the adjacent QR codewith your smart phone or tablet to viewthe RuralHealthValue.org website.

The module is organized into sections that build upon each other. The first sections will help you understandthe concepts, and later sections delve into planning and action. At the end of this learning module, resourcesare listed that will help you learn even more. Many groups will want to start at the beginning and workthrough section by section. Others may want to jump around through the content; either approach can beeffective.Sections follow a similar format: Read/Research: You will be encouraged to read about a topic or to use links to look up data aboutyour local county. These activities are designed to help you understand the facts about socialdeterminants of health. Analyze/Discuss: Once you are exposed to the topic, this learning module encourages you to discusswhat you’ve learned with others on your team. There aren’t right or wrong answers; the point is foryou to think and talk about what you’ve learned. Plan/Act: Finally, the module prompts you to act. A well-known quote by Abu Bakr, a sixth centuryMuslim leader, sums up why we include action planning in this tool: “Without knowledge, action isuseless and knowledge without action is futile.” Since we don’t want you to spend time on a futileeffort, we encourage you to consider planning activities that will improve the health of yourcommunity.Note that not all sections have all these elements. For example, some sections don’t have an Act element, andthe final sections don’t have a Research element.INTRODUCTIONIf you’ve worked in health care for any significant period, you’ve come to realize that what happens in thedoctor’s office or the hospital isn’t the only thing that affects health. This realization is supported by a growingbody of research. Although the exact amount of influence various factors have on health has not beendefinitively established, the U.S. Centers for Disease Control and Prevention (the CDC) uses the following chart(Figure 1) to summarize the influence of various factors:

Figure 1: From htmlThere aren’t percentages assigned to the pieces of the pie in the chart above, but you can see that medicalcare and genes and biology together account for less than 25% of the determinants of health. The otherfactors have to do with behavioral, social, societal, and environmental factors. Since you have dedicated yourlife (or at least your working hours) to improving health, understanding these factors is important. This isespecially true for people who work in rural communities, because many of these factors contribute to thepoor health that is often prevalent in rural America. As you work through this tool, you’ll learn more abouthow these social determinants of health affect rural communities, and we hope you’ll be inspired to act toimprove those conditions.

Section 1: Defining the Social Determinants of HealthOVERVIEWIn this section you will learn the definition of social determinants of health and discuss how they affect yourcommunity.READThere are two similar definitions of the social determinants of health. The Rural Health Information Hub uses the World Health Organization’s definition: “the circumstancesin which people are born, grow up, live, work and age, and the systems put in place to deal with illness.These circumstances are in turn shaped by a wider set of forces: economics, social policies, andpolitics.” erminants-of-health). In a comprehensive white paper, the CDC uses this definition: “Social determinants of health (SDH) arethe complex, integrated, and overlapping social structures and economic systems that include thesocial environment, physical environment, and health services; structural and societal factors that areresponsible for most health inequities. SDH are shaped by the distribution of money, power andresources at global, national, and local levels, which are themselves influenced by policy docs/sdh-white-paper-2010.pdf)DISCUSSIn your group, discuss some of the social determinants of health that affect the people in your community orcounty. For example, what are important economic factors that are at work in your area? Or what about thecircumstances that people are born into, like race, ethnicity, or national origin? Then, talk about what youexperience as caregivers: Do these factors affect the health of people in your community or county?

Section 2: Understanding Why Social Determinants Are Important to Rural HealthOVERVIEWIn this section, you will look at a number of maps to begin to understand factors that affect your community.READ/RESEARCHFollow the three links below to look at three maps. If possible, print the maps for side-by-side comparison: Urban/Rural population: http://www.cdc.gov/nchhstp/atlas/sdh-slide-7.html Poverty in the United States by county: http://www.cdc.gov/nchhstp/atlas/sdh-slide-1.html Multiple Chronic Diseases by 4 0442 01 lg.jpgNote that the data depicted on the maps tend to line up. That is, there is a high correlation by county acrossthe factors of being rural, having high rates of poverty, and having high rates of multiple chronic diseases in theMedicare population.Continue to learn about a large number of social determinants and how they affect the health of ruralresidents by reading the FAQ on the Rural Health Information Hub ial-determinants-of-health#faqsDISCUSS Go back to the three maps. Find your county on each one. With your group, talk about how thesemaps make you feel about the work you do. What are your reactions when you compare your countyto others in the nation? In Figure 2, below, you will find a graphic from the County Health Rankings and Roadmaps, which is ajoint project funded by the Robert Wood Johnson Foundation at the University of Wisconsin’sPopulation Health Institute1: http://www.countyhealthrankings.orgo Look at the factors that are listed that affect health. Note that this is a similar, but slightlydifferent, take on data presented in the pie chart in Figure 1.oWith your group, discuss which of these factors plays a significant role in your community orcounty. How do poverty or rural setting or other social conditions contribute to these factors?

Figure 2: From County Health Rankings and Roadmaps: works-for-health

Section 3: Using Cardiovascular Disease to Understand Social Determinants of HealthOVERVIEWIn this section, you will delve into statistics and research associated with cardiovascular disease (CVD) and howit affects people in your county, as an example of exploring a prevalent rural health condition through the lensof social determinants.THE IMPORTANCE OF CARDIOVASCULAR DISEASE AND MEASURES OF CVDCVD is a broad term for a range of diseases affecting the heart and blood vessels. Heart attacks and strokes are themost common indicators of CVD. In the United States in 2015, heart disease was the leading cause of death formen and women, accounting for one in every four deaths, and affecting significantly more men than women.Common measures of CVD used to measure population health by county as well as other subcategories are: All Heart Disease Coronary Heart Disease Heart Attack Cardiac Dysrhythmia Heart Failure High Blood Pressure All Stroke Ischemic Stroke Hemorrhagic Stroke Preventable/Avoidable DeathThe CDC maintains extensive statistics for each of these categories, and the data are parsed by county. Thisallows you to look at many factors and to plan interventions that will improve outcomes for your community.2Cardiovascular health is defined by the absence of clinically manifest CVD, together with the presence ofoptimal levels of seven metrics representing modifiable disease risk factors3: Blood pressure Smoking status Physical activity Healthy diet Healthy weight Cholesterol Blood glucose

THE RELATIONSHIP OF CARDIOVASCULAR DISEASE TO SOCIAL DETERMINANTS OF HEALTHThe American Heart Association (AHA) scientific statement on the Social Determinants of Risk and Outcomesfor Cardiovascular Disease, published in August 2015, emphasizes the importance of addressing socialdeterminants, in order to achieve the 2020 goals of promoting cardiovascular health for all. The AHA hasadopted the “culture of health” model (now being widely promoted more formally by the Robert WoodJohnson Foundation); targeted the multicultural, multisectorial determinants of health; and promoted theconcept of population health. Population health improvement requires attention to the broader socialdeterminants of cardiovascular health, such as education (schools), housing, transportation, and economicdevelopment, in addition to health care.4There are particular disparities between rural and urban populations in terms of both heart disease mortalityand the presence of modifiable risk factors in the population5: Nationally, heart disease death rates for both men and women aged 20 years or older are highest insmall rural counties. For both men and women, residents of the most rural counties had the highest age-adjustedprevalence of obesity. Although the pattern varies by region, nationwide physical inactivity during leisure time was mostcommon for men and women in rural counties when compared to urban counties.Health is determined, at least in part, by the places people live, work, and play, which is reflected by the 18%–20% difference in cardiovascular mortality among different groups in different parts of the United States. Thisobservation reflects the fact that social factors not only influence the incidence of CVD, but also impact themanagement (treatment) and the outcomes of clinical cardiovascular diseases. The impact of socialdisadvantage on cardiovascular health is substantial. Socially disadvantaged groups lose ideal cardiovascularhealth at an earlier age and experience an excess risk of clinical CVD and mortality across the lifecycle.6 As aresult, there is a need to understand the role of social determinants in cardiovascular health and to developinnovative approaches that address modifiable risks and social barriers to cardiovascular health.7RESEARCH/READThe CDC provides detailed county-level maps that allow you to research and compare CVD death rates andlook at many factors including race, education level, and urban/rural status.

Use these maps to investigate your county and state:1. Go to http://www.cdc.gov/dhdsp/maps/atlas/index.htm2. In the Select Map Area: pick your state from the drop down list.3. In the Select Data and Filters Area: Click on the sign next to Heart Disease and Stroke Data4. Click the sign next to All Heart Disease5. Click on Deaths6. Scroll down and click on Show MapYou will see a map of your state, with each county colored to show heart disease deaths per 100,000.Find your county on the map and compare it to other urban and/or more affluent counties in your state.(Note: If you don’t know which counties are more urban, you can create a map showing urban and ruralcounties by using the filter for Social and Economic Data in the choices at the bottom of the web page.)While hovering over your county, click on the View County Report option to see details about the race andethnicity breakdown of heart disease deaths in your county.Note: One reason that heart disease deaths could be high in your county is that many rural counties have ahigher percentage of older people than do urban counties. To check whether this is a factor in deaths(compared to other counties), select the Under 75 filter in the age category and compare the heart diseasedeath rate in your county to the rate in more urban or affluent counties. In many cases, you may notice thatheart disease death rates for comparatively younger people remain high in your county when compared toothers.DISCUSS1. Why do you think the heart disease death rates in your county are different from those in othercounties in your state?2. Earlier in this section, we provided a list of seven modifiable factors that contribute to CVD. Theyinclude blood pressure, smoking status, physical activity, healthy diet, healthy weight, cholesterol, andblood glucose. Do you have evidence that causes you to think that one of these factors might be highin your county, compared to other counties in your state?ACTTalk with your colleagues. Are there initiatives you might pursue to reduce smoking or lack of access to fruitsand vegetables, or to increase physical activity? If so, what do you need to do to get started? Note that in thelast section of this learning module, there are links to many examples of rural communities that are working toaddress some of these important health-related issues.

Section 4: Using Diabetes to Learn About Social Determinants of HealthOVERVIEWIn this section, you will look at rates of diabetes as an indicator of social determinants of health.THE RELATIONSHIP OF DIABETES TO SOCIAL DETERMINANTS OF HEALTHMost health care workers know that rates of diabetes are skyrocketing. But sometimes we don’t connect thedots between all the factors that contribute to the increased incidence of this disease. Below is an excerptfrom a thoughtful article that discusses the social factors that contribute to diabetes.8As illustrated in Figure 3, Type 2 diabetes is part of a cyclical process: it both results fromand contributes to adverse outcomes. Poverty and material deprivation, defined as a lack ofresources to meet the prerequisites for health, may play a key role.9 For disadvantagedindividuals, the constant scramble to make ends meet results in high levels of chronic stress,spurring both psychological and biologic responses.10,11 Chronic stress can lead to increaseddepression and anxiety, reduced self-esteem, and decreased energy and motivation, whichamplify the likelihood of self-destructive behaviors and choices (eg, tobacco use, excessivealcohol intake, and consumption of unhealthy foods).12,13Figure3: Socio-biologic Cycle of Diabetes. From Hill J, Nielsen M, Fox MH. Understanding the social factors thatcontribute to diabetes: a means to informing health care and social policies for the chronically ill. Perm J. 2013Spring;17(2):67–72.

The physical manifestation of chronic stress leads to the negative consequence of allostaticload, which includes increased blood pressure, cortisol, and blood glucose levels, as well asimpaired ability to effectively respond to future stressors.11,14,15 Over time, these physiologicreactions, coupled with detrimental psychological responses, and behavioral practicesincrease the likelihood of obesity and Type 2 diabetes.11Type 2 diabetes can be particularly problematic among less advantaged patients for severalreasons. First, the personal financial burden of increased health care costs can furtherintensify the effects of poverty, particularly because it consumes a greater portion ofincome (as compared with those who have greater financial resources).16 Second, adisadvantaged individual may not have sufficient access to the resources necessary tomanage the condition, such as adequate housing, nutritious food, and health careservices.17,18 Third, diabetes can decrease an individual’s productivity at work or limiteducational attainment, particularly if left unmanaged, which can lead to furtheremployment-related problems.19 These conditions exacerbate the cycle of inequality, asthey lead to further poverty, material deprivation, and social exclusion if disadvantagedindividuals are left to fend for themselves.20RESEARCH/READIn this exercise, you’ll look at a map of diabetes prevalence for the United States and compare it to the mapsyou looked at in the first section. Then, you will use a CDC map to find the diabetes rate in your county andcompare that rate to the rate in wealthy counties. Look at the CDC map of diabetes prevalence ydata/atlas.html Compare the shading on this map to the shading on the maps you downloaded in the first section(maps of poverty, rural vs. urban, and prevalence of multiple chronic diseases by county). Use the CDC site above to locate your county. Find the 2010 percentage of your county’s populationthat has a diagnosis of diabetes. Write that number down. Compare that percentage to Fairfield County, Connecticut, one of the wealthiest counties in the UnitedStates, where the 2010 diabetes prevalence was 7.1%.DISCUSSWhy do you think there is such a strong correlation between the prevalence of diabetes and poverty and ruralcommunities?

RESEARCH/READIn this exercise you will look at the percentage of people who are inactive during their leisure time. This is animportant statistic, because there is a strong correlation between lack of exercise and diabetes. Further, thereare well-documented positive effects of exercise on people with diabetes. Go back to the CDC map: .html On the top left, click on the Indicator tab and select Leisure Time Physical Inactivity. Look at the map that comes up. Find your county and compare the percentage to other counties.Increasingly, rural counties are working to address some of the issues associated with diabetes, particularlyfood and exercise. Follow the links below to some stories about successes in rural counties: View the Facebook page of a community garden sponsored by Lake Region Healthcare in rural OtterTail County, Minnesota: ine Read a story about Manistique, Michigan, where members of the Sault Indian Tribe teamed with othercommunity members to increase healthy lifestyles in this rural nistique-mi Read a story about McDowell County, West Virginia, where community members teamed with healthcare providers to increase rtakes-extra-step-keep-west-virginiaACTWith your colleagues, discuss some ideas to increase access to healthy food or exercise in your community.Make a list of steps you would have to take to enact some of these ideas. A great guide to developing asustainable program for change is located here: http://ww