I'm Monica Lypson. Welcome back to Service Transformed, Lessons in Veteran Centered Care. We're here with unit two, where we'll focus on the social determinants of health, and how those may impact health care disparities for veterans in the United States. Here in unit two, we'll spend some time illustrating individual-based sources and also systems-based sources of healthcare disparities for veterans, and for patients in general. One of the things I would like you to think about is, please indicate whether this is an example of a health disparity or a healthcare disparity, the lack of access to preventative health measures, or rehabilitative services. The determinants of health have been well described by Dahlgren and Whitehead in 1991 and they provide a scope of understanding about what goes into determining whether or not a patient or a person is healthy or not. When we think about things we want to think about food security, access to various supplements and nutrients in a diet. We want to think about a housing. What types of shelter do people have access to? What environment, either at home and at work, are people exposed to in their daily lives? In addition, other impacts on disparities, or the determinants of health include employment status, income, access to resources, sanitation. One of the things in Western countries that we often don't really think about but are as critical to the determinants of health. The health care delivery system is a piece of the determinants of health. But it is just that, a piece, and then finally access to education and other resources. It is the culmination of all these pieces that really go into determining whether one has the potential to be healthy. And it's the interaction between the social and community networks, individual lifestyle factors and the general environmental conditions that really add to the impact on health. So if we look at that, the answer to the question was the lack of access to preventative health measures or rehabilitative services is really a health care disparity. Again, only one piece of the social determinants of health. When we think about determinants, here are three definitions that I want you to think about as we go through the rest of this segment. Social determinants of health are the conditions in which people are born, grow, live, work, and age. We've talked about that before. Health disparities are the differences in health that is closely linked with social or economic disadvantage. And then health care disparities are the differences in availability, accessibility, and quality of health care services specifically aimed at prevention, treatment and management of diseases and their complications. So these are three different definitions that sometimes people use interchangeably, but we wanna really make sure that we focus on what we're really talking about in this segment. Dr. Cooper at Johns Hopkins has really thought about this and provided us a conceptual framework for the barriers and mediators of equitable healthcare. What we'll focus on mostly in this course, in particular, are the mediators that we can focus on. One of my interests is about communication skills and how you actually can hone as a healthcare professional your communication skills to be able to elicit some of these mediators of equitable healthcare. And we will focus on these as we go along. We'll hear a little bit from Dr. Ebraham at the Philadelphia VA about these issues. Another way to think about this is Dr. Adler and Stead in the New England Journal of Medicine. As we have thought about ways to actually make an inventory of social and behavioral determinants of health. These are some examples of which you can include in your electronic health record or in a patient intake form that will allow you to ask the right questions to be able to explore these things with your future patients. Specifically asking about how does a patient identify their gender? Focusing on asking a patient about ethnicity followed by race, you want to actually do it in that order. And remember ethnicity, Hispanic, is about the issues about growing up in a culture of using the Spanish language. Latino often gives you an idea about where somebody is from etc. Other questions you might wanna ask, in the last week have you exercised? These are all things that give you information about the determinants of health in a patient. We'll watch two videos that you'll talk a little bit about that give you an example of what health equity is and also a nice example of what the determinants of health is. Those are two links that you'll have. >> Dr. Said Ibrahim, VA Health Services researcher and primary care physician conducts health equity research. >> So I'm interested in understanding who gets knee and hip replacement. We did research initially that sort of said, is everybody getting knee and hip replacement who clinically needs it? And we found, to our surprise, that minority patients are significantly less likely to get knee replacement or hip replacement compared to non-minority patients, even when you take into account the clinical indications and the access to care. We were funded by VA Health Services Research to study why this is. What we have learned is that minority patients hold different views or beliefs about the value of knee replacement compared to non-minority patients. And then we said well why is that? We found out part of it has to do with access to the information about the risks and the benefits of the treatment and people who may have had the treatment who may live in the neighborhood, for instance. So if you are someone who has had a relative or a family who has had knee replacement, you know more about knee replacements and what they're good for than someone who's never seen anyone with a knee replacement. But it turns out that the minority patients at the VA, at least, that we have studied were less informed about the benefits and the risks of the treatment. And it was that reason that they were sort of expressing in their lack of interest in this. So we have designed an intervention that shows that if you provide information to these minority patients who clinically need an intervention on their knee, they're more likely to actually accept the treatment offer and recommendation than if you don't educate them about the risks and the benefits of the treatment. So that's a classic example of a research that goes through the steps in health equity research. Understanding the problem, figuring out what the problem, the source of the problem is, and designing interventions that allow you to address it. What gets a physician to want to be a doctor at the VA? And the answer is the VA doesn't only provide you the opportunity to practice medicine as you were trained, but it actually gets at the heart of why many of us became physicians, which is service. We want to serve, and we feel that we wanna provide care to people who appreciate and need the care that we provide. So the VA is actually a great way to exercise that principle without compromising your ability to practice medicine. So, it gives you both the opportunity to practice medicine, but to also feel good at the end of the day, where you go home to say that I'm actually useful to my community, and I'm providing help to someone who needs it. [MUSIC] >> After we've explored what the definitions are of health determinants of health and also what health equity is, one of the things that we learned from the inventory is that you wanna explore with your patients what are the visible and invisible identities that they bring to the healthcare encounter? And most of these things you actually have to ask about. You have to actually engage with the patient in a patient-centered way to find out the information is related to. I like analogy of an iceberg. When you want to think about visible identities, the things you can see, and then the invisible identities, those things that I hold personal, and that the only way you're gonna find them out is actually to engage in conversation with me. So, one of the questions that you might want encounter is, which of the following are considered visible identities? Religious beliefs, race, ethnicity, personal opinions, and philosophical views. So, one would expect that visible identities can be race and ethnicity. However, you always wanna ask and follow up and make sure that you've actually made the correct determination or actually you wanna see how the patient themselves identify. That's important information for you to know. Another example is what you would consider an invisible identity, one would be race, ethnicity, gender, or sexual orientation. Again, sexual orientation would be something that you would have to ask about and is really an invisible identity but has a large impact on people's access to resources, how they use them and what the potential impacts on their health is. When we think about the contributions and individual attributes that are associated with health care disparities, there's economic characteristics. Quite frankly income, education, employment as an extension. And then physical characteristics. Things that are sometimes modifiable, sometimes not. But you need to explore. Disparities in health care services are things really around access, access to healthcare, access to primary care, access to rural versus urban, what's available in your local area, and also access to health care technology. As we go and focus more in this course, we're gonna focus on veterans who often seek care at the Veterans Health Administration. What we do know about those veterans are that they're more likely to be impoverished, they report a lower quality of life measures, they exhibit multiple comorbidities. And so you're often managing multiple illnesses, they're less likely to have access to health information, and less experience with a doctor patient relationship. So which of the following are potential sources of healthcare disparities? Socioeconomic factors, geographic factors, bias and lack of trust, or all of the above. As we think about moving into segment two, we really wanna focus on those social issues as they're related to the determinants of health.
