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Social determinants set lifetime course for health

Jun 14, 2018, 07:00 AM

Portland, Ore. — Ever notice that people living in poverty often have a greater number of health issues? Environment and life experience have a huge impact on a person’s health now and in their future.

Social determinants of health include structural issues, such as income, educational status, occupation, gender and race/ethnicity. They affect a person’s relationship to society and health.

“In addition, there are social determinants that have an even closer tie to health outcomes, such as stable housing, neighborhood quality, access to nutritious food, social support structures, health behaviors, the amount of stress in a person’s life and how they cope with it,” says Rebecca Ramsay, MPH, BSN, CEO of Housecall Providers and an executive director at CareOregon.

In 2011, the Annie E. Casey Foundation published a groundbreaking study that demonstrated that children who aren’t reading well by third grade and are living in poverty have a much lower chance of graduating from high school. A study published in Health Affairs a year later showed that health outcomes and life expectancy are worse for individuals who did not graduate from high school, as compared to individuals with more than 16 years of education.

“We have learned over time that dental caries is one of the biggest factors associated with absenteeism in kindergarten and elementary school, where children begin formal reading education,” says Ramsay. “Children living in poverty have higher rates of dental caries due to many barriers, such as unstable housing, lack of access to dental care, and limited knowledge about the importance of diet and regular dental care.”

Ramsay defines the slippery slope of social determinants of health. Poverty can increase the risk of dental caries, which becomes a barrier for reaching reading proficiency. Reading deficiency then puts high school graduation at risk, which limits career opportunities and income stability and creates a vicious cycle that produces poorer health outcomes.

At CareOregon and its affiliated health plans, the dental department focuses on encouraging healthy dental care not only for adults and teens, but also for pregnant women and for babies from Day One. They work with dental care organizations around the state to integrate oral health into pediatric, prenatal and physical health practices. Most children in their first three years see their pediatric doctor between seven and 11 times, creating a good opportunity for oral health screenings and interventions, as well.

“Poverty is the single most critical social determinant of health,” says Ramsay.

Since nutrition and eating behaviors directly influence health outcomes, the ability to get and prepare healthy food is one of the critical social determinants. 

“Most of us understand that obesity is the main culprit in the development of Type 2 Diabetes,” says Ramsay. “Most cases of obesity are the result of high-calorie malnutrition. But for those living in poverty, it is much harder to obtain healthy food. And if you have unstable housing, no ability to cook or prepare your meals, or live in a neighborhood with few grocery stores, it becomes even more challenging.”

The most affordable foods are high-calorie, low-nutrient foods, a factor that is even more of an issue during pregnancy. For that reason, over the past few years, CareOregon and its partner Coordinated Care Organizations (CCOs) have either developed programs or sought out sponsorship opportunities for local nutrition and exercise programs geared to members’ specific health concerns.

“For example, we developed a prenatal nutrition curriculum and then trained the nurse practitioners at Women’s Health Care Associates as part of our Food Rx program,” says Kristian VanDoorn-Logan, CareOregon’s Food Access Coordinator, Community Health Innovations Programs. “We also sponsor Cooking Matters® four times a year for members.”

According to Ramsay, stress is another major factor in health. “If you experience domestic violence or sexual abuse, you are in a nearly constant state of ‘fight-or-flight,’” says Ramsay. “This means that your body is sending neurological signals to your brain, which then result in a cascade of hormones designed to give you extra energy or focus to keep you safe. But if your body is flooded with these chemicals on a regular basis over long periods of time, they actually cause inflammation and organ damage leading to chronic health conditions. We now know from numerous studies that the number of toxic stressors a person experiences during childhood is directly related to their risk of developing chronic health conditions, such as lung disease, depression and addiction problems.”

Stress can also be caused by social isolation, something that is of special concern for those who are homebound. Recognizing the damage to physical and psychological health this can cause, CareOregon partnered last year with its newest subsidiary, Housecall Providers. By providing home-based primary care, palliative care and hospice services to patients who are often homebound, Housecall Providers responds to a full range of health needs. 

“This kind of social, emotional and spiritual support is paramount for individuals with serious medical illnesses as they become more frail and limited in their ability to access care outside of their homes,” says Ramsay.

Jackson Care Connect, another CareOregon partner CCO, offers YMCA scholarships to whole families. The programs address stress, nutrition and emotional support, along with physical exercise. Local providers can recommend that patients receive scholarship support for anything from diabetes to obesity and more.

“The YMCA also helps reduce stress for families by providing childcare for our working parents and reducing the price of summer camps,” says Jennifer Lind, CEO of Jackson Care Connect.

Since social determinants of health are all around us, are there ways to change these patterns?  Ramsay believes there are.

“The most obvious thing we can do as a society is to create policies that close the income gap in our country,” says Ramsay. “Things like raising the minimum wage, addressing institutional racism, making higher education affordable for all people, developing much more robust and accessible child care options for families and single-parents.”

Ramsay cites the many examples in the community of supportive school programs that identify children and families at high risk, then provide education and social support to families.

For example, Columbia Pacific CCO, also part of the CareOregon family, has supported the school districts in its area in educating teachers, parents and the community about Adverse Childhood Experiences (ACEs). 

“By understanding the effects of ACEs on children’s behavior, schools have learned to work with students and families in trauma-informed ways that reduce physiological and psychological stress that could lead to future health issues,” says Nancy Knopf, the CCO’s Community Health Parnership manager.

“I am a big proponent of allocating some of the money we are spending on managing high-cost health care services toward social determinants, such as education, permanent supportive housing programs, exercise vouchers and food prescriptions for low-income individuals,” Ramsay says. “As a nation, we must begin to address the issues that put us far below other comparable countries in terms of health and well-being.”

For information, contact Jeanie Lunsford, 503-416-3626,

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