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For the First Time, Healthy People Initiative Focuses on Social Determinants of Health

By Nancy Breen, Ph.D.
Economist, Office of Strategic Planning, Analysis and Reporting, NIMHD and NIMHD Representative to the Healthy People Social Determinants of Health Workgroup

Healthy People Background

The Healthy People initiative is a federal program that provides “science-based, 10-year national objectives for improving the health of all Americans.” For the past 40 years, Healthy People has monitored the health of Americans and set benchmarks for how we can all be healthier. You can read more about Healthy People online at www.healthypeople.gov.

Nancy Breen, Ph.D.

Nancy Breen, Ph.D.

Healthy People provides a national 10-year framework for health promotion and disease prevention, with measurable objectives and goals, and it invites states and localities to use the national framework and objectives for their own plans. While the focus has always been health promotion and disease prevention, the Healthy People 2020 agenda is the first to use social determinants of health (SDOH) to frame the conceptual understanding of health. For 2000, an overarching goal to “reduce health disparities” was introduced, partly in response to the 1985 Report of the Secretary’s Task Force Report on Black and Minority Health (often referred to as the “Heckler Report”).1 For 2010, that goal was strengthened to “eliminate health disparities.” For Healthy People 2020, one of the overarching goals is to “achieve health equity, eliminate disparities, and improve the health of all groups.”2 The graphic from Healthy People 2020 shows that the overarching goals emphasize the determinants of health.

The mission of Healthy People 2020 includes identifying health improvement priorities; increasing public understanding of the determinants of health, disease, and disability; and engaging multiple sectors to identify opportunities for progress. Including health disparities in this framework improves the chances that federal interventions will be able to reduce health disparities and increase health equity for all Americans. The choice to highlight social determinants as a leading health indicator (LHI) is important, because LHIs are used to motivate action on high-priority health issues and challenges at the national, state, and community levels.3

One of the Healthy People initiative’s key roles is to identify research, evaluation, and data needs. The National Center for Health Statistics conducts two assessments for each 10-year initiative. These midcourse and final reviews provide an opportunity to see the initiative’s impact along the way. The 5-year review for Healthy People 2020 was released in January 2017 and can be found on the CDC website, at https://www.cdc.gov/nchs/healthy_people/hp2020/hp2020_midcourse_review.htm.

Healthy People 2020 Framework

Healthy People 2020 Framework. Graphic from www.healthypeople.gov.

Chapter 39 of the Midcourse Review focuses on SDOH, and some of the most important findings are described below. Healthy People 2020 defines SDOH as “conditions and the environment in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”4 The 33 SDOH objectives are organized into five domains:

  1. Economic stability (9 objectives)
  2. Education (5 objectives)
  3. Health and healthcare (6 objectives)
  4. Neighborhood and built environment (10 objectives)
  5. Social and community context (3 objectives)

Highlights from the Midcourse Review

Economic Stability

How much money people spend on housing can have a meaningful impact on their well-being. Economic experts recommend that families spend no more than one third of their income on housing, so that adequate funds are available for other expenditures. Studies show that spending more than half of a family’s income on housing puts householders at high risk of losing their home. The Midcourse Review shows that more people are being affected on both measures, suggesting that, overall, Americans are not doing as well in terms of economic stability as they were 5 years before.

  • From 2007 to 2011, the proportion of households that spent more than 30 percent of their income on housing rose from 35 percent to 38 percent; in 2011, Hispanics/Latinos were the racial/ethnic group most at risk. Householders with less than a high school education, with low family income, with a disability, or who lived in metropolitan areas were also at higher risk.
  • From 2007 to 2011, the proportion of households that spent more than half of their income on housing increased from 16 percent to 18 percent. Householders who were African American had less than a high school education, were poor, or lived in nonmetropolitan areas were at higher risk.

Education

Today, having a college education is important for getting a job and staying employed. The Midcourse Review showed that, unfortunately, the percentage of young people going to college after completing high school is lower than it was a few years ago.

  • Individuals ages 16–24 who had completed high school and enrolled in college the following October decreased from 68 percent to 66 percent between 2010 and 2013. High school completers from low-income families were less likely than completers from high-income families to enroll in college right after high school graduation.

Health and Healthcare

Having health insurance is an important part of making sure that people can afford access to an ongoing source of healthcare when they get sick. The Midcourse Review showed that more people under the age of 65 have insurance now than they did in 2007 and that people of all ages are more likely to have a source of ongoing healthcare. In addition, more people than before say that they can understand their doctor or nurse’s instructions.

  • The proportion of people under age 65 with medical insurance increased from 83 percent in 2008 to 87 percent in 2014, and the proportion of people of all ages with a source of ongoing care increased from 86 percent in 2008 to 88 percent in 2014.
  • The proportion of people age 18 and over who reported that their healthcare providers’ instructions were easy to understand increased from 64 percent in 2011 to 66 percent in 2012.

Neighborhood Context and the Built Environment

Under the well-known “broken windows” theory, an orderly environment signals that an area is monitored and that criminal behavior is not tolerated: Neighborhoods with a strong sense of cohesion assert social responsibility and control by fixing broken windows and other small but visible problems. Air quality and lead levels are important indicators of a clean and safe environment, and crime rates are an indicator of social cohesion.

  • Between 2008 and 2012, there was a decrease in the rate of arrests of minors and young adults ages 10–24 for serious violent crimes (from 444 to 324 per 100,000 population) and serious property crimes (from 1,527 to 1,223 per 100,000 population).
  • Days when the Air Quality Index (AQI) exceeded 100 (weighted by population and AQI) decreased from 2.2 billion to 982 million between 2006–2008 and 2012–2014. Also, lead levels in blood samples among children ages 1–5 years in the 97.5 percentile decreased from 5.8 mcg/dL to 4.3 mcg/dL between 2005–2008 and 2009–2012.

Social and Community Context

Social support is especially critical for children and adolescents, who are in their formative years. New items that may be measured in the final review of Healthy People 2020 include civic participation, incarceration, and discrimination.

  • The proportion of adolescents ages 12–17 who reported having an adult in their lives with whom they could discuss serious problems rose slightly, from 76 percent in 2008 to 78 percent in 2013; however, it is striking that almost a quarter of adolescents did not report having such an adult in their lives.

Overall, the Healthy People 2020 Midcourse Review underscores a basic fact: Improving the social determinants of health and mitigating their adverse impacts on population health is complicated. Even so, trends for 15 of the 25 objectives that have targets are moving toward or have met national targets. The Midcourse Review provides an opportunity to assess progress and identify remaining opportunities for interventions so that more can be accomplished by 2020. Addressing SDOH in localities, states, and the nation is an important step toward reducing health disparities. We have made some progress, especially in healthcare and family communication, but there is still work to be done.

Learn more about NIMHD’s work to eliminate disparities and improve the health of all groups.

 

References

1. National Center for Health Statistics. Chapter 4: Leading Health Indicators. Healthy People 2020 Midcourse Review. Hyattsville, MD. 2016. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-B04-LHI.pdf

2. National Center for Health Statistics. Chapter 39: Social Determinants of Health (SDOH). Healthy People 2020 Midcourse Review. Hyattsville, MD. 2016. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-C39-SDOH.pdf

3. U.S. Department of Health and Human Services. Report of the Secretary’s Task Force on Black and Minority Health. Volume I: Executive Summary. Washington, DC. 1985.

4. National Center for Health Statistics. Chapter 1: Introduction. Healthy People 2020 Midcourse Review. Hyattsville, MD. 2016. https://www.cdc.gov/nchs/data/hpdata2020/HP2020MCR-B01-Introduction.pdf

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Mental Health Risk Factors and Interventions for American Indian and Alaska Native People

By Spero M. Manson, Ph.D.
Distinguished Professor of Public Health and Psychiatry; Director, Centers for American Indian and Alaska Native Health; and The Colorado Trust Chair in American Indian Health and Associate Dean for Research at the Colorado School of Public Health, University of Colorado Denver

Over the past 20 years, as research on alcohol, drug, and mental health disorders has advanced, scientific inquiry among American Indian and Alaska Native (AI/AN) people has shifted from a primary focus on describing the prevalence of such problems to explorations of ways to address well-documented health disparities.

smmanson_portraitOne example involves detecting and managing depression and subsequent alcohol and substance abuse, risk of suicide, and, more recently, trauma among patients in large primary care settings operated by tribal health programs. In 2001, the Southcentral Foundation’s Primary Care Center in Anchorage, Alaska, initiated Screening, Brief Intervention, and Referral for Treatment (SBIRT) among Alaska Native patients age 18 and older.1 Their efforts, which integrated masters-level behavioral health clinicians within the care teams, demonstrated that such evidence-based practices could be tailored to this population in scientifically sound and clinically meaningful ways.2 Over a 5-year period beginning in 2004, 55 percent of the 8,000 patients who scored positive for alcohol use disorder agreed to follow-up treatment. Thanks to those results, the state of Alaska authorized Medicaid reimbursement for SBIRT, leading to the service becoming fully self-sustainable. This approach has been expanded to other tribal primary care settings in Alaska and in rural, reservation, and urban clinics in the lower 48 states. It now includes AI/AN youth ages 12 to 17 and covers other conditions, notably suicide risk and trauma.3

A second example arose in response to the widespread lack of access to mental healthcare in rural, isolated Native communities. In 1999, I co-developed a pilot project with funding from the Veterans Health Administration that deployed real-time, interactive videoconferencing to increase tribal veterans’ access to treatment resources.4 The effort proved remarkably successful and was singled out by Telehealth Magazine as one of the 10 best telemedicine programs in the United States, well before use of such technologies to address the mental health needs of disadvantaged populations became common. Research sponsored by the National Institute on Minority Health and Health Disparities documented the effort’s organization, process, clinical reliability, treatment, and cost outcomes and justified its expansion across the country.5 The U.S. Department of Veterans Affairs now funds 12 telepsychiatry clinics co-located in tribal veterans centers and Indian Health Service primary care clinics that serve hundreds of patients and family members.

A third example reflects increasing attention to the role of anxiety, depression, and trauma in the risk, prevention, and treatment of chronic physical health conditions such as diabetes and cardiovascular disease, which occur with alarming frequency among Native people. Supported by the National Institute of Diabetes and Digestive and Kidney Diseases, my colleagues and I examined the association of psychological distress, coping skills, family support, trauma exposure, and spirituality with initial weight and weight loss among participants in the Special Diabetes Program for Indians’ Diabetes Prevention Program, which was implemented at 36 Indian health care programs across the country.6 Psychological distress and negative family support were linked to greater weight at the beginning of the study, while cultural spirituality was correlated with lower weight. Furthermore, over the course of the intervention, psychological distress and negative family support predicted less weight loss, and positive family support predicted greater weight loss. These findings demonstrate the influence of psychosocial factors on weight loss in AI/AN communities and have substantial implications for incorporation of additional intervention components.

These exciting advances, all supported in part by the National Institutes of Health (NIH), illustrate how the emphasis and scope of alcohol, drug, and mental health research among Native people have evolved over the last two decades. They represent the continued marriage of good science with local benefit, consistent with the expectations of NIH and tribal communities.

References

1Dillard DA, Muller CM, Smith JJ, Hiratsuka VY, Manson SM. The impact of patient and provider factors on depression screening of American Indian and Alaska Native people in primary care. J Prim Care Community Health. 2012; 3:120-124.

2Hiratsuka VY, Smith JJ, Norman SM, Manson SM, Dillard DA. Guideline concordant detection and management of depression among Alaska Native and American Indian people in primary care. Int J Circumpolar Health. 2015; 74: 28315. doi: 10.3402/ijch.v74.28315

3Hiratsuka VY, Moore L, Dillard DA, et al. Development of a screening and brief intervention process for symptoms of psychological trauma among primary care patients of two American Indian and Alaska Native health systems. J Behav Health Serv Res. 2016 doi: 10.1007/s11414-016-9519-6.

4Shore JH, Brooks E, Anderson H, et al. Characteristics of telemental health service use by American Indian veterans. Psychiatr Serv. 2012; 63(2): 179-181.

5Shore JH, Brooks E, Savin D, Manson SM, Libby A. An economic evaluation of telehealth and in-person data collection with rural and frontier populations. Psychiatr Serv. 2007; 58(6): 830-835.

6Dill EJ, Manson SM, Jiang L, et al. Psychosocial predictors of weight loss among American Indian and Alaska Native participants in a diabetes prevention translational project. J Diabetes Res. 2016; 1546939. doi: 10.1155/2016/1546939.

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