Social Determinants as crucial factors for good health have been a major focus of The World Health Organization during the last decade. The establishment of the Commission on the Social Determinants of Health (CSDH) by the World Health Organization and its final report released in 2008 set the stage for a deep discussion and independent research on the importance of social determinants. During these last eight years since the report, the conversation has deepened, resulting in a need for all providers of health (including mental health service payers and providers) to better understand the issues and importance of integrating social determinants into treatment planning and services for children and families.
This emerging world-wide trend, and its effects on treatment planning and delivery of services to children, is most recently becoming a significant discussion at our national level (See these OPEN MINDS articles titled, “The Social Service Factor In The Health Care Value Equation,” from May 13th, 2015 and, “Medicare’s Path To Incorporating Social Determinants Into Value-Based Payment,” from May 24th, 2016). Both of these pieces illustrate the national focus on these factors affecting health.
Essentially, social determinants of health as defined by the World Health Organization are “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries.” (See http://www.who.int/social_determinants/sdh_definition/en/)
HealthyPeople.gov, a website of the Office of Disease Prevention and Health Promotion (See https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health), states that:
“Social determinants of health are conditions in the environments 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. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.”
In addition to the more material attributes of “place,” the patterns of social engagement and sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.
Understanding the relationship between how population groups experience “place” and the impact of “place” on health is fundamental to the social determinants of health—including both social and physical determinants.”
The Kaiser Family Foundation categorizes the social determinants of health to include;
- Economic Stability: Employment, Income, Expenses, Debt, Medical Bills, and Support
- Neighborhood & Physical Environment: Housing, Transportation, Safety, Parks, Playgrounds, and Walkability
- Education: Literacy, Language, Early Childhood Education, Vocational Training, and Higher Education
- Food: Hunger and Access To Healthy Options
- Community & Social Context: Social Integration, Support Systems, Community Engagement, and Discrimination
- Health Care System: Health Coverage, Provider Stability, Provider Linguistic and Cultural Competency, and Quality Of Care
After reviewing this subject, the question arises as to why social determinants are important to the mental health of our clients. The answer is that many mental disorders are shaped by the environmental conditions (social, economic, and physical places) in which our clients live. Research on this subject reveals that disadvantages begin before birth of our clients and continue to increase with age. We must begin to look at our clients through this lens of social determinants in order to achieve the desired immediate and long-term health and mental health outcomes we are seeking. We must all take action at the early stages of a child’s life to positively boost their chances to avoid mental and behavioral issues. Research backs up this statement, and it just makes sense to me that early childhood initiatives to improve social determinants is one major area we must financially support.
At this point, you might ask, “How will this world-wide focus on social determinants affect the way I deliver services in the future?” The answer, in my professional view, is that providers will have to adapt to this knowledge and incorporate and integrate social determinants into:
- Treatment Planning
- Service Delivery
I believe our assessment tools must capture the social determinant information to inform us of the social situation that the child and family have been facing. We must go beyond our traditional assessment categories and assess the above described social determinants to inform the treatment team on what needs to be addressed to achieve successful outcomes. Our treatment planning must, at its very core, incorporate tactics to address the social inequities being faced by our clients. Funding for this type of treatment planning will be challenging, as it appears that organizations that are at this time in history delivering services to address social determinants are being financially supported by grants and community fundraising. But, hope is on the horizon as Medicaid is wrestling with this issue. I believe it is just a matter of time before our governmental funding streams will include social determinants service delivery as fundable events. Assuming we assess, plan, and deliver services according to what we know about the effect of social determinants, we must recognize that aftercare services will become extremely important. We must recognize that aftercare services should be delivered in such a manner that focuses upon assisting our clients to improve their social status in their specific areas of disadvantage. This means continued assistance in the areas of housing, job training, access to physical health and substance abuse services, and for the children we treat, safe and appropriate parenting, permanency, excellent education, and nutrition.
Providers in our industry that hope to meet the challenges of a new health care system will not find it difficult to grasp the importance of integrating social determinants into their treatment programs once a source of funding is available. The challenge today is how to address these factors to improve the behavioral and mental health of our clients! I suggest you start the conversation with your leadership team and Board of Directors and review the literature and research that is rapidly emerging on this subject. Being aware of the importance of this area to achieve our overall goals with clients is the first and most important step. Hopefully, it will not take long before we are addressing what we can without formal funding and readying our organizations for this change when it becomes financially supported. Let me know what you think about this subject. I would love to know if you are addressing social determinants as part of your assessments and treatment planning. I will keep you posted on the developments in this area.