Place Matters to Your Patients’ Health

Where one lives can affect health, positively or negatively. Beyond the traditional numbers associated with health, such as blood sugar and weight, it is well documented that an individual’s address, ZIP code, and census tract can greatly impact health equity. An individual’s physical activity level, eating habits, and other health behaviors are impacted by the design of their neighborhood and their access to community resources, such as transportation, parks, recreational facilities, and healthy food outlets. As physicians, you may make recommendations to your patients to eat healthy and exercise, but does their environment support these recommendations? Do they have access to buying healthy foods or a safe place for recreation?

The Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances and Disease Registry (ATSDR) working group describe the “social determinants of health” as factors in the social environment that contribute to or detract from the health of individuals and communities. These factors include, but are not limited to, socioeconomic status (e.g., education, employment status, income), transportation, housing, access to services, discrimination by social grouping (e.g., race, gender, class), and social or environmental stressors.

Recent studies show differences in the medical treatment and outcomes of different racial and ethnic groups (1). These differences persist even when comparing patients of the same gender, condition, age, income, and insurance. Those with a higher income have better health outcomes compared to poorer citizens. Striking health disparities or health inequities are associated with higher rates of cancer, infant mortality, diabetes, and asthma to name a few (1). For example, in San Diego County the adjusted rates per 100,000 population for diabetes hospitalization in 2007 are 346 for Black, 235 for Hispanic, and 100 for White. In comparison, the adjusted rates for asthma hospitalizations in 2007 were 217 for Black, 68 for Hispanic, and 54 for White (2).

In its Healthy People 2010, the CDC offers two broad health goals for the nation: increasing the quality and years of healthy life, and eliminating health disparities/inequities. There is also the global movement sponsored by the World Health Organization (WHO) to address health inequity. In 2005, WHO established the Commission on Social Determinants of Health to review data and develop programs and policies to achieve health equity through impacting the social determinants of health for the world’s citizens.

Locally, County Health and Human Services Agency (HHSA) and community partners work together to address many issues of inequities by focusing efforts on environmental and policy changes. In December 2008, Public Health Services sponsored the “Unnatural Causes: Place Matters” forum based on the Public Broadcast Service (PBS) series that described the unequal distribution of social, economic, and environmental conditions that impact health, and how communities can come together to find a solution for these “unnatural causes.” The “Place Matters” segment identified examples of how where a person lives can potentially affect their health, depending on the surrounding physical, economic, social, and service environmental factors. For more information on this compelling series, go to: UnnaturalCauses.org.

The San Diego County Childhood Obesity Initiative (COI), a countywide public/private partnership collaboration, was designed to engage community partners to implement the strategies outlined in the Call to Action: San Diego County Childhood Obesity Action Plan. County Board of Supervisor Pam Slater-Price and Supervisor Ron Roberts provided leadership in the creation of the Obesity Action Plan and the ongoing efforts to work collaboratively with community partners to address this issue. To access the plan, visit OurCommunityOurKids.org. This comprehensive plan emphasizes policy and systems changes that will positively impact the health of San Diego County children (and their families). The Action Plan identifies seven domains where efforts can have the most influence in shaping healthful environments: governments; healthcare systems and providers; schools, before and after-school providers; childcare and preschool providers; community-based, faith-based, and youth organizations; media outlets and the marketing industry; and the business domains. To learn more about these domains, visit OurCommunityOurKids.org.

Through the COI “government” domain, community leaders and key stakeholders have participated in a forum discussing environmental design and how the built environment can support healthy lifestyles. The “Growing Green, Growing Healthy” committee convened a follow-up workshop, “Healthy General Plans,” to discuss how local county and city planning departments can integrate health and active living concepts into long-range general plans.

Planning and public health professionals across the nation are adopting a new framework for neighborhood design that views the built environment as an opportunity to enhance public health. Transportation and community design factors can increase an individual’s risk of chronic disease, such as asthma, obesity, and diabetes, in addition to other adverse health outcomes, including pedestrian and motor vehicle injury, as well as violence. It is well documented that mitigation of environmental risk factors within transportation and community design can have a positive impact on health. A study conducted during the 1996 Atlanta Olympics documents that asthma-related emergency room visits decreased significantly (41.6 percent) when traffic was reduced and use of public transportation increased (3). Research from Saleans and Sallis (2003) demonstrated that residents of a “walkable” San Diego neighborhood were more fit than demographically matched residents in a less walkable neighborhood (4). Environmental risk factors that contribute to adverse health outcomes can include unsafe walking and biking conditions, lack of access to nutritious foods, poor air quality, and limited access to opportunities for daily physical activity. In San Diego County, several local governmental jurisdictions, including Chula Vista, La Mesa, and the City and County of San Diego, are incorporating these public health ideas and language in to planning documents.

The COI “healthcare systems and providers” domain surveyed physicians to receive feedback on the most pressing needs and strategies to improve their practice relating to obesity. The results indicated a desire for trainings to enable physicians to become advocates in their community to assist in policy changes. Another need that is currently being addressed is a community resource directory to provide information on efforts to prevent and treat obesity. With 211 San Diego taking the lead, in collaboration with Rady’s Children’s Hospital and the COI as content experts, this directory is currently being developed. The healthcare systems and provider domain would welcome any physician interested in participating on this domain work group. If interested, please contact Cheri Fidler at cfidler@rchsd.org or at (858) 966-7748.

Another local initiative, the Healthy Eating, Active Community (HEAC), which is based in Chula Vista and receives funding from the California Endowment, offers a unique project developed through the California Medical Association’s Obesity Prevention Project. This project was piloted with the HEAC by lead physician Chris Searles, MD. After the successful pilot, it has been extended to the COI government domain and works in partnership with County Parks and Recreation. The RecreationRx program empowers “Physician Champions” to advocate for health and obesity prevention in their area. The concept is to promote health through recreation by facilitating partnerships between healthcare and recreation providers and the communities they serve. The program promotes the benefits of physical and mental health as essential in any plan to change one’s lifestyle. The “Recreation Prescription” is an actual prescription for physical activity. It supports physician’s recommendations for healthy activity and social connections and builds community partnerships. To receive prescription pads, learn how to implement your own program, and receive updates and step-by-step guidance, visit RecreationRx.org.

Grasping the concept of the social determinants of health and understanding how this principle links to health equity is vital to improving the health of patients, communities, and the nation. Overall, the health of San Diego County residents is improving in many key health outcomes, such as heart disease, stroke, infant mortality, asthma, and cancer. However, when we explore the prevalence and rates of these conditions by race and ethnicity, in some cases the numbers reveal differences among some groups. Our goal is to achieve health that is better than the best for all residents of San Diego County. Partnership with community stakeholders will be the key to this success. As physicians you are part of this solution.

References:

1. Unequal treatment Confronting Racial and Ethnic Disparities in Health Care (2002), Institute of Medicine.
2. Hospital Discharge Data (CA OSHPD) All rates are per 100,000 population and are adjusted to 2000 Standard U.S. Population.  County of San Diego, Health & Human services Agency,  prepared by Community Epidemiology 2/2009.
3. Friedman M, Powell K E, Hutwagner L, Graham L M, Teague W G. Impact of Changes in Transportation and Commuting Behaviors during the 1996 Summer Olympic Games in Atlanta on Air Quality and Childhood Asthma. JAMA, Feb 21, 2001-Vol 285, No. 7.
4. Saelens BE, Sallis JF, Black JB, et al.  Neighborhood-based differences in physical activity: an environmental scale evaluation.  American Journal of Public Health.  2003;93:1552-8.