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SOCIAL DETERMINANTS
OF HEALTH
continued from page 13
Figure 2

Examples of the first pathway include home visiting programs
for pregnancy and for parents of young children, the earned
income tax credit, efforts to increase the federal minimum
wage, and increased protections for job safety/worker pro-
tection (e.g. PPE) particularly during the pandemic
among essential workers or expanding the Family Med-
ical Act to cover smaller employers and add paid leave
or criminal justice and sentencing policies. The evidence
6
for the effectiveness for these approaches is robust.
Examples of the second pathway include nutrition as-
sistance in federal programs like Supplemental Nutrition
Assistance Programs (SNAPs), local direct assistance by
the San Antonio Food Bank, and direct assistance for spe-
cific patients who screen positive for food insecurity in our
clinics. Also in this pathway are programs that promote chil-
dren’s cognitive and social skills by expanding access to high-qual-
ity child-care and preschool (e.g., PreK for SA) as well as those that

promote high quality primary and secondary schools. Regulations

that incentivize healthy behaviors such as limiting tobacco and elec-

tronic nicotine delivery systems (ENDS) in multiunit housing, mak-
Conceptual Model for Community Solution s to promote health equity
ing healthy food options more salient and affordable, increasing the Source: National Academies of Science, Engineering, and Medicine. 2017.

price of sugar-sweetened beverages that may reduce overweight and Communities in action: Pathways to health equity.
Washington, DC: The National Academies Press. Doi:10.17226/24624.
obesity, and promoting firearm safety.

In terms of the third pathway, health care financing strategies to re-

duce health disparities, to allocate resources with the best effectiveness
References
to improve patient outcomes are needed. The current fee-for-service
1. Hood, C. M., Gennuso, K. P., Swain, G. R., & Catlin, B. B. (2016).
payment system prioritizes “doing things to people rather than for
County health rankings: relationships between determinant fac-
people”, an emphasis on volume rather than on outcomes. Examples
tors and health outcomes. American Journal of Preventive Medi-
in this pathway include payment systems that value intervention and
cine, 50(2), 129-135.
services that improve access and patient trust (e.g., transportation as-
2. WHO (World Health Organization). 2012. What are the social
sistance and trust bridges by community health workers with clinical
determinants of health? Available at: https://www.who.int/
teams). Global capitated payment systems or value-based payments
health-topics/social-determinants-of-health#tab=tab_1 (accessed
modeled on shared savings or accountable care organizations are ex-
December 6, 2020).
amples of these innovative payment approaches. All these changes are
3. AMA (American Medical Association) 2001. AMA Declaration
not accessible to those most in need without expansion of health in-
of Professional Responsibility Available at: https://www.ama-
surance coverage. Efforts to expand coverage need to be included
assn.org/delivering-care/public-health/ama-declaration-profes-
along with changes to current policies to reduce further barriers to
sional-responsibility (accessed December 6, 2020)
care among those who have coverage.
4. National Academies of Science, Engineering and Medicine. 2017.
The task to reduce health inequities in Bexar County requires that
Communities in action: Pathways to health equity. Washington,
we stray from the comfort of our exam rooms, hospitals, procedure
DC: The National Academies Press. Doi: 10.17226/24624.
rooms and executive suites. We need to reclaim the healing mission
5. The Health Collaborative. (2019). 2019 Bexar County Community
that inspired us to get into our profession. With tenacity and enthu-
Health Needs Assessment Report. San Antonio, TX: The Health
siasm, let’s engage with partners to address the other 80% that drives
Collaborative. Available at: http://healthcollaborative.net/wpcon-
the health of the patients, families and communities we serve. We can
tent/uploads/2019/10/Community2019_CHNAReport_com-
do this together.
pressed.pdf (accessed December 6, 2020)

6. Adler, N. E., Cutler, D. M., Fielding, J. E., Galea, S., Glymour, M.
Carlos Roberto Jaén MD, PhD, FAAFP is the Chair of Fam-
M., Koh, H. K., & Satcher, D. (2016). Addressing social determi-
ily and Community Medicine at the Long School of Medicine
nants of health and health disparities: A vital direction for health
and a member of the Bexar County Medical Society and the
and health care. NAM Perspectives.
National Academy of Medicine.

14 SAN ANTONIO MEDICINE • January 2021 Visit us at www.bcms.org 15