Your Zip Code Does Affect Your Health. Part 1

 

Can where you live, employment status and social networks – social determinants of health – affect how healthy you are and how long you live? They absolutely can. Some people may say that you can change this by moving, getting another job, or getting more support. But in reality, it’s not so simple. Adjusting these social determinants, which also include issues like food security, early childhood development, and education, among others, is often a lot easier said than done. 

Let’s take a look at how social determinants can affect two women, both in their mid-30s with the same health issues, Amanda and Cathy. They have type 2 diabetes and are at risk for developing a fairly common complication, an ulcer (sore) on the foot. If the wound doesn’t heal properly, they could develop an infection, which could lead to sepsis, amputation, or even death. 

Amanda

Amanda has a primary care provider (PCP), Dr. Williams, who she sees every six months or so if her blood glucose (sugar) levels are where they should be. She could see Dr. Williams more often if her glucose is not under control. During these regular visits though, she usually has a:

• Blood pressure reading
• Weight check
• Medication review
• Discussion about any issues, such as the new sore on her foot

Dr. Williams recommends Amanda see a podiatrist who is in the next building. She should also buy better shoes that won’t rub against the spot and will protect her feet overall. She has been warned against restricting shoes or those that could expose her feet to debris or cuts. Or Dr. Williams may begin treatment right away, including draining discharge, applying antibiotic ointments, and prescribing frequent dressing changes by a nurse. Before Amanda leaves the office, she checks who she should contact if she has any urgent concerns before her next follow-up appointment. Amanda may also receive detailed instructions, including the importance of checking her feet twice a day and take photos with her smart phone to document progress.

If Amanda needs to continue her medications or has a change in her prescription, she gets her medications at a local pharmacy and speaks to the pharmacist about any concerns or questions. The pharmacy has a record of all her medications, including those for any other health issues, ordered by a different healthcare professional so they can watch for any dangerous combinations or duplications, avoiding serious problems.

Amanda can also consult with a registered dietician to help her with food choices, and has exercise opportunities: cycling, hiking, gardening, or any activity in her community, or a gym membership for something more targeted. Some doctors can prescribe memberships if they’re covered by insurance.

The result? Amanda’s social determinants and access to healthcare meant that her diabetes is under good control and her foot healed.

Lack of access

Health and wellness are not equally available across the country. The most common issues include:

• Lack of PCPs. Many communities, rural and urban, don’t have enough PCPs to see everyone who needs them. More than 100 million people in the U.S. don’t have access to a PCP. And for those who do, their PCP may be rushed, only able to provide care in 15-minute slots. 
• Lack of physical access. If patients have no car or live in an area with unreliable public transit or none at all, how can they get to the doctor if they can find one? As rural hospitals close, distances to travel become farther all the time. This issue isn’t restricted to rural areas too. According to this article, “Although urban residents may live close to concentrations of physicians, they do not have access to automobiles and are forced to travel on a crowded bus or on a convoluted urban mass transit system.”
• Lack of work or under-employment. No job or minimum-wage jobs may mean no or limited health insurance. If patients can’t afford to see a doctor, they may only go for help when it’s an emergency. If their doctor then recommends treatments, they may not be able to afford them. There may be no pharmacy in their neighborhood so when they can afford to fill prescriptions, they gets them through a mail service, but have no pharmacist to talk to if there are problems.
• Lack of good nutrition options. If patients live in an underserved community, they may live in a food desert, where access to healthy food is limited. This results in uncontrolled blood glucose levels, which put them at higher risk for chronic diseases like diabetes.
• Limited exercise opportunities. Like living in a food desert, patients may live in an area where they can’t get much physical exercise. Some communities are not safe for walking either because of infrastructure (no sidewalks) or safety issues – especially for women. Or patients may also be working and caring for family members, leaving less time to exercise. 
• Lower education levels. Patients may not have finished high school, may have a reading disability, or English might not be their first language. These can lead to problems understanding pamphlets and information sheets, or even understanding what their PCP told them.

Cathy

Cathy’s life situation is different from Amanda’s. Her social determinants don’t allow for her to get the same care

Cathy’s blood glucose is out of control because she has to eat the food she can find in her neighborhood. She has limited time to exercise because she has a one-hour commute to and from her work, where she puts in 8-hour shifts at a minimum-wage job before going home to care for her children and aging parents. She needs to see a doctor not only for her glucose control but a sore she noticed on her foot. She can’t get an appointment though. Or she can get an appointment, but can’t take time off work or she can’t get there. 

If she does manage to see her PCP for her foot ulcer, he recommends a treatment that she can’t afford, so she tries to manage on her own. He also suggests she wear better shoes, which she can’t afford. She can’t test her blood glucose levels because she can’t afford the test strips. She has no idea how out-of-control her diabetes is. Before long, the wound becomes infected and Cathy is admitted to the hospital. She misses work, has more bills to pay, and may end up disabled if the wound becomes so serious she may need an amputation.

Two women, different social determinants

Here are two women, the same age, with the same disease and complication. But two very different outcomes because of their social determinants.

So, what can be done to help people like Cathy? Watch for part 2 of social determinants and health.

(The effects of social determinants of health was a topic covered in a session during my participation in the Association of Health Care Journalist’s 2023 CDC Fellowship.)