The Journal of the Arkansas Medical Society Issue 3 Vol 115 | Page 5
COMMENTARY
Appathurai Balamurugan, MD, DrPH, MPH
When the Rubber Does
Not Meet the Road
W
e are familiar with the
phrase, “When the Rub-
ber meets the Road,”
and often use it to refer to when
words are or are not translated. In
the context of clinical practice, we encounter some
of our patients who may know what needs to be
done or hear from us what needs to be done to
improve their health – be it medication adherence
or lifestyle modification for chronic disease man-
agement – but are regularly nonadherent. While
sometimes, we may stop and reason out
why, many times in our busy practice we
don’t have time to stop and think or ask
why. When the rubber does not meet the
road, do we regularly stop to think or ask
why? One of the commonly cited reasons for
this has been the challenges posed by non-
medical social needs or social determinants
of health.
The conditions in which people are
born, grow, live, work, or age that influence
individual choices and significantly impact
health are defined as the social determi-
nants of health (SDOH). These conditions
are, in large part, responsible for the health
inequities that pervade our society at pres-
ent times. A renowned physician and epide-
miologist, Sir Michael Marmot, states, “Why treat
people and send them back to the conditions that
made them sick in the first place?” Assessing and
addressing the conditions that made them sick in
the first place would be a good first step to achiev-
ing health equity. The Department of Health and
Human Services Officer of Disease Prevention and
Health Promotion describes five key areas of SDOH,
as illustrated in the schema here.
They are as follows:
• Economic stability (employment, food insecurity,
housing instability, poverty)
• Education (early childhood education and devel-
opment, enrollment in higher education, high
school graduation, language and literacy)
• Social and community context (civic participation,
discrimination, incarceration, social cohesion)
• Health and health care (access to health care, ac-
cess to primary care, health literacy)
• Neighborhood and built environment (access to
foods that support healthy eating patterns, crime
and violence, environmental conditions, quality
of housing).
These key areas impact our patients, prevent-
ing them from making health a priority. These five
key areas impact health in various ways; for exam-
ple, housing instability could include homelessness,
difficulty paying rent, or poor housing conditions due
to bug infestation or mold, and could lead to respi-
ratory and cardiovascular diseases, death from ex-
treme temperatures, or risk of at-home injury. Lack
of child care could be a barrier for educational or
employment opportunities for patients. Exposure to
interpersonal or community violence may impact the
physical and emotional health of our patients.
The American Academy of Family Physi-
cians and other national organizations have de-
veloped some screening tools (https://www.aafp.
org/patient-care/social-determinants-of-health/
everyone-project/tools.html#patients) for SDOH
that can help identify specific needs or challenges
faced by our patients. These screening tools can
be administered by receptionists or medical as-
sistants, or integrated as part of intake form in
patient’s electronic health records. Nurses, phy-
sician assistants, or physicians can review the
completed SDOH screenings to determine patient
needs and create an action plan during the
visit. Engaging care managers, social work-
ers, or community health workers to deter-
mine available resources in the community,
facilitate referrals, and ensure follow-up
between patient visits would go a long way
toward improvement. Each patient’s need
may be different, as there is no one-size-
fits-all in addressing SDOH. Some social
services available at the practice level to
help address social needs of the patients
include a free, online social services search
engine called Aunt Bertha (www.auntb er-
tha.com), 211 Helpline Center, and State
Health Departments (https://www.healthy.
arkansas.gov/resources).
The SDOH screening tools and patient action
plan provide a starting point to assessing and ad-
dressing SDOH in a busy practice. With the move-
ment toward value-based payment models, phy-
sicians are held accountable for health outcomes
rather than processes. Assessing and addressing
SDOH would assist with behaviors and social fac-
tors that impact health outcomes.
The views expressed in this commentary are
that of the author and are not necessarily those of
the Arkansas Department of Health.
NUMBER 3
SEPTEMBER 2018 • 53