International Forum focuses on social determinants of health

On April 20, 2018, at Internal Medicine Meeting 2018 in New Orleans, internal medicine society leaders from over 34 nations, including those from the European Federation of Internal Medicine (EFIM), the International Society of Internal Medicine (ISIM), and several key opinion leaders (KOLs), convened as part of the ACP International Forum to consider the impact of nonbiological factors on health and well-being from national perspectives.

The discussion was structured with panelists representing Asia, Australia, Europe, North America, and South America serving as the primary discussants around a set of predetermined questions defined by ACP's International Council and previously released to the panelists. The questions included the following:

• What are the most significant social determinants of health in your country or region?
• What is the physicians' role in identifying and addressing social determinants of health in your country or region?
• How do governmental and nongovernmental agencies and organizations address social determinants of health, and how does this impact the physicians' role?
• What are the primary barriers in effectively addressing the social determinants of health in your patients?
• What strategies (i.e. educational initiatives, policy changes, etc.) do you believe would be effective in your country or region to help overcome these barriers to help physicians more effectively address social determinants of health?
• How can internists internationally help each other address social determinants of health?

Panelist comments for all questions were followed by open discussion from all participants. Representation was present from all continents except Antarctica. This discussion took place in the context of the nine policy positions highlighted in ACP's recent position paper, “Addressing Social Determinants to Improve Patient Care and Promote Health Equity,” published in Annals of Internal Medicine on April 17, 2018.

A global perspective on social determinants

The starting point for the discussion was the recognition that humans are biological and social entities. As humans living in communities, we are exposed to multiple social factors that impact health-related outcomes. Given the small proportion of time that individuals, in general, spend engaging with the health care system, and the much greater proportion of time that individuals spend living in their community, we are increasingly aware that health itself is mostly a product of social determinants than of the health care system. An example of the importance of these social factors is the lack of direct relationship between U.S. health care expenditures and healthy outcomes. The United States spends approximately 18% of its gross domestic product (GDP) on health care, compared to 10% to 12% for most other developed nations, and does not lead in health outcomes including life expectancy, infant mortality, and disability-adjusted life-years. In contrast, U.S. expenditures in public health and prevention are more modest than other countries where investment may be more impactful. For example, countries with universal access to health care and stronger safety net public systems have noted significantly improved health outcomes.

Multiple determinants have been documented to impact health inequity including socioeconomic status, race, ethnicity, gender, disability, housing, education, numeracy, health and digital literacy, employment and income, geographic location (frontier/rural/urban), access to safe drinking water, and others; with lack of economic opportunity, poverty is suggested as the most impactful of these determinants. Persons living in poverty tend to co-experience other negative factors, such as lack of access to quality education, underfunding of schools, food insecurity, lack of access to nutritious food, lack of access to safe spaces to exercise, and increased risk of exposure to violence. These factors are not linear in influence. For example, poverty influences education, which can influence income and poor access to health, while limiting social mobility, lifespan, early childhood development, and adequacy of elder care.

The role of culture and religion in health care access was identified as important across continents. Belief systems regarding the cause of disease and illness can impact trust in allopathic interventions and adherence to treatments including use of vaccines and injectable therapies. Cultural factors may be strongly linked to health-related behaviors. Partnering with community members and working together is essential to learn to support health through culture, including religion.

The health of native populations across the planet was also identified as a high priority. Native populations were noted to have high health care need across multiple continents. Although not populous, health care use is high and life expectancy is poor due to multiple factors including geographic isolation. Successful approaches may be a prototype for this work as they will require providing education, restructuring health care delivery systems, and partnering with governmental and nongovernmental resources to address social determinants of health.

We present a summary of the discussion as linked to ACP's policy recommendations.

1. The American College of Physicians supports increased efforts to evaluate and implement public policy interventions with the goal of reducing socioeconomic inequalities that have a negative impact on health. Supportive public policies that address downstream environmental, geographical, occupational, educational, and nutritional social determinants of health should be implemented to reduce health disparities and encourage health equity.

The Royal Australasian College of Physicians noted that its motto is to “serve the health of the people,” which appreciates the significant role of social determinants and requires becoming involved in health policy and advocacy. Some examples of focused efforts within the Australian and New Zealand system to improving health outcomes include supporting health during the first 1,000 days of life (from prenatal through the first few years of life) and preventing alcohol and tobacco use. The latter resulted in smoking rates in Australia being among the lowest in the world. This work acknowledges that health care and genetics only account for 40% of health outcomes, while behavioral, social, and environmental factors account for 60% of health outcomes.

Physicians and medical societies as advocates for health equity

Physicians have a respected voice in their area of their expertise: patient care. This opportunity for advocacy at the local, regional, and national level cannot be underestimated. In a recent election, New Zealand physicians recently successfully campaigned to make health equity the norm, and working groups and reports have been generated by physicians within the European Union related to social determinants of health. Clinical expertise can move political leaders. Physicians acting on behalf of our patients can encourage health ministers and policymakers to focus on prevention and social determinants rather than on illness, which often represents a failure of prevention. The advocacy role of the physician may engage them directly in political efforts. Physicians in the political arena can serve to educate and inform other policymakers on the complexity of health care issues.

As existing social forums, medical societies can work together across countries to impact policy by serving as a unified voice of the profession for health equity. Topics of global impact, such as obesity and climate change, are natural starting points for collaborating, setting agendas, and working with legislatures in different countries. Medical societies may interact with government and policymakers at many levels, including being represented in organizations that develop policy. They should also engage patients in the policy development process. Societies will need to maintain awareness of the variability of social determinants across countries, including wide variation in per capita spending on health care and life expectancy. As members of society, physicians and medical societies have expertise and responsibility to their patients and to the communities they serve.

Bridging governmental and nongovernmental approaches

Fractured, segmented, heterogenous, disorganized, and uncoordinated national and municipal health systems were described and were noted not to emphasize prevention, to increase costs, to result in misuse of resources, and to be overall detrimental to health. Since services may be outsourced by government to nongovernmental organizations, substantial cost-shifting may be taking place. Strategic and collaborative efforts must include all stakeholders including government, nongovernmental organizations, and patients.

Bridging clinical practice and public health

As clinicians, physicians are on-the-ground agents of change working with their patients one-on-one. Guided by the Charter on Medical Professionalism and the principle of social justice, participants noted a responsibility to care. Many voiced an understanding of health as a cornerstone essential for well-being and observed a disconnect between the practice of medicine, public health, and population health. This failure of integration limits physician action on the social determinants while fragmented health policies continue to impact clinical practice and patient care. Perpetuating these “silos” increases costs, limits access, and does not effectively promote health.

2. The American College of Physicians recommends that social determinants of health and the underlying individual, community, and systemic issues related to health inequities be integrated into medical education at all levels. Health care professionals should be knowledgeable about screening and identifying social determinants of health and approaches to treating patients whose health is affected by social determinants throughout their training and medical career.

To institutionalize and normalize health equity, the science of the social determinants must be part of the core curricula of medical education, postgraduate training, and lifelong learning. If this is so, a patient may be cared for in context as an individual, living in a family and in a community. This approach encourages a contextual understanding of the patient's narrative instead of creating a judgment.

The benefits of this approach are multifold as physicians actively seek to develop the right skills to treat the patient they meet in front of them every day. Addressing the social factors that increase the risk for disease will help shift the culture of medicine from one that is reactive to one focused on prevention. Making the social determinants an educational priority that is important to discuss and share will support the learning process and help address gaps among practicing physicians who may lack the skills in this area.

To address current medical education deficiencies, learning opportunities can emerge from the integration of the health sector, medical education, and social service delivery in an interprofessional team-based model (please see #3 below). Educational content must address the science of the impact of social determinants on health and illness and the availability of local partners and resources to assist with their management. Examples across the medical education spectrum include:

Undergraduate

• Course in social medicine
• Experiential learning in an underserved community including experience in accessing local partners' resources

Graduate

• Present the science of health equity
• Engagement with governmental and nongovernmental resources addressing social determinants including experience in accessing local partners' resources
• Team-based care training
• Partner with interprofessional colleagues to care for patients' mental, functional, and social concerns

Postgraduate

• Identify and partner with local communities to integrate resources necessary to address social determinant needs in your patient population
• Best practices in social determinants of health as a routine topic for professional meetings including international scientific meetings
• Develop skills to serve as mentors, role models, and community leaders

Technology and social media

Medical education has begun to include the role of technology in day-to-day practice and the opportunities for connectivity that mobile technology offers to address social determinants. Although “the digital divide” has narrowed in some ways, i.e. more populations have access to a reliable internet connection, the type of digital tools available is not uniform across or within communities. Medical educators must keep this inequity in mind to prevent exacerbating it.

Bridging medical education and public health

Integration with public health can include a more robust partnership in didactic and experiential learning. Public health topics would be integrated and presented as part of all medical education topics, not just those where the connection appears more evident, i.e. flu pandemics, asthma and climate change, and the “diseases of despair” such as substance use disorder and self-harm. Medical educators must continue to remember our contextual understanding and explore the impact of social factors in all aspects of health and illness. This approach supports interprofessional team-based care.

Patient education

Education is empowering. Engaging patients in their own care supports patient self-sufficiency and self-confidence. This may best be accomplished through interprofessional teams. From our historical “siloed” concept of health, social factors such as poverty, education, racism, and others may not always be seen as linked to health. Part of the role for physicians and medical societies is to stay up to date on the science of health equity and to share these data with our patients, communities, and policymakers.

With the documented benefit of education on health and longevity, physicians and other health professionals should consider advocating for improved education from elementary school to university based on the anticipated impact on health and well-being including decreased health care costs due to illness. Improved education will also likely result in better employment outcomes, which is associated with improved financial security, socioeconomic status, personal development, social engagement, and self-esteem, which promote healthy behaviors such as physical activity and healthy nutrition, increases access to health care, decreases the risk of violence and crime, and protects against physical and psychological disorders.

Social media brings tremendous opportunity for education and engagement. One example is to counter the marketing efforts of unhealthy products such as fast food, sugary drinks, alcohol, and cigarettes that support unhealthy behaviors and can extend to antivaccine campaigns and efforts to increase awareness around disease risk and prevention, i.e. creating a World Dengue Day. These efforts impact populations broadly regardless of age, economic status, gender, or other demographic factors. Social media can also be used to support medical education.

3. The American College of Physicians supports increased interprofessional communication and collaborative models that encourage a team-based approach to treating patients at risk to be negatively affected by social determinants of health.

The complexity of clinical care requires examining and addressing the impact of social factors on health. Restructuring health care delivery systems toward interprofessional practice will allow extension of the “15-minute visit” and help to alleviate physicians' daily workload. Physicians frequently feel overworked and short of time and note that they are experiencing increasing clinical demands that make it difficult to find time to address social determinants.

Health care teams including social workers, nutritionists, physical therapists, psychologists, and others are critical in identifying and addressing the needs of the patient and the community. An interprofessional approach supports the development and dissemination of solutions to address many of the social determinants of health. Interprofessional practice will require modifications in the education of health professionals as outlined in #2 above.

4. The American College of Physicians supports the adequate and efficient funding of federal, state, tribal, and local agencies in their efforts to address social determinants of health, including investments in programs and social services shown to reduce health disparities or costs to the health care system and agency collaboration to reduce or eliminate redundancies and maximize potential impact.

Despite some strong national health systems and robust patient safety nets, many representatives noted insufficient resources for each patient to achieve wellness. Adequate integrated funding would include support to address the social factors that are impacting patients' health; to support the modifications in medical and health professions education; and to assess the impact of interventions so that approaches may be guided by evidence.

With the greying of the global population, support for elder care is generally insufficient and families are often unable to manage alone. Other recently recognized at-risk populations include the disabled and the unemployed whose social benefits may be too low to meet needs even in nations with ready access to health care. Adequacy of funding should not include redistribution of health care funds that divert resources from other recognized needs.

5. The American College of Physicians supports increased research into the causes, effects, prevention, and dissemination of information about social determinants of health. A research agenda should include short- and long-term analysis of how social determinants affect health outcomes and increased effort to recruit disadvantaged and underserved populations into large-scale research studies and community-based participatory studies.

The global community is characterized by great variability in health outcomes reflecting different socioeconomic realities and robustness of health budgets. This variability offers an opportunity to define research questions that may elucidate essential elements for health and well-being. Similar nations and regions may identify factors of common impact that may expedite progress.

For example, several countries are experiencing drops in life expectancy. Studying causes, similarities, and differences across national boundaries may help define the core interventions necessary for health. This work may also add to the growing body of knowledge regarding the impact of place on health. As one of the representatives noted, “A ZIP (postal) code influences health more than the genetic code.”

Other areas for potential study include the impact of interventions related to health literacy, integrated care, and the interprofessional care of the growing elderly population. With economic shifts, the outcomes of natural experiments can also be explored, such as the impact of employment, under-employment, and unemployment on health across countries with varying approaches to access to health care.

6. The American College of Physicians recommends policymakers adopt a “health in all policies” approach and supports the integration of health considerations into community planning decisions through the use of health impact assessments.

Although governmental policies are critical to health across our different health systems, other sectors also impact health. “Health in all policies” asks policymakers to consider their policy activity through the health lens with the goal of developing a comprehensive approach to health. Housing, education, and transportation policies, to name a few, all impact health across a person's lifespan. Engaging municipal planners, economic developers, and transportation agencies may address health needs in new ways.

Specific projects include programs such as “Farm to Plate” and “Farm to School,” which address food insecurity, nutrition, physical activity, and healthy behaviors. Pediatricians in the United States have developed best practices. The “Bright Futures” program mandates that part of the well-child visit include a health history that assesses social determinants and addresses identified needs through universal nurse-based home visit programs that assess mother and newborn infant health in the home, parent-child clinics, and social workers embedded in high-value pediatric practices. Best practice approaches are evolving to promote clinical and community collaborations that enable resources to reach patients where needs related to social determinants have been identified. In Australia, health organization partnerships are developing to address indigenous care and the rising problem of obesity through multifaceted interventions. The Royal Australasian College of Physicians has a Faculty of Occupational Environmental Medicine that recently produced a revised version of their position paper on the health benefits of work titled “Health Benefits of Good Work.” The paper emphasized the importance of work on health and the positive impact of work that takes health into account by maximizing collegiality, minimizing repetitive labor, and supporting healthy behaviors.

7. The American College of Physicians recommends development of best practices for utilizing electronic health record (EHR) systems as a tool to improve individual and population health without adding to the administrative burden on physicians.

No comments on EHR utilization were noted.

8. The American College of Physicians recommends adjusting quality payment models and performance measurement assessments to reflect the increased risk associated with caring for disadvantaged patient populations.

No comments on quality payment models and performance measurement assessments were noted.

9. The American College of Physicians recommends increased screening and collection of social determinants of health data to aid in health impact assessments and support evidence-driven decision making.

Strategies, successes, and ineffective approaches should be shared broadly to enrich knowledge and incorporate lessons learned. Regions with similar cultural backgrounds may benefit the most from mutual data dissemination. These approaches may help identify and focus tailored interventions for vulnerable populations.

Future directions

The Forum participants expressed several priorities for future action that can proceed under the auspices of ACP's International Council. The priorities are presented as those within ACP and those to be accomplished more broadly. The first common step is the availability of these proceedings and wide dissemination across all participant constituencies, thus raising international awareness, with accompanying talking points to reach patients, health professionals, and policymakers.

Work within ACP

• Propose scientific sessions at Internal Medicine Meeting 2020 through an international collaborative focusing on social determinants of health
• Revisit ACP's team-based care paper with a focus on social determinants

Work with partner societies

• Develop educational program across the spectrum of medical education
• Engage communities and policymakers
• Engage in future planning exercise to foster innovative solutions
• Propose scientific sessions at international meetings broadly as part of an international collaborative focusing on social determinants of health
• Develop collaborative international strategies to address social determinants

Conclusion

The work of addressing the social factors impacting health is part of our professional and moral obligation to act on behalf of our patients and our communities. The dialogue of the Forum included remarkable insights that shed light on the complexity of this work and generally aligned well with the themes outlined in ACP's recent social determinants position paper. The international community, represented at the Forum, affirmed the importance of social factors on health and illness, the need for education to support interprofessional practice, and the importance of international partnership in bringing forward effective recommendations. The participants expressed strong interest in improving our local and regional understanding of the topic, sharing our best practices, and conducting collaborative research. These efforts would give physicians an international platform that most felt was crucial to implement change. The participants stated their desire to continue this conversation and to follow up with subsequent opportunities.

ACP International Forum Panelists:

Mark A. Levine, MD, FACP, Regent, ACP Board of Regents

Florencio Olmos, MD, FACP (Hon), President, Buenos Aires Society of Internal Medicine

Runolfur Palsson, MD, FACP, President, European Federation of Internal Medicine

Catherine Yelland, MD, FACP (Hon), President, The Royal Australasian College of Physicians

ACP International Forum Participants:

ACP Officers

Jack Ende, MD, MACP, President

Susan Thompson Hingle, MD, MACP, Chair, Board of Regents

Ana María López, MD, MPH, FACP, President-elect

Andrew Dunn, MD, MPH, FACP, Chair-elect, Board of Regents

Robert H. Lohr, MD, FACP, Treasurer

Thomas G. Cooney, MD, MACP, Chair, Board of Governors

George M. Abraham, MD, MPH, FACP, Chair-elect, Board of Governors

Darilyn V. Moyer, MD, FACP, Executive Vice President, Chief Executive Officer

Robert M. McLean, MD, FACP, President-elect Designee, Board of Regents

Douglas M. DeLong, MD, FACP, Chair-elect Designee, Board of Regents

Omar Atiq, MD, FACP, Chair-elect Designee, Board of Governors

Internal Medicine Society Representatives

David James Galloway MD, FACP (Hon), President, Royal College of Physicians and Surgeons of Glasgow

Pritam Gupta, MD, FACP (Hon), President, Association of Physicians of India

Mary Horgan, MD, FACP (Hon), President, Royal College of Physicians of Ireland

Tadashi Matsumura, MD, FACP (Hon), President, Rakuwakai Healthcare System, Kyoto, Japan

Teresita Araujo de Garay, MD, President, Paraguayan Society of Internal Medicine

Khan Abul Kalam Azad, MD, FACP, President, Bangladesh Society of Medicine

Juan D. Barrios, MD, FACP, President, Panamanian Society of Internal Medicine

Aland Bisso Andrade, MD, President, Peruvian Society of Internal Medicine

Luis Manuel Barreto Campos, MD, FACP (Hon), President, Portuguese Society of Internal Medicine

Frank Bosch, MD, FACP, Past President, Dutch Society of Internal Medicine

Richard Ceska, MD, PhD, FACP (Hon), President, Czech Society of Internal Medicine

Jane Elizabeth Dacre, MD, FACP (Hon), President, Royal College of Physicians of London

Maritza de Jesus Durán Castillo, MD, FACP, President, Venezuelan Society of Internal Medicine

Fredy A. Figueroa, MD, President, Internal Medicine Society of the Dominican Republic

Jean-Michel Gaspoz, MD, FACP, Co-President, Swiss Society of General Internal Medicine

Andrew Goddard, MD, FRCP, Registrar, Royal College of Physicians of London

Kenneth Yu Hartigan-Go, MD, FACP, President, Philippine College of Physicians

Heli Hernandez Ayazo, MD, FACP, President, Latin American Society of Internal Medicine (SOLAMI)

Hans-Peter Kohler, MD, MACP, Secretary General, International Society of Internal Medicine (ISIM)

Johanna Adriana (Adri) Kok, MD, FACP, President, Faculty of Consulting Physicians of South Africa

Nadine Lahoud, MD, FACP, Secretary-Treasurer, Canadian Society of Internal Medicine

Chak-Sing Lau, MD, FACP (Hon), President, Hong Kong Academy of Medicine

Margus Lember, MD, FACP, Past President, Estonian Society of Internal Medicine

Claudio S. Liberman, MD, FACP, Past President, Chilean Society of Internal Medicine

Dragan Lovic, MD, PhD, FACP, President, Serbian Association of Internal Medicine

Sally Aman Nasution, MD, FACP, Secretary General, Indonesian Society of Internal Medicine

Jorge Alberto Rodriguez Garcia, MD, FACP, President, Mexican College of Internal Medicine

Aru W. Sudoyo, MD, FACP, President, International Society of Internal Medicine (ISIM)

Jose A. Acuña Feoli, MD, FACP, Vice-President, Costa Rican Association of Internal Medicine

Ming-Shiang Wu, MD, PhD, Secretary General, Taiwan Society of Internal Medicine

ACP 2018-2019 International Council

Charge:

Advise the Board of Regents on strategic direction that will enable the College to actively participate in the international medical community and to consolidate and coordinate international leadership, input and direction for the College, and provide a direct link between international leadership and the Board.

Joseph M. Li, MD, FACP, Chair

Nestor Sosa, MD, FACP, Vice-chair

Kenneth L. Connell, MBBS, PhD, FACP

Maha Mishari Abdulaziz Al Saud, MD, FACP

Jack Ende, MD, MACP

David A. Fleming, MD, MA, MACP

Michael Kenyon, MD, FACP

Tiffany Leung, MD, MPH, FACP

Guillermo J. Ruiz-Arguelles, MD, MACP

Tabassum Salam, MD, FACP

Fumiaki Ueno, MD, MACP

Soma Wali, MD, FACP