Public Health: Social determinants and health equity, a health officer report

As we enter a new year, we take the time to reflect on the successes and challenges of this past year, but more importantly set our sights on the future. Healthy individuals, community and environment are our vision states for 2024, and Lewis and Clark Public Health continues to strive for conditions that result in positive health outcomes for all people in our county.

Drenda Niemann 2023

Drenda Niemann

Lewis and Clark Public Health provides high-quality home visiting services, vaccination consultations and administration, restaurant, pool and public accommodation inspections, on-site wastewater monitoring, tobacco prevention activities, behavioral health advocacy, and so much more. While these services are foundational and honorable, according to our 2021 Community Health Report, we continue to see poor health outcomes in the areas of lung health, cancer, heart disease, housing insecurity, mental illness and substance misuse.

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So how can we fine tune our highly effective public health tools to gain larger strides toward greater health in these areas? Health departments across Montana and across the nation are zeroing in on strategies that address the social determinants of health to achieve better health outcomes for all county residents and more equitable health outcomes for those who are underserved in our community.

According to the Centers for Disease Control and Prevention, “Social determinants of health are the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies, racism, climate change, and politic systems.”

There are five social determinants of health that have the potential to double down on improving health outcomes for residents of this county: economic stability, education, health care access and quality, neighborhood and the built environment, and social community context.

Economic stability is the connection between a person’s financial circumstances, such as income and cost of living, and their health. Key issues are poverty, employment, food security and housing affordability. From 2015 to 2019, the county’s annual poverty rate slightly increased for the population aged 65 year or older (2021 CHA).

Access to quality education is the connection between a person’s education and their health. Key considerations are high school graduation, literacy and access to early childhood education. The percent of Lewis and Clark County high school students who dropped out of school decreased from 7% in 2009-2010 school year to 4% in 2019-2020 school year [Figure 3]. The high school dropout rate over time improved more for the county and remained about the same for the state (2021 CHA).

Access to quality health care is the connection between a person’s access to health care and their health. Key issues are affordability, transportation and health literacy. In 2021, the most common (22%) barrier to obtaining a health care provider for county residents was difficulty in getting a medical appointment (2021 CHA).

Neighborhood and built environment is the connection between where people live and their health. Key issues are safe housing, interpersonal violence and physical environmental conditions. In 2019, approximately 40% of Lewis and Clark County residents spent at least 30% of their household income on rent. The rent expense exceeded the recommended Health People 2030 target of 25.4% (2021 CHA).

Social community context is the connection between a person’s social support, family circumstances, community engagement and their health. Key issues are community participation, incarceration of a family member or discrimination. Non-white Lewis and Clark County residents had a higher rate of disabilities. Thirty-two percent of Black or African American residents reported at least one disability type. The rate was almost three times higher compared to white residents (2021 CHA).

According to the World Health Organization, “The Social Determinants of Health have an important influence on health inequities – the unfair and avoidable differences in health status seen within and between countries. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.” This stands true right here in Lewis and Clark County as well.

To quote the Frame Works Institute, “Equity means fairness and justice. It involves ensuring that every individual and group get what they need to thrive and participate fully in society. Achieving equity often asks us to rethink uniform, one-size-fits-all treatment. It sometimes involves devoting more resources or different resources in communities that face injustice, to correct imbalances caused by unfair or unequal treatment.”

Achieving health equity requires valuing every person and their health fairly; addressing unfair practices and unjust conditions that can harm the health of specific groups in society; and working with different groups in specific, sensitive ways to address health issues that affect them. What it does not mean is stopping or diverting public health services that all residents of the county deserve in order to serve a few. Lewis and Clark Public Health’s mission is to improve and protect the health of ALL Lewis and Clark residents. It’s not a withdrawal of services, but rather an added layer of dedicated effort to ensure the underserved populations in our community achieve their greatest potential for health as well as those with better access to health care, education, housing, healthy foods and a positive social network.

Solving these complex issues cannot be done by any one entity alone. In order to make sizable advances in addressing homelessness, hunger, poverty, violence, and lack of child care and community engagement – which all negatively impact individual and community health – we must all come together. It will take individuals, agencies and government to bring knowledge, experience, expertise, resources and determination to realize our vison for healthier people, community and environment.

Public Health’s role in addressing social determinants is to convene community partners, integrate efforts to avoid duplication and fill gaps, influence decision makers to adopt policies that improve conditions for all, and contribute experience and expertise to solve big health problems and create the necessary changes across the county that positively impact the health of all residents. This is our mission, and we resolve to improve and protect health for all county residents into the new year.

Drenda Niemann is the health officer with Lewis and Clark Public Health.

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