Number 729 (Replaces Committee Opinion Number 493, May 2011)
Committee on Health Care for Underserved Women
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved Women in collaboration with committee members Carolyn Sufrin, MD, PhD, Autumn Davidson, MD, MS, and Glenn Markenson, MD.
ABSTRACT: Awareness of the broader contexts that influence health supports respectful, patient-centered care that incorporates lived experiences, optimizes health outcomes, improves communication, and can help reduce health and health care inequities. Although there is little doubt that genetics and lifestyle play an important role in shaping the overall health of individuals, interdisciplinary researchers have demonstrated how the conditions in the environment in which people are born, live, work, and age, play equally as important a role in shaping health outcomes. These factors, referred to as social determinants of health, are shaped by historical, social, political, and economic forces and help explain the relationship between environmental conditions and individual health. Recognizing the importance of social determinants of health can help obstetrician–gynecologists and other health care providers better understand patients, effectively communicate about health-related conditions and behavior, and improve health outcomes.
The American College of Obstetricians and Gynecologists makes the following recommendations for obstetrician–gynecologists and other health care providers to improve patient-centered care and decrease inequities in reproductive health care:
Inquire about and document social and structural determinants of health that may influence a patient’s health and use of health care such as access to stable housing, access to food and safe drinking water, utility needs, safety in the home and community, immigration status, and employment conditions.
Maximize referrals to social services to help improve patients’ abilities to fulfill these needs.
Provide access to interpreter services for all patient interactions when patient language is not the clinician’s language.
Acknowledge that race, institutionalized racism, and other forms of discrimination serve as social determinants of health.
Recognize that stereotyping patients based on presumed cultural beliefs can negatively affect patient interactions, especially when patients’ behaviors are attributed solely to individual choices without recognizing the role of social and structural factors.
Advocate for policy changes that promote safe and healthy living environments.
Traditional biomedical explanations of disease tend to focus on biologic and genetic factors as well as individual health behavior as determinants of who gets sick and from what conditions. Although there is little doubt that genetics and lifestyle play an important role in shaping the overall health of individuals, interdisciplinary researchers have demonstrated how the conditions in the environment in which people are born, live, work, and age, play equally as important a role in shaping health outcomes 1 2 3 4 5. These factors, referred to as social determinants of health, are shaped by historical, social, political, and economic forces and help explain the relationship between environmental conditions and individual health 6. It is well established that social determinants of health are responsible for a large proportion of health inequities that exist in the United States. Awareness of the broader contexts that influence health supports respectful, patient-centered care that incorporates lived experiences, optimizes health outcomes, improves communication, and can help reduce health and health care inequities. Social and structural factors account for more than one third of total deaths in the United States in a year, and evidence suggests that addressing social needs of individuals results in improved overall health 7 8 9.
Social and Structural Determinants of Health
Social and structural determinants of health describe environmental conditions, both physical and social, that influence health outcomes. Physical conditions such as lack of access to safe housing, clean drinking water, nutritious food, and safe neighborhoods contribute to poor health. Socio-political conditions such as institutional racism; police violence targeting people of color; gender inequity; discrimination against lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) individuals; poverty; lack of access to quality education and jobs that pay a livable wage; and mass incarceration all shape behavior and biological processes that ultimately influence individuals’ health and the health of communities 5 10 11 12. Such social conditions not only influence individual health but also work to create cycles that perpetuate intergenerational disadvantage.
Social determinants of health have been shown to affect many conditions treated by obstetrician–gynecologists, including but not limited to preterm birth, unintended pregnancy, infertility, cervical cancer, breast cancer, and maternal mortality 13. Obstetrician–gynecologists and other health care providers should seek to understand patients’ health care decision making not simply as patients’ individual-level behavior, which at times may appear foreign or irrational to health care providers, but rather as the result of larger systems that create and maintain inequalities in health and health care. Recognizing the importance of social determinants of health can help obstetrician–gynecologists and other health care providers better understand patients, effectively communicate about health-related conditions and behavior, and improve health outcomes.
The social determinants of health approach also acknowledges intersectionality—the overlapping categories of social identities such as gender, race, class, disability status, and sexual orientation and related structures of oppression and discrimination as they manifest in health care and outcomes. The reproductive justice framework acknowledges this interconnected nature of social and structural forces as they come to bear, in part, on people’s sexual and reproductive health 14. Relatedly, a shared history and daily experiences of discrimination among patients of color might negatively influence their health outcomes and feelings about health care systems 15. For some, this may be expressed as avoiding care, mistrusting health care providers, or not following recommended treatments; this also may be true for LGBTQ patients seeking sexual and reproductive health care 16. Immigration status also is a social and structural determinant of health. For example, an undocumented immigrant may not access health care because of lack of coverage, or may fear deportation if she presents to a health care facility 17 18.
A patient-centered approach to care recognizes the role of such historical and contemporary forces in clinical encounters. For example, a pregnant patient with gestational diabetes who has not checked her blood sugars may be labeled as irresponsible or noncompliant. An approach that recognized the effect of social determinants of health may probe deeper and discover that the patient lacks stable housing and forgets to bring her glucometer each time she moves to another family member’s or friend’s house. Communicating with this patient about the importance of blood sugar control as the only strategy to address glycemic control would be ineffective. Rather, working with social services to address her housing issues would more likely enable her to manage her diabetes.
Another example is a pregnant patient with poor weight gain who is evaluated for medical comorbidities when deeper probing into the etiology reveals she was fired from her job and cannot afford enough food for herself and her two children. Ordering tests or discussing the importance of good nutrition in pregnancy would be meaningless if not accompanied by referrals for food assistance. Another commonly encountered scenario influenced by social determinants of health is the ability of patients to arrive at scheduled appointments on time. Many low-income women rely on often unreliable public transportation and may arrive late to appointments and be forced to reschedule, which creates the impression of nonadherence. Such examples highlight the importance of inquiry into the underlying reasons for these care challenges. In fact, asking about certain social factors can be time-saving in some circumstances and can help to address systematic barriers to health care. This strategy has been shown to reduce clinician burnout, decrease health disparities, and also may reduce health care spending 19.
Most physicians recognize the importance social determinants play in health outcomes. In one survey, 85% of physicians felt that patients’ social needs were as important to address as their medical ones, yet 80% felt they were not confident in addressing them 20. Indeed, addressing the root cause of many of these problems requires wide-reaching, policy-level changes, and most health care settings are generally under-resourced to address the social needs of individual patients. However, tools have been developed to assist clinicians in screening for some conditions, such as food insecurity and housing instability, and to incorporate these questions into electronic medical records 19 21. Including social indicator prompts in physician encounter tools has been shown to increase referrals to social services 19. Providing referrals to housing or food services while patients are in the clinic can improve their health care usage 19. These and other strategies have been described in an approach called “structural competency” 5. This framework recognizes that the way society is structured (for example, through racial, economic, and gender inequalities) influences clinical interactions and health outcomes. Structural competency aims to help clinicians intervene on these upstream contributions to disparate health outcomes, and also to recognize that these structural explanations have limitations and are not comprehensive 5.
Cultural Awareness, Humility, and Sensitivity
In the 1990s, a concerted recognition emerged among health care professionals and educators that patients come from diverse cultural backgrounds that may influence their understanding of health and illness, interactions with health care providers and institutions, and engagement with treatment recommendations 22. This was formalized into the framework of “cultural competence,” which provided health care professionals with tools to address cultural differences in their patient care interactions. It aims, in part, to understand patients’ health-related behaviors as resulting from their cultural beliefs—beliefs that may influence patients’ health care-decision making.
Although this approach has elevated discussions of diversity in health care settings, an over-emphasis on culture frequently conveys stereotyped representations of individuals from various ethnic groups while also overlooking diversity within groups by equating individual beliefs with group beliefs 23. Categorizations like race and class often are reduced to cultural positions, rather than complex political, social, historical, and economic phenomena. Moreover, cultural competency overlooks the cultural dimensions of health care systems and clinicians themselves. It also suggests that we can be “competent” in another person’s culture, when culture itself is not a skill to be mastered. The emphasis on cultural beliefs thus tends to simplify patients’ behavior into simple, individual choices, which impedes a deeper understanding of complex interactions of the social, economic, political, and environmental circumstances of patients’ lives.
Despite the limitations of a cultural competence approach, it is nonetheless critical for health care providers to recognize that both patients and clinicians hold their own set of values stemming from individual life experience and, in some cases, cultural backgrounds. It may be especially helpful, for instance, for a clinician working in a locale with a large population of immigrants from a particular country to learn about cultural specificities of that group, recognize variations within that group, and understand the overlaying general experience of being an immigrant.
Instead of “competence,” which mistakenly implies that culture is a skill that one can master, other ways to recognize that culture matters in certain clinical encounters include cultural humility, cultural awareness, cross-cultural care, and cultural respect 24 25 26. These approaches include the clinician being humble about recognizing the limits of her or his knowledge of a patient’s situation, avoiding generalizing assumptions, being aware of clinicians’ and patients’ biases, ensuring mutual understanding through patient-centered communication, and respectfully asking open-ended questions about patients’ circumstances and values when appropriate 27.
Although attention frequently is focused on reducing health inequities through public health initiatives and state and national policies, obstetrician–gynecologists and other health care providers can have a significant effect by designing their own clinical practice with an awareness of the importance of the key social and structural determinants of health. Even small changes in practice can make a significant difference with minimal financial sacrifices if deliberate planning is done to address these determinants. Some changes to consider include the following:
Screening for Social Determinants of Health—Provide patient-completed intake questionnaires, expanded medical history questions, and integrated electronic medical records prompts. When purchasing or customizing electronic medical records for the office, obstetrician–gynecologists and other health care providers should request structured fields that capture information on social and behavioral determinants 12 21 28 29 Table 1.
Medical–Legal Partnerships—Obstetrician–gynecologist practices that are part of a community health care clinic or network should encourage the facility to establish medical–legal partnerships. This involves colocating legal services in the same site as the clinic, which enables patients to receive assistance with problems such as toxic environmental exposures in their homes, access to stable housing, legal aid for immigration challenges, and other legal matters that directly affect individuals’ health. Medical–legal partnerships are available in many federally funded health care clinics and have been shown to positively affect health outcomes, including adverse pregnancy outcomes such as low birth weight 5 30. Individual obstetrician–gynecologist practices may not be able to have such services on location, but relationships can be developed with existing medical–legal partnerships to provide needed services.
Liaisons with Community-Based Social Needs Programs—Obstetrician–gynecologists and other health care providers should develop partnerships with social workers and local community advocates who provide assistance with basic resources such as food pantries and home utility bills. Patients in need may feel less inhibited from using assistance programs when the obstetrician–gynecologist frames the referral letter to the community assistance program as a prescription, for example, to promote a healthy pregnancy. For more details on methods linking physicians to community social services see the Health Leads website at www.healthleadsusa.org.
Interpreter Services—Language barriers can be partially addressed by having professional interpreters available when the patient’s language is not the clinician’s language (see Committee Opinion No. 587, Effective Patient–Physician Communication. In-person interpretation can enhance interpersonal interactions, but when this is not possible, using a phone service or video interpretation service is a good option with high patient-satisfaction ratings 31.
Transportation and Logistics—Underserved populations often have difficulties obtaining transportation to health care facilities. Therefore, access to public transportation should be considered when planning office locations. In addition, underserved women often must bring family members to an office visit. In order to facilitate attendance at health care appointments, obstetrician–gynecologists and other health care providers should avoid making arbitrary rules that prevent children and other family members from attending office visits.
Social and structural determinants of health affect health outcomes as much as biological and individual level factors. Although cultural competency is advocated to improve patient–health care provider communication with the ultimate goal of reducing racial and ethnic inequities in health outcomes, the model has significant limitations. Obstetrician–gynecologists and other health care providers should be aware of these limitations and, rather than solely explain health inequities by cultural differences, recognize that inequities are largely the result of forces that influence health at a point upstream from individual behavior. By understanding these inequities as manifestations of larger social pathologies, health care providers may begin to address patient needs in a deeper and more effective way. Obstetrician–gynecologists and other health care providers may address social determinants of health by implementing key practices such as employing multilingual staff, ensuring adequate interpreter services, partnering with medical–legal organizations, and engaging with community resources. These small steps can have a significant effect on health outcomes at the individual level and can help reduce health inequities at a population level.
For More Information
The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob-gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/SocialDeterminants.
These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization website, or the content of the resource. The resources may change without notice.