A Deep Dive for Pharmacists on Social Determinants of Health

Social Determinants of Health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.¹

During his session at the American Pharmacists Association 2022 Annual Meeting & Exposition, Nimit Jindal, PharmD, health and labor legislative assistant to Congressman Joseph Morelle (D) of New York, gave attendees a “deep dive” on SDOH.²

Jindal pointed to 4 barriers that can prevent patients from achieving physical and mental wellness. These barriers include:

A lack of education, which can mean that a patient doesn’t fully understand the care plan they receive in their provider’s office, and that can result in a poor clinical outcome. A 2020 study found that a college-level education, in particular, can influence infant mortality, life expectancy, and child vaccination rates.³

Housing instability, which can translate to a patient not having a refrigerator to store medications. A 2021 study found that emergency room visits were cut in half among children without access to stable housing in Boston when families were given access to housing counselors and, in some cases, rent subsidies.⁴

Insufficient income, which may mean that a patient can’t afford health insurance, medication, or a healthcare procedure. Uninsured people with diabetes are more likely to be using less costly and less effective insulin, per a 2020 Commonwealth Fund study; these patients are also more likely to pay full price than patients who have private insurance or Medicaid.⁵

A lack of access to clean air and water. Disinfection of drinking water has reduced the prevalence of waterborne diseases such as typhoid, cholera, and hepatitis.⁶ Air pollution is responsible for more than 6 million premature deaths annually as a result of heart attacks, respiratory diseases, and strokes.⁷

To drive home his point about the impact of SDOH on clinical outcomes for patients, Jindal recalled a common scenario he faced when consulting with patients who have type 2 diabetes, many of whom also have other chronic conditions. After reconciling a patient’s medications and reviewing their labs, Jindal often made 2 discoveries: first, that the patient’s type 2 diabetes wasn’t well controlled and second, that they were typically taking multiple medications to treat the same conditions. And, many of these patients were underdosing their insulin to stretch out their supply. That’s in addition to avoiding dentist appointments because saving money for food and rent was a higher priority, Jindal explained.

Patients with type 1 and type 2 diabetes are more likely to experience tooth decay, early gum disease, and advanced gum disease, according to the Mayo Clinic, which recommends twice-yearly visits with the dentist for professional cleanings, X-rays, and checkups.⁸

“As [a] pharmacist, you’re always trained to zero in on the medication pieces, because those are the pieces you can control,” said Jindal. “You can provide education on how to use the medication, you can contact the doctors to make sure that they’re on the right medication if they’re on something that’s duplicative.”

But that conversation can come to a sudden halt when advising a patient on lifestyle and dietary changes, only to be told by a patient, “I can’t afford it. The only thing that I can afford is the fast-food item on the dollar menu at McDonald’s,” said Jindal.

With no real follow-up conversation and no referral network, the conversation typically stops there. What’s missing is the pharmacist’s understanding about the context of that patient’s daily life, he said.

Jindall’s advice requires pharmacists to serve as advocates. This advocacy work can include:

Finding the disparities, or, he said, “the things that we can and can’t control.” Focus on inequities that are systemic, avoidable, and can be targeted directly.

Developing and advocate for policy changes that will have long-term impacts.

Building partnerships and coalitions to identify structures and policies that allow for some of these inequities, “getting at the root of the problem,” said Jindal.

Working with patients and communities to help build solutions to these problems.

Constantly reassessing community needs and use leadership to reflect on any changes and internal biases.

Pharmacy deserts are another issue. Jindal pointed to 2015 data showing that 26.7% of White and 28.2% percent of ethnically diverse communities are pharmacy deserts, compared with 38.5% of Black communities and 39.5% Latino communities.⁹

“We’ve already seen, just in sheer access to a pharmacy and all of the great services that clinical community pharmacies are able to provide, that there’s a disparity there,” said Jindal, who argued that there’s more that policy makers and the pharmacist profession can do to address the gap.

References

1. Raghupathi V, Raghupathi W. The influence of education on health: an empirical assessment of OECD countries for the period 1995–2015. Arch Public Health. 2020;78, 20. doi:10.1186/s13690-020-00402-5
2. Jindal N. Legislation and policies: How can we advocate for more equitable healthcare. Presented at: American Pharmaicsts Association 2022 Annual Meeting & Exposition; March 18-21, 2022; San Antonio, TX.
3. Health starts at home: Evaluation final report. The Boston Foundation. June 2021. Accessed April 6, 2022. https://www.tbf.org/-/media/tbf/reports-and-covers/2021/hsah-may-2021-report527_v4.pdf.
4. Glied SA, Zhu B. Not so sweet: Insulin affordability over time. The Commonwealth Fund. Published September 25, 2020. Accessed April 6, 2022. https://www.commonwealthfund.org/publications/issue-briefs/2020/sep/not-so-sweet-insulin-affordability-over-time
5. Drinking water. United States Environmental Protection Agency. Accessed April 6, 2022. https://www.epa.gov/report-environment/drinking-water
6. Health impacts of air pollution. Environmental Defense Fund. Accessed April 6, 2022. https://www.edf.org/health/health-impacts-air-pollution
7. Diabetes and dental care: Guide to a healthy mouth. Mayo Clinic. Published November 3, 2020. Accessed April 6, 2022. https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes/art-20043848
8. Guadamuz JS, Wilder JR, Mouslim MC, Zenk SN, Alexander GC, Qato DM. Fewer pharmacies in Black and Hispanic/Latino neighborhoods compared with White or diverse neighborhoods, 2007-15. Health Aff. 2021;40(5):802-811. doi: 10.1377/hlthaff.2020.01699