58 Insights Vol. 7

7Visual Insights

on Social Determinants

Insights Vol. 7 59

Examining health through a di!erent lens helps to uncover bigger, underlying social issues that can’t be solved by the latest app or device alone. This visual exploration helps us to “see the forest for the trees” as it relates to health in the Metro Washington D.C. area.

S t o ry & P h o t o s By T e d E y ta n , M D

We are relying too much on modifying a person’s individual choices to improve health.

The social determinants of health can loosely be de!ned as how the circumstances in which people develop and live affect their mental and physical well-being and life expectancy, and have been characterized as the causes of the causes of health (or ill health)1

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Seven Visual Insights on Social Determinants

1Many citizens,few health professionals

If you look visually at a health system, like this example based on Kaiser Permanente, you can see that we are out-personned. There aren’t enough people working in health care to reach every person we serve to guide their daily choices. People and organizations outside of health care are needed.

9.0 Million Patient Members

0.18 Million Staff

0.05 Million Nurses

The Actions of a relativley small staff/Nurse/Physician groupÉ�����bbY�½��Fb�8����obY�½}²�Âu}���Y�È�YÂ8�V�O8²b�Yb��Èb²ËV�and population approaches.

0.017 Million MDs

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Seven Visual Insights on Social Determinants

2What we are

working to improve,

should matter to people.

People aren’t hoping that we’ll improve their health care experience; they are hoping that we improve their ability to live a long healthy life.

The groundbreaking Marmot Review in 2010 depicted big differences in life expectancy and disability-free life expectancy among the best-off and worst-off neighborhoods in England.

The graph above (licensed under the Open Government License v1.0)2 is full of information that shows that people who are socially deprived will not (a) get to a certain age and (b) if they get to that age, are unlikely to get there without a disability.

We don’t usually measure this in United States health care today.

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Seven Visual Insights on Social Determinants

3 Use images, not words

The difference between the most healthy and the least healthy people describes the health inequality in a population. Society is better off when there is a smaller difference in this range. We can show the spread via the disability-free life expectancy metric, using smooth bars. Their height is equal to the disparity between the healthiest and the least healthy. The gray bar shows the spread for or own staff – their health inequality matters, too. And images are the most powerful way to demonstrate this.

# OF PEOPLE

LEASTHEALTHY

MOSTHEALTHY

patients staff

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Seven Visual Insights on Social Determinants

INTERVENTIONS

# OF PEOPLE # OF PEOPLE

LEASTHEALTHY

MOSTHEALTHY

LEASTHEALTHY

MOSTHEALTHY

patients staff

patients staff

# OF PEOPLE # OF PEOPLE

LEASTHEALTHY

MOSTHEALTHY

LEASTHEALTHY

MOSTHEALTHY

INTERVENTIONS

patients staff

patients

staff

4Two alternate futures

There are two alternate futures. The future we want is the one where everyone is healthier. There is less of a disparity between the most healthy and the least healthy. Our staff shows even greater health gains, leading our members.

The future that scares us is the one where the most advantaged are much healthier, the least advantaged are only a little healthier, and our staff is no healthier than the people they are serving.

The Future We Want

The Future That Scares us

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Seven Visual Insights on Social Determinants

5A total health approach

“These serious health inequalities do not arise by chance, and they cannot be attributed simply to genetic makeup, ‘bad’, unhealthy behaviour, or difficulties in access to medical care, important as those factors may be.”2

This image describes the interventions that are focused on individual choices – this could be a calorie counting app or a game that promotes competition among friends. If 100% of our effort is applied to these interventions, we won’t reduce health disparities.

On the other hand, a Total Health approach, based on the social ecological model !rst advanced nearly 30 years ago, addresses the family, community, and societal environment that shapes individual behavior choices. There’s some investment at every level, as the image below depicts.

emphasison

individual

Individual & Family

Home, School & Work

Neighborhood & Community

Society

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Seven Visual Insights on Social Determinants

6The tomorrow we

want

Using the visual thinking approach, this is the one image that includes the Who/What and How of behavior change and social determinants to improve health.

If we spend the right amount of time at the individual level as well as the societal level, people at all levels of the health gradient will improve their health, and the gap between them will decrease. We will model the improvement in our own workforce.

# OF PEOPLE # OF PEOPLE

LEASTHEALTHY

MOSTHEALTHY

LEASTHEALTHY

MOSTHEALTHY

Individual & Family

Home, School & Work

Neighborhood & Community

Society

TotalHealth

Approach

TODAY: 2013 TOMORROW: 2020

patients staff

patients

staff

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Seven Visual Insights on Social Determinants

7The tomorrow we don’t want

If we invest poorly, and do what seems easiest, we’ll get the outcome we don’t want. The most advantaged, who didn’t need as much help in the !rst place, will get healthier. The least advantaged may or may not get healthier. Our workforce will not achieve greater health gains. Our costs, and more importantly their costs (money, time, lives) will not be manageable. That will make all of us unhappy.

# OF PEOPLE # OF PEOPLE

LEASTHEALTHY

MOSTHEALTHY

LEASTHEALTHY

MOSTHEALTHY

emphasison

individual

TODAY: 2013 TOMORROW: 2020

patients staff

patients staff

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Seven Visual Insights on Social Determinants

Visualization of crime in Washington, DC, with the biggest cutouts being homicide, the smallest assault.

Ted Eytan, MDPhysician Dir., Center for Total Health Kaiser PermanenteWashington D.C., USA

However, we are not trying to !x an image. We’re trying to !x real social problems like obesity and crime represented in the images to the right (data and images from present day, Washington, DC, USA)

We need to understand the role of health care in improving health; we cannot do it alone We need to have a measurable goal in mind – not just pounds lost or blood pressure lowered, but longer, healthier life, and less inequality between the most healthy and the least healthy

When we talk about innovating in health, we need to think beyond individual interventions – this is in the scope of health care and a health care Innovation Learning Network.

The ambition is to create the conditions for people to take control over their own lives. If the conditions of daily life are favourable, and more equitably distributed, then they will have more control over their lives in ways that will in"uence their and their families’ health and health behaviours.2

1. Royal College of Physicians, How doctors can close the gap: Tackling the social determinants of health through culture change, advocacy and education. 2010.

2. Marmot M. The Marmot Review: Strategic Review of Health Inequalities in England post-2010.

3. Garner T, Trombatore D, Raza U. Obesity in the District of Columbia. Washington, DC; 2010.

4. Eytan, T. Quanti!ed Community: Visualizing the Health and Illness of Washington DC Through Open Data and Art. www.tedeytan.com. 2012

References