How will healthcare organizations help achieve health and well being for a population? (Population Health, Social Determinants, Public Policy)

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Health Promotion through Collaboration
Kelly Klarich
St. Mary’s University of Minnesota
Schools of Graduate & Professional Programs
In partial fulfillment of the requirements for
HS698 Capstone
Jerry Lovrien, MHA
January 8, 2016

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Table of Contents
Chapter One: Introduction..........................................................................................................3
Purpose ..........................................................................................................................3
Significance....................................................................................................................3
Scope...............................................................................................................................6
Terms..............................................................................................................................7
Chapter Two: Literature Review................................................................................................8
Health Indicators.............................................................................................................8
Critical Influences/Social determinants of Health..........................................................9
........................................................................................................................................
Partnerships.....................................................................................................................12
Healthcare Organizations & Policies..............................................................................13
Chapter Three: Conclusion.........................................................................................................15
Recommendations...........................................................................................................15
........................................................................................................................................
Lessons Learned.............................................................................................................17
........................................................................................................................................
Further Research.............................................................................................................18
Summary.........................................................................................................................19
References...................................................................................................................................20

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Health Promotion
Chapter One: Introduction
Purpose
Healthcare can only go so far in controlling the health of a patient or population due to
social, economic, environmental and behavioral determinants such as economic stability,
education, food sources, environmental impacts and the individual choices people make with
respect to their health. As a result of these influences not in the control of the healthcare system
is it realistic to think that healthcare organizations can impact the over-all health of a population
group on their own? The purpose of this paper is to examine the social determinants impacting
the health of individuals not easily controlled by a healthcare organization and develop
recommendations for ways to improve the health of American’s collaboratively with other
partners.
Significance
According to the Center for Medicare & Medicaid Services (CMS) “ U.S. spending for
healthcare rose nearly 3.6 percent, reaching $2.9 trillion or $9,255 per person in 2013” (Centers
for Disease Control and Prevention. 2015a. para.2). The U.S. compared to all other countries
spends a larger percent of its gross domestic product (GDP) on healthcare (Yesalis, 2012, p 3).
According to the Commonwealth Fund the U.S. spent 17.1 percent of its GDP on healthcare
spending, and was the only country studied which spent more on healthcare spending than social
service spending (Squires and Anderson, 2015). Figure 1 below demonstrates the healthcare
spending in comparison to social spending as compared to eleven countries. American’s were
also noted for having the highest out-of-pocket expenses, with a quarter of individuals

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experiencing cost-related health care access issues (Morrison, 2015). Although, American’s are
spending more on healthcare the Commonwealth Fund cited the U.S. as underperforming in
many health measures such as cost, quality, value, and consumer responsiveness compared to
those same eleven countries (Morrison, 2015, para.7).
Figure 1 Health and Social Care Spending as a Percentage of GDP (Squires and Anderson,
2015). Adapted from “U. S. Health Care from a Global Perspective: Spending, Use of Services,
Prices, and Health in 13 Countries” by Squires, D., Anderson, C. 2015. The Commonwealth
Fund. October 2015. Copyright 2015 by The Commonwealth Fund.
For decades there have been many initiatives implemented with a goal of improving the
overall health of individuals and reducing healthcare costs, most geared directly at curing
individuals from disease once they become sick and most driven by healthcare organizations or
third party payers. Many of the efforts associated to reducing costs are directly passed along to
healthcare providers and patients holding them accountable to reduce spending and absorb costs,

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while also holding providers responsible to increase quality with little impact of improving the
health of the overall population if the other determinants of health are not improved as well.
Healthy People 2020 recently high-lighted the importance of health starting in homes,
schools, workplaces, neighborhoods, and communities, and that to truly impact the over-all
health of an individual there must be a shared responsibility, one that takes into account all
determinants of health to include social determinants (2015, para.1 & 2). It seems as though a
stronger call to action by healthcare leaders and leaders in other governmental and social sectors
focusing on increasing the national spending allocated to population wide approaches to
improving health from 5 percent to a more proportional rate with the 95 percent spent on medical
care will have the greatest impact to the overall health of a population (McGinnis, Williams, and
Knickman, 2002, p.78).
As health systems navigate the changing landscape, so too are pediatric healthcare
leaders interested in how best to prevent the onset of illness by investing in the right programs to
address the determinants of health. As a pediatric healthcare leader I am particularly interested in
the work the Children’s Association is doing to support the health paradigm shift and to better
understand the overall landscape. In the fall of 2014 the Children’s Hospital Association began
collaborating with other industry leaders to define the impacts of health determinants on the
pediatric population. Figure 2 illustrates the associations break down by percentage by
determinants of health for the pediatric population.

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Figure 2 Determinants of Health (Children’s Hospital Association, 2015). Adapted from
Children’s Hospital Association. (2015, March 15). Creating Health. Retrieved from
https://www.childrenshospitals.org/issues-and-advocacy/population-health/fact-sheets/childrens-
hospitals-creating-health
Scope
As a result of the limited research on the impact of social determinants of health for the
pediatric population the scope of this research will be focused on obtaining a better
understanding of the social, environmental and behavioral determinants of health to inform
leaders of the most effective approaches to improving the overall health of a population by
identifying health indicators, understanding the social determinants, critical health influences,
structures, methods and approaches to achieving health promotion through partnerships,
collaborations, and policies.
As healthcare leaders we have an obligation to take an active role in health promotion
and are well positioned with the necessary skills and knowledge of health behaviors, genetic

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make-up, and designing medical health-directed approaches to influence social determinants of
health, we just need to know where to focus our limited resources to achieve the greatest impact.
Terms
Health promotion. The term Healthy People defined as “any combination of health
education and related organizational, political, and economic interventions designed to facilitate
behavioral and environmental changes conducive to health” (Koh et al., 2011).
Social determinants. Conditions in the environment that impact health, functioning, and
quality of life outcomes and risks (Healthy People, 2015).
Health determinants. Factors that influence an individual and a population’s health (Shi
& Singh, 2013, p.34).
Structural approaches. “Modifications to the physical, social, political, and economic
environment in which people make health-related decisions” (Lieberman, Golden, and
Earp, 2013).
Health disparities. The Health Services Research Information Center defines health
disparities as “differences in access to or availability of facilities and services” (HSRIC,
2014).

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Chapter Two: Literature Review
The evidence is mounting on the impact of social circumstances and determinants.
Inequalities have clearly been identified as health risks as have other critical influencers. “The
WHO Commission on Social Determinants of Health claims the vast majority of inequalities in
health are avoidable (2015b, p.4).” WHO also noted the importance of family affluences as an
important predictor of health.
If leaders are to impact overall population health, understanding the impacts of social
determinants impacting society’s ability to make good choices is a good place to start.
Understanding the determinants that impact health can better position leaders to make
appropriate changes in policies and spending to have the greatest impact on health promotion
while reducing or redistributing government spending. This chapter will explore indictors of
health, critical influences of health, social determinants, structural approaches to health,
partnerships, healthcare organizations ability to influence change, and examples of how policies
can improve the overall health of a population.
Health Indicators
Using the medical model an indicator of health is the absence of illness or disease (Shi &
Singh, 2013, p. 30). The Society for Academic Emergency Medicine (SAEM) indicates health as
“a state of physical and mental well-being that facilitates the achievement of individual and
societal goals (Shi & Singh, 2013, p. 30). Recent scientific evidence suggests that an individual’s
health is an outcome resulting from various health determinants. The determinants or factors
impacting the health of an individual or population are comprised of genetic make-up, individual
behaviors, medical practice, social, economic, and environmental factors based on the choices
that people make in response to options they have (Koh, Peotrowski, Jumanyika, Fielding, 2011,

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p. 552 & Shi & Singh, 2013, p.34 & McGinnis et al., 2002, p. 78). The choices people make can
be impacted significantly by social economics restricting an individual’s options. Health is
influenced by multiple factors. Understanding the impact or influence of social determinants on
an individual’s health can help guide leaders and help with planning and priorities of healthy
initiatives.
Critical Influences/Social determinants of Health
As indicated above there are many influences that impact the health of individuals. This
report is focused primarily on those social circumstances or determinants that impact health.
Education, employment, income disparities, poverty, housing, crime, and social cohesion are all
very powerful influences in health with the most consistent predictor being cited as the level of
education (McGinnis et al., 2002, p. 80). Gender, ethnicity, age, and disability are also social
differences which can impact health of individuals (WHO, 2015b, p.5).
According to Healthy People, social determinants are conditions in the environment that
impact health, functioning, and quality of life outcomes and risks (2015, para. 4). Social
determinants are further broken down into three sub-types, social, economic, and physical
(Healthy People, 2015, para. 4). Examples of social determinants include safe and affordable
housing, access to education, public safety, healthy foods, emergency and health services, and
toxin-free environments (Healthy People, 2015, para. 5).
The scope, design, implementation and effectiveness of structural approaches to
improving people’s health by keeping them free from disease and chronic conditions which
require healthcare services requires intervention in the physical, social, political, and economic
environment and requires decision making of individuals in an effort to provide these structural
changes (Lieberman, Golden, and Earp, 2013, p. 520). Below are examples of a few influences

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and social determinants that can impact the health of individuals and some specific examples of
conditions these social determinants have on the population.
Education and poverty level. According to the National Center for Health Statistics,
individuals with higher levels of education have death rates 2.5 times lower than persons with
lower education levels as they are more likely to seek healthcare services sooner and are more
likely to take preventative measures in an effort to keep from getting sick such as becoming
vaccinated (1998). Individuals who live in poverty are 6 percent more likely to have a higher
mortality rate than those individuals who do not do to the inability to obtain healthcare, seek
preventative services, purchase necessary prescriptions, become vaccinated or eat healthy
(McGinnis et al., 2002, p. 80). “In general, cost may restrict families from adopting healthy
behaviors such as eating fruit and vegetables and participating in fee-based physical activities
causing inadequate access to health resources and leading to obesity, which is associated to co-
morbidities such as cardiovascular disease such as heart attacks and diabetes (Curie, et al., 2012,
p.6). The lack of distribution of wealth or socioeconomics creates health inequalities which may
be causing poorer health in the most vulnerable populations influencing their ability to achieve
optimal health and quality of life associated to healthy living.
Physical environment. The physical environment such as the places we live and work
also can impact an individual’s health status. A lack of grocery stores with healthy food choices
in low-income neighborhoods and pricing on healthy food options can be linked to obesity and
associated diseases. Toxic agents such as lead in paint, smoke, etc, found in the environment and
in the food and water supplies can have a profound impact on mortality and morbidity rates,
particularly cardiovascular, pulmonary disease, and cancers and blood disorders. According to
the Johnson, Hayes, Brown, Hoo, & Ethier, lung cancer was the leading cause of cancer deaths,

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accounting for 27% of all cancer deaths in 2011 and can be attributed to behavioral risks and or
environmental factors related to tobacco smoke (2014, p.8). Foodborne illnesses such as
Salmonella and E.coli have also increased during the past three years to a rate of 1.15 cases per
100,000 individuals impacting the health of individuals (Johnson et al., 2014, p.4).
Housing and crime. Having safe neighborhoods where people can be active and free
from harm can greatly reduce the likelihood of obesity, which according to the World Health
Organization (2014a) “Childhood obesity is one of the most serious public health challenges of
the 21st
century” (para. 1). Estimates indicate the frequency of obese children has increased two
to five times in developed countries and up to four times in developing countries between 1980
and 1990 (Flynn et al., 2006, para. 1). “Obesity is a major contributor to cardiovascular disease,
diabetes, and several types of cancer (Frieden et al., 2010, p.357; CDC, 2014c).
Although many factors shape an individual’s health, 40 percent of deaths are caused by
behavioral patterns that could be modified by preventative interventions if health equalities could
be managed (McGinnis et al., 2002, p. 78). Behavioral patterns such as dietary and physical
activity leading to obesity, unprotected sexual intercourse leading to disease, and substance
abuse such as tobacco usage results in nearly 900,000 deaths in the U.S. each year, resulting in
the single biggest influencer of health across all determinants (McGinnis et al., 2002, p. 80).
While behavioral patterns have been identified as a major impact to health, the focus of this
report is on the social determinants impacting health status, which may also have an impact on
the choices individuals make impacting their overall health. Understanding how and where all of
these determinants of health intersect to impact the overall health of the population will require
advances through partnerships from all sectors.

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Partnerships
Many recent health initiatives were defined and executed as a result of coordinated
efforts at the federal level through partnerships with governmental, public health, private and
other health and human service networks through a Healthy People initiative who’s focus was to
“promote a stronger legacy for a healthier nation” by promoting a shared societal responsibility
for change (Koh, Peotrowski, Jumanyika, Fielding, 2011). Structural approaches such as policy
changes, price modifications, redesign of community environments, changing social norms
through resource redistribution and empowering individuals and communities to make healthier
choices are not new to public health but are grounded in social and health behaviors and will
require data, resources, and education across all spectrums of the social, environmental, and
political structures to improve the health of the population (Lieberman et. al., 2013). Healthcare
organizations and leaders have a role to play in becoming stronger partners in influencing
changes that impact the social determinants of health.
Healthcare Organizations
As leaders of healthcare organizations the goal of improving the overall health of the
population seems somewhat of a daunting task. Healthcare organization’s strategy efforts have
historically focused on advances in technology and evidence-based care related to treating sick
patients. A shift in the paradigm has given-way to new responsibilities for healthcare
organizations. A stronger concentration on health-directed structural initiatives impacting
particular health issues and changes in the environment, in an effort to reduce the social
determinants associated to health risk, have entered the strategic plans for health organizations.
Finding ways to educate others on the health risks associated to environmental factors such as
smoke-free environments, bike lanes, restrictions on sugar-sweetened beverages, expanded

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insurance coverage on preventative screening, and implementing “opt-out” testing to drive
increased compliance could have a profound effect on changing health behaviors and outcomes
(Lieberman et. al., 2013). Healthcare organizations are starting to adopt new ways to partner with
organizations to provide exercise memberships to their own employees and are promoting other
organizations to do so as well to promote a healthy living style. Pediatric organizations in
collaboration with community partners, schools, and others have started to educate parents and
children on the importance of the 5-2-1-0 tool as a way to bring awareness to nutrition and
physical activity to reduce the likelihood of diseases later in life as a result of obesity and
improper eating. The tools suggests eating five fruits and vegetables or more, cutting screen time
to two hours or less a day, participating in at least one hour of moderate physical activity and
restricting sugary beverage intake to zero (Foundation for Healthy Communities, 2015).
The value of the data collected at healthcare organizations to improve care across the care
continuum can facilitate the creation of health equality policies and can help in identification of
access and quality issues related to social determinants of health (Shi & Singh, 2013, p.46).
Interoperability of data to ensure information crosses the care continuum and is shared with
federal and state data repositories or databases is vital to the cross-functional partnerships of the
Healthy People initiative and other organizations focused on the social, environmental, and
behavioral determinants of health.

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Health Policies
The data collected from public health and healthcare organizations is just one of many
tools and efforts in place to help leaders think more broadly about public and community health
policies. According to the CDC, The ATSDR Brownfield/Land Reuse Action Model is a great
tool for community leaders aimed at encouraging people at the local level to design their
communities with health, community, land and environment, and buildings and infrastructure in
mind to promote wellness and improved access, to increased health benefits (2015b). The CDC
also maintains a chronic disease policy tracking database to inform lawmakers from each state of
policies related to chronic disease prevention and health promotion, many of which were
developed to improve access to healthy food choices, improving physical activity and public
transportation (2015b).

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The Health in All Policies collaborative is another resource that has taken an active role
in integrating and articulating health considerations across various sectors into policies. The
collaboration is designed to help identify gaps in achieving health equity and provides ways to
achieve the National Prevention Strategy and Healthy People 2020 goals by creating a call to
action across the country (2015b). These examples are just a few of the many resources being
developed at the federal and state level to help influencers and lawmakers improve the number of
Americans who are healthy through efforts to increase healthy and safe community
environments, eliminate health disparities, empower individuals, and build preventative medical
and community services to promote health. Policies aimed at creating a tobacco free
environment, preventing drug abuse and excessive alcohol use, eating healthy and creating an
active living style, improving mental and emotional well-being, reducing sexually transmitted
disease and creating safe environments will all help reduce the social determinants impacting the
overall population’s health.
Summary
This chapter explored the indictors of health, critical influences and social determinants,
structural approaches, partnerships, healthcare organizations role in influencing change, and
examples of how policies can improve the overall health of a population. Chapter three will
focus on recommendations for healthcare leaders and others related to impacting social
determinants of population health.
Chapter Three: Recommendations
Tackling the increasingly high cost of health care without regard to social, environmental,
and behavioral changes seems a little overwhelming and more than healthcare organizations can
accomplish without partnerships and collaboration with public health, government officials, large

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corporations, local communities and individuals, as it requires changing American’s social
values. Educating American’s on the importance of changing social inequalities impacting health
and influencing individual health behaviors is essential and will require changing where tax
dollars are spent and may be difficult to accomplish, as elected government officials and strong
lobbyist by big agencies such as tobacco companies and other strongly funded special interest
groups may not always place the health of society before individual agendas, and individuals
require health literacy and increased access to services in order to change their behaviors.
According to Koh, The U.S. needs to broaden healthier public policies and private sector
practices outside the public health domain, similar to recent policy changes such as the smoke-
free community buildings change in an effort to reduce chronic cardiovascular and pulmonary
diseases (2011). Koh also recommended establishing new collaborations between healthcare
organizations, education, transportation, community design, food and agriculture, housing, and
social services similar to the Healthy People 2020 collaboration (2011). In partnership with
health leaders, these groups can provide health education geared towards changes to the physical,
social, political, and economic environments to improve health. They can also help create a
stronger emphasis and focus on preventative interventions related to behavioral patterns in an
effort to influence the choices individuals make, while shifting individual habits and social
norms. “Our environments cultivate our communities, and our communities nurture our health
(Ramirez, Baker, Metzler, 2008).” Figure 3 illustrates the impact of social determinants and
inequities on our health.

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Figure 3 Growing Communities: Social Determinants, Behavior, and Health (Ramirez, Baker,
Metzler, 2008). Adapted from “Promoting Health Equity” by Ramirez, Baker, Metzler, Atlanta:
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention,
2008.
Collectively, the data gathered by healthcare organizations and public health agencies can
be used to study the impact of social, environmental, and behavioral changes and can be used to
help educate local and federal government officials on the adoption of new policy changes to
food environments, like reducing the costs of healthy food choices namely fruits and vegetables
and shifting those costs to non-healthy food choices such as taxing sugary drinks and junk food
which could have a positive impact on consumer choices and improve nutrition while reducing
the impact on obesity (Frieden et al., 2010, p.357).
Lessons Learned

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Healthcare and public health organizations, government officials, and other corporate
sectors have begun to realize that shifting the health paradigm might be better served by
investing more time and resources on social, environmental and behavioral determinants rather
than on controlling healthcare spending as roughly 80% of the overall health of an individual is a
result of non-healthcare determinants (Magnan et al., 2012). Figure 4 below illustrates the
breakdown of population health by social determinants. This new realization is a result of
improved data and research. Through initiatives such as the Healthy People 2020, researchers
have determined that behavioral modifications may be the single most effective way to improve
health and reduce healthcare spending, even greater than focusing on social determinants.
Figure 4 Social Determinants of Health (Magnan et al., 2012). Adapted from Achieving
Accountability for Health and Health Care. Retrieved from Accountable-Health-Communities-
White-Paper.pdf
Making environmental modifications like placing fruits and vegetables rather than
candies and sweets by check out registers in stores, and cafeterias and eliminating sugary drinks

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in vending machines in schools and family-centered businesses could significantly change
individual choices and empower them to make good decisions. Raising taxes on junk food,
alcoholic beverages and soda and shifting the dollars to making healthy food more affordable
and available to vulnerable populations will promote healthy behaviors. People want to make
good choices but unfortunately do to social injustices are unable to make healthy choices.
Healthcare organizations can actively influence and educate policy makers by providing
health related information on the impact of social determinants to health indicators. Health
leaders may have little control over structural changes such as vending machine modifications or
income redistribution but may be able through education to help policy makers understand the
impacts of policies on health promotion efforts and the causes of chronic disease as it relates to
social, environmental, and behavioral determinants. The role of healthcare organizations today
can and should be focused on health literacy, health prevention, policy advocacy for vulnerable
populations, community involvement in an effort to better understand the barriers to healthy
living, and improvement of access to health services and education.
Further Research
As a pediatric healthcare leader my concern is the limited studies specific to the pediatric
population and the effects of social and behavioral influences on the long-term health of our
youth population. The choices we make as individuals are learned at a very young age, as are our
social values. Why hasn’t a stronger emphasis been placed on education and funding to support
additional research and programs geared at changing behavioral choices and improving access to
healthy food choices and physical activity for people in our most vulnerable populations?
Secondly, the studies researched have failed to provide adequate criteria or tools for measuring
the exact cause and effect related to each change making it very difficult to really understand

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what one effort had the largest impact on improving the overall health of the population. This
inability to identify which change had the greatest impact may result in excess spending in an
area that had little impact.
Summary
The health of an individual or population is determined by a person’s physical, mental,
and social well-being, not just the absence of being free from disease. To examine improve the
health of an individual or population requires more than just looking at the medical determinants
impacting health. The goal of this research and better understand the social determinants
impacting the health of individuals not easily controlled by a healthcare organization and
develop recommendations for ways to improve the health of American’s collaboratively with
other partners. As healthcare leaders our role is to inform, motivate and partner with community
leaders, public, private, and governmental agencies to promote healthy living by advancing
policies and spending on complex social, environmental, and behavioral forces impacting health
promotion. We, as healthcare leaders have an important role to play in collecting and sharing
data, influencing decision makers, partnering with communities, schools, and businesses to
improve health literacy, expanding access to quality medical care, controlling costs, and
empowering individuals to adopt healthy behaviors. Understanding the determinants that impact
health and collaborating with others is essential in establishing a healthier population.

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