Overcoming Social Determinants in Wound Management

Published evidence on wound management is heavily focused on addressing pathophysiological factors affecting wound healing. Historically, there has been little focus on overcoming patient-related considerations. More recently, attention is being directed towards developing ways clinicians can support patients and help overcome health care disparities in a push to positively affect their ability to achieve better wound healing outcomes. Despite advances and improvements in the health of US citizens, health care disparities remain.

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Defining Health Care Disparity

A health care disparity exists when there is a higher burden of illness or injury experienced by one group when compared to another.¹ Race or ethnicity, gender, gender identity, education, age, disability, and geographic location all have an impact on health care outcomes.¹ Health disparities are often linked to social and economic factors. Gaps in health insurance coverage, restricted access to care, and decreased quality of medical services all are examples of contributing factors. The larger the disparity, the worse the health care outcome.

Inequities in health care exist when there are variations in the distribution of resources based on the geographic location of a population that contribute to the lack of opportunity and lead to the unavoidable differences in health outcomes.² The World Health Organization reports that the highest proportions of the global burden of disease and disability fall on regions that also suffer the most significantly from physician shortages.³

How do we as wound care clinicians bridge these gaps to produce the best healing outcomes? Understanding the contributing factors involved in the development of disparities in health care will help providers to ensure that their practice incorporates patient engagement strategies to minimize inequalities in care. 

How Social Determinants Impact Health

The social and environmental conditions in which people are born, grow, live, work and age account for 80% of health outcomes while only 20% are a result of care delivery.⁴ Socioeconomic status (SES) is one of the most well recorded predictors of health care outcomes. Higher incomes generally allow for the acquisition of health insurance, access to doctors and hospitals, healthy food sources, and exercise programs. Conversely, studies have shown that lower socioeconomic groups are 3–4 times more likely to partake in activities that negatively affect their health outcomes compared to those with higher SES.⁵ Education can significantly impact a patient’s overall health status. A comparative study examined the overall mortality risk in patients with only a high school degree versus those with a college education.⁶ The investigators concluded that having a college degree translated into half the mortality risk and essentially was the equivalent to being 8 years younger.⁶ Higher rates of missed visits and non-adherence have been recorded in patients with diabetes with lower education levels.⁷

Community influences are an integral part of a patient’s health and overall wellbeing. Care is not always equitably provided in all neighborhoods. Access to specialists may be limited in certain areas of the country. Cultural considerations in diverse populations should not be overlooked. Health care barriers in minority populations include a lack of knowledge or understanding of health care screening or treatment options, language barriers, alternative beliefs, lack of culturally appropriate materials, mistrust of the health care system, and generalized fear.⁸ Having a strong social support network has also shown to have an impact on one’s overall health. Socially connected adults have been shown to live longer and healthier lives than their socially secluded peers.⁹

Mortality rates in rural areas of the U.S. have exceeded those in urban areas since the 1980s and the gap continues to widen.¹⁰ U.S. life expectancy has also been found to be lower in rural versus urban areas.¹⁰ Although no one definitive cause of these differences can be pinpointed, it has been suggested that social determinants of health such as income, education, unemployment, insurance coverage, and race/ethnicity are at play.¹⁰ Of note, primary care physician supply has steadily decreased from 2005–2016 in rural areas of the U.S.¹¹ Patients residing in low income environments have been found to exhibit an increased risk for cardiovascular disease, diabetes, cancer, hypertension, and a higher overall mortality.¹² The remainder of this article will focus on ways providers can help patients overcome barriers to care.

Disparities in Access to Care

Roughly two-thirds (65%) of people with annual household incomes of less than $30,000 describe U.S. health care as average or below average.¹³ By comparison, half of Americans earning $100,000 or more say America’s health care is the best in the world.¹³ There is also a gender gap—men (44%) are more likely than women (34%) to say America’s health care is the best in the world or above average.¹³

What is the cause of this disconnect? Perhaps it is due to the large number of Americans lacking a usual source of care (USC). Hispanic individuals have a 66% higher rate of no USC compared to their white counterparts in 2019.¹⁴ In contrast, non-Hispanic Black individuals had a 38% higher rate of no USC compared to their White counterparts in 2019.¹⁴ Additionally, 46% of 18–34-year-olds had no USC in 2019—up from 34% in 2014.¹⁴ Having no USC is particularly detrimental in the at-risk chronic wound patient population. Many of these patients are of advanced age and have multiply comorbid systemic conditions such as diabetes and peripheral arterial disease (PAD). Failure to manage these conditions leads to poor patient outcomes and rises in morbidity and mortality.

Attaining Health Literacy

Health literacy is strongly associated with the patient’s ability to engage in complex disease management and self-care. Patients who are unable to successfully interpret health information have increased hospitalization rates, develop more diseases, and experience higher mortality.¹⁵ Low health literacy is associated with patients who are older, have limited education, lower income, chronic conditions, and those who are non-native English speakers.¹⁵ Approximately 80 million adults in the United States are estimated to have limited or low health literacy.¹⁵

These findings highlight a significant gap of knowledge that health care providers must be aware of in diverse populations and settings. There is a need to develop and implement educational interventions targeted at improving health care literacy. By examining clinical interventions that target different health literacy levels among minorities, providers can have a broader impact on patient self-care and treatment adherence.
 
Figure 1: Tips to achieving better healthcare literacy.

Improving Treatment Adherence

We all know that adherence with wound care therapies contributes to better outcomes. Our patient populations include people of every race, gender, and age—the melting pot of humanity. When patients see themselves in the health care workforce, they have more trust in the system.¹⁶ When there is diversity among care providers, patient communication and understanding is improved.16 In communities that have access to providers of the same ethnicity not only is adherence increased, but patient satisfaction scores are higher.¹⁶

The US spends $0.56 on social services for every $1 spent on health care.¹⁷ On average, other industrialized nations spend about $1.70 on social services for every $1 on health services.¹⁷ It should come as no surprise that the U.S. has an unusual combination of high healthcare spending and less than optimal patient outcomes. The focus should be on rebalancing social and medical spending. The U.S. Centers for Disease Control estimates that health behaviors, medical care, and genes together contribute approximately 50 percent of the influence on population health, while social and environmental characteristics contribute the remaining 50 percent.¹⁶ Developing programs that can support our patients’ health and wellbeing through improving their living environment and lifestyle habits will go a long way.

Additionally, partnering with existing social services is key. Many health plans have case workers to help patients navigate the system. It has been my experience that social workers and case managers can help to decrease barriers to specialists and wound care supplies, even can advise on decreasing medical debt. Linking these services to our clinics/practices will help improve care coordination.

Embracing Lifestyle Medicine

Lifestyle medicine is a subspecialty that incorporates therapeutic lifestyle interventions as a method of treating chronic conditions. Practitioners take an evidence-based, whole person approach to lifestyle changes to help to reverse many clinical conditions. Using food as medicine is an essential component of lifestyle medicine programs. Eating nutritious food can support a longer, healthier life, and improve wound healing, but for many people, accessing healthy food can be a challenge.

The result is the creation of food deserts throughout the U.S. Food deserts are geo­graph­ic areas where res­i­dents have few to no con­ve­nient options for secur­ing afford­able and healthy foods. Many residents will rely on fast food, instead of fresh fruits and veg­eta­bles. A dis­pro­por­tion­ate­ly large number of food deserts are found in high-pover­ty areas. Food deserts create another hurdle for patients with limited means to live a healthy lifestyle.

Programs like the one provided by Geisinger, a health and wellness organization in Pennsylvania, give patients access to a Fresh Food Farmacy.¹⁸ By providing patients (and their household) with enough food to make 10 nutritious meals each week they are helping them manage these conditions and start their journey toward better health.¹⁸ The result have been indisputable. Patients enrolled in the program have lower A1c levels, fewer ER visits, fewer hospital admissions, and engage in more preventative care.¹⁸

In Conclusion

With the recent shift towards payment for performance incentives, the impetus is on improving the quality of care to reduce costs. The utilization of health care services is often disjointed in areas where health care disparities persist thus resulting in inefficiency and poor outcomes. Awareness of health care disparities and implementing key principles discussed in this presentation will allow for clinicians to make mindfully adjusts to the care they are providing. Considerations of race, ethnicity, socioeconomic status, religious beliefs and other factors will produce the best care plans for a diverse population. Chronic wounds have a significant impact on quality of life and are a drain on the health care system and the number of patients suffering with chronic wounds is increasing. Implementing these strategies can help health care providers make the best use of resources to produce the greatest long-term results for each patient in need.

Windy Cole, DPM, has practiced in Northeast Ohio for over 22 years. She is an Adjunct Professor and Director of Wound Care Research at Kent State University College of Podiatric Medicine. She is board certified by the American Board of Foot and Ankle Surgery and the American Board of Wound Management. Cole is a member of the American College of Clinical Wound Specialists Board of Directors. Additionally, she holds multiple advisory and editorial positions with various medical and wound care publications, and sits on the advisory board of multiple emerging biotech companies and has been integral in collaborating on innovative research protocols in the space.

A version of this article originally appeared in the August 2022 issue of Podiatry Today.

References
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