Increasing the odds with Social Determinants
We are constantly influenced by others and our situations, and it is our evolving uniqueness that makes life both exciting and complex. If you saw my iPhone, you would know I am not interested in the latest tech, but I don’t want to be left too far behind in an increasingly digitized world.
This individuality is a challenge for those creating solutions targeting the greatest number of people. Apple probably has a sticky note and matrix that lumps me with other customers by what “too far” means and what convinces us to want an upgrade. In the medical space, new products or health services all want to improve an individual's health and quality of life. But even with the best intentions, oftentimes they aren’t designed or deployed with the context influencing a person’s decision, and innovators (and their funders) are left surprised at the lack of interest.
Social determinants within a community are complex and seem anecdotal, but they represent opportunities and barriers that should be addressed for a new product or health service. Individuals are influenced by their community and a community blends generational, political, religious, and/or cultural perspectives regionally or virtually. The magic happens when this anthropological data guides improvements in design and delivery, with continuous improvements that adjust in an ever-changing ecosystem.
For instance, biology and physiology only unearth a small part of the picture and there might be social determinants that slow or stop the course of one disease, such as a healthier lifestyle or a cleaner environment. And there might be social determinants that worsen another disease, such as increased stress or pollution. If you are developing a magic pill, this information could help enhance its effect (e.g. supplement with healthy eating and exercise) or explain why it did not work as expected (e.g. fear/distrust or added stress by requiring too many pills in one day). Over my career, I’ve seen a graveyard of “perfect is the enemy of good-enough” diagnostic testing prototypes that failed in the field because they were built solely on the latest science to measure “something”. Technology developers are reluctant to “tune down” cool technologies, so these often overshot what was needed by clinicians or were too complex to use beyond a pilot study.
Learning from Designing Public Health Programs
The link between social determinants and innovations was strikingly apparent during the COVID-19 pandemic, in which transmission could not be controlled by new tests and vaccines alone. Different public health strategies were needed to support the delivery of these new technologies to various neighborhoods. How did my city know which communities were most vulnerable to uncontrolled transmission of COVID-19? They used a 2019 Community Health Improvement Plan to focus on specific neighborhoods in addition to outbreak reports.
This plan was completed before the pandemic and based on epidemiological, socioeconomic, and social determinants data from surveys and physical walks through different neighborhoods. These surveys identified significant health disparities in our city, including a five-year difference in life expectancy if you lived in one neighborhood compared to another one less than a mile away. Among the many possible causes of these disparities was the cost of transportation that discouraged traveling to health and other community services, as well as access to healthier food. This resulted in a decision to make our buses free for everyone. Did the fareless bus solution make a difference, compared to other improvements such as housing conditions? Are there new social determinants of public health that have emerged since the first survey, particularly after experiencing a pandemic? These are some of the goals of an upcoming survey that updates the next plan.
Earlier this month, I had the opportunity to help the Health Department update this survey. Over 120 community members volunteered to design the “walking surveys” through their individual perspectives and small group discussions. To get them to share their perspectives and those of their neighbors, posters described several fictional archetypes of people with their demographics and life situations. This exercise builds empathy and relatability to propose opportunities and barriers for someone else, similar to what our Kidney Health Initiative used for the Human Centered Design for Kidney Failure Technologies.
After each person reflected on their perspectives and those of their neighbors, I facilitated a small group discussion that included city residents who were: two recent college graduates, two people who recently immigrated, and a mental health therapist. As a tabletop exercise, we “walked” through different neighborhoods to identify considerations for the walking survey. I’m excited to see how insights from all the group discussions strengthen the survey’s design and how data from those surveys result in more effective public health services.
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In our discussion, some neighborhood attributes that could impact public health included:
An Existing Plan + An Emerging Pandemic = An Improved Plan
During the onset of the COVID-19 pandemic, the Community Health Improvement Plan helped design the Health Department’s mass testing and vaccination programs through community surveys > workshops > plans > tabletop exercises > full-scale exercises in partnership with local leaders and members. Based on this iterative and continuous learning-improving model, they hosted smaller-scale testing and vaccination events ranging from local community centers, elementary schools, and apartment buildings, each ending with a staff “hotwash” to discuss areas for improvement.
Scheduled around people’s situations to accommodate those having multiple jobs or caring for family members, these strategies reduced some barriers to learning about and getting a COVID-19 test or vaccine. A neighbor’s word-of-mouth was also one of the most powerful ways to dispel myths and engender trust. It was amazing witnessing word-of-mouth spreading through a community as we canvassed during slower times of a day-long event. On numerous occasions, people had already talked to their neighbors and our events would inevitably experience a mid-late afternoon surge. The Washington DC region also has a high cost-of-living and several people shared that they couldn’t go to our event between their multiple jobs or couldn’t take time off to deal with the vaccine’s side effects.
Social Determinants and Innovative Medical Products
These public health approaches for identifying and using Social Determinant considerations can also help those pursuing innovative medical products that benefit a single individual. Medical treatment decisions are similarly subject to social determinants that can be opportunities and barriers for clinicians and patients, including influencing factors by care partners and the community. Archetypes, surveys, and workshops are just some of the tools that the biomedical innovation community can use to translate what seems like anecdotal and person-specific preferences into Target Product Profiles that design better products and increase the odds of improving an individual’s quality of life and health.
That was the motivation of KHI's Human Centered Design Toolkit for Kidney Failure Technologies because as with public health programs, the build it and they will come strategy for innovation also rarely works, even with the best intentions and the best science. Back to the diagnostic innovation examples, if a clinician doesn’t know why a test result will strengthen their decision or if a person doesn’t know what to do with the test results (particularly for a genetic disease), then those are some potential barriers that should be addressed by solely presenting test results based on what the clinician or patient (and their family) seeks. Nothing more, nothing less, and just good-enough.