May 9, 2018

Social Determinants

Social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work and age.” They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care.

Q: How does Sweetwater Urban Farms help with identifying and managing social determinants specific to food desserts?

A: We take one of the most comprehensive approaches to attacking this issue. With typical social determinant databases you are able to explore the care gaps of patients with Diabetes connected with the simple question of prevalence. By bringing in CDC prevalence data we can understand the context for the potential size of the challenge relative to other locations. We then look at gaps in care within the population of interest.

What we are really interested in though, are the relationship between social determinants and our patients with a chronic condition like diabetes related gaps in care. Knowing the importance of healthy behaviors related to food and nutrition for our population, we explored the concept of access. We were able to integrate data on the presence of food desserts and map that to our hot spots.

Our Social Determinants work is really an effort to create a holistic profile which will enable us all to offer patient centered care.  This rich context will let us better understand what may be getting in the way of patients taking action, what barriers may be addressed through messaging or support, whether we may have resources that already exist but could be better targeted and ultimately where we should prioritize resources.

We understand that you cannot just “build it” and they will come. You need to involve the community including social workers, care managers and urban planning in the process. Once you have a solution in place you need to continue to monitor from a holistic perspective to ensure compliance and improvement.