How do social determinants of health indicate accessibility and quality of health care?

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Introduction

In this project, I looked into how socioeconomic status and community indicators might be used to assess someone’s access to health care and the quality of the care they receive. The indicators include household income, median home price, and urban planning (i.e., city layout and transportation).

By using data about healthcare facilities and socioeconomic status in San Francisco, I was able to analyze the potential correlations between the two.



Social Determinants of Health

Economic Stability
  • Employment
  • Food Insecurity
  • Housing Instability
  • Poverty
Social and Community Context
  • Civic Participation
  • Discrimination
  • Incarceration
  • Social Cohesion
Neighborhood and Built Environment
  • Access to Foods that Support Healthy Eating Patterns
  • Crime and Violence
  • Environmental Conditions
  • Quality of Housing
Health and Health Care
  • Access to Health Care
  • Access to Primary Care
  • Health Literacy
Education
  • Early Childhood Education and Development
  • Enrollment in Higher Education
  • High School Graduation
  • Language and Literacy

Social determinants of health are the conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

Although the SDOH model does not encompass all factors that affect health, it does provide a robust framework that covers many of the aspects pertaining to someone’s health.

Examples

Social Determinants
  • Availability of resources to meet daily needs (e.g., safe housing and local food markets)
  • Access to educational, economic, and job opportunities
  • Access to health care services
  • Quality of education and job training
  • Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
  • Transportation options
  • Public safety
  • Social support
  • Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
  • Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)
  • Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
  • Residential segregation
  • Language/Literacy
  • Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
  • Culture
Physical Determinants
  • Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
  • Built environment, such as buildings, sidewalks, bike lanes, and roads
  • Worksites, schools, and recreational settings
  • Housing and community design
  • Exposure to toxic substances and other physical hazards
  • Physical barriers, especially for people with disabilities
  • Aesthetic elements (e.g., good lighting, trees, and benches)

Examining San Francisco

San Francisco Community Health Needs Assessment 2019


Accessibility of Health Care

Click on the headers below to expand each section.

Research & Data
NeighborhoodTotal PopulationNumber of Housing UnitsMedian Year Structure BuiltMedian RentMedian Home ValueMedian Household IncomePercent in PovertyPercentage of Population Taking Public Transit
Bayview Hunters Point37,45011,9201957$1,820$476,820$51,45022%27%
Bernal Heights25,8409,8001934$2,000$788,530$92,5509%32%
Castro / Upper Market20,2609,8001934$2,000$788,530$92,5509%32%
Chinatown14,6007,3501899$570$959,020$19,95028%31%
Excelsior39,96011,3401943$1,220$579,820$65,2009%34%
Financial District / South Beach16,54011,9001994$1,480$778,030$119,1209%21%
Glen Park8,3203,8701950$923,360$111,7508%33%
Golden Gate Park50401949$119,4400%29%
Haight Ashbury17,9209,0501908$2,010$1,064,020$114,15010%39%
Hayes Valley17,7709,5601921$1,200$714,160$77,75016%42%
Inner Richmond21,3409,9801925$1,750$1,018,910$74,73014%38%
Inner Sunset28,02012,6801944$1,830$910,010$96,21010%34%
Japantown3,9202,4201969$604,610$55,70020%45%
Lakeshore13,2205,1301954$1,850$651,870$46,99025%31%
Lincoln Park300801944$750,000$76,9204%23%
Lone Mountain / USF17,1806,7901937$854,350$82,55012%31%
Marina24,85015,1201919$2,140$1,252,210$121,0706%35%
McLaren Park8503101973$605,260$12,41043%33%
Mission56,48024,9701907$940$743,500$73,03016%41%
Mission Bay9,8005,0002001$645,970$113,78012%38%
Nob Hill25,54017,1701919$1,210$817,860$56,26016%31%
Noe Valley22,38011,6401926$1,570$1,018,050$120,4706%33%
North Beach12,7607,2101943$1,610$904,390$69,99017%24%
Oceanview / Merced / Ingleside27,3908,2201945$1,650$591,600$68,31015%33%
Outer Mission23,6106,6901936$840$627,160$76,7208%33%
Outer Richmond44,98020,0801938$1,430$859,310$69,33010%31%
Pacific Heights23,67014,5801918$1,840$1,151,420$113,3906%32%
Portola15,9404,8601950$1,130$607,850$74,53012%25%
Potrero Hill13,1006,3801946$1,010$837,870$145,3707%24%
Presidio3,4501,3201949$1,650$144,8006%24%
Presidio Heights10,4105,1501909$1,520$1,197,820$114,3209%29%
Russian Hill18,61011,1301873$1,780$911,330$102,94010%36%
Seacliff2,3601,0301923$2,854,840$155,5608%13%
South of Market17,83011,3801986$1,020$649,200$37,03025%30%
Sunset / Parkside79,79028,7101944$1,740$747,680$81,69010%27%
Tenderloin27,64018,7501899$880$378,460$20,75031%48%
Treasure Island3,0808401963$1,810$37,79046%48%
Twin Peaks6,9503,7101962$570$820,680$91,5705%22%
Visitacion Valley17,4505,3001953$770$493,250$47,76017%34%
West of Twin Peaks37,28014,6301935$1,700$914,570$126,1206%26%
Western Addition20,40012,2501969$1,570$602,340$47,00020%37%
San Francisco Neighborhoods Socio-Economic Profiles American Community Survey 2010–2014
From this table, we can see that the prevalence of disease or illness is much higher in lower-income families. The disparities in both living conditions, diagnostic capabilities, and quality of treatment for these various groups are so large that they can cause extreme differences in the presence of disease and illness.
Looking at this graph, we can see that self-reported health follows a similar trend. People whose income fall below $35,000 are the most likely to feel that their health is poor or fair. Why might this be?
Analysis

Based on the data above, we can see that the percentage of residents in each neighborhood who take public transportation as their main way to get to and from work has no significant correlation with their socioeconomic status.

Looking at the map above, large hospitals in San Francisco seem to be evenly spread throughout the city. A large number of them are also very close to public transit stations. If we compare the median rent, home value, household income, and poverty rate for each neighborhood with the locations, we can see that the hospitals are also relatively evenly distributed according to population density rather than socioeconomic factors.

Conclusions

So what does this mean? San Francisco’s hospitals and healthcare facilities do a good job of providing healthcare to a large percentage of its residents. They are easy to access by public transit and are dispersed across the city, allowing for less crowding and more options.

A map of hospitals in San Francisco and public transportation routes throughout the city.

Quality of Health Care

According to U.S. News, the top three hospitals in San Francisco are UCSF Medical Center (Inner Sunset), CPMC Pacific Heights Outpatient Center (Pacific Heights), and Kaiser Permanente San Francisco Medical Center (Lone Mountain / USF). All three of these hospitals are located in neighborhoods with some of the highest household incomes, rent amounts, and home values.

Although there are a lot more factors at play, there is still a strong correlation between the socioeconomic factors of the area surrounding a medical facility.

Often, these hospitals in “richer” or “more well-developed” areas tend to have larger and cleaner spaces, more advanced technology and equipment, better doctors and nurses, and more healthcare professionals involved in cutting-edge research.


What does this mean?

In my analysis of hospital placement and locations, I determined that access to health care is not really an issue for most San Francisco residents. However, the issue of cost and insurance is something that continues to hinder access for many people.

This means that while people are able to get to many different facilities easily from where they live, they may not necessarily be able to actually receive treatment there. The largest barriers for them are usually high out-of-pocket costs or uninsured status. Because of this, the “good” hospitals that often charge higher amounts due to their higher operational costs remain options primarily for wealthier communities. Those in poverty or who cannot afford these facilities will then turn to lower-tier facilities.

So what options exist for the homeless population?

For the homeless, the San Francisco Health Care for the Homeless Program provides very adequate health care solutions. The award-winning Street Outreach Services (SOS) program is a mobile medical clinic for homeless San Franciscans. According to their website, “SOS seeks out those who have long been disconnected from health services, provides on-the-spot urgent care, and connects patients to ongoing primary care so that chronic conditions — like heart disease and diabetes — can be managed effectively and not progress to more expensive and emergent situations.”

And what about the uninsured?

Healthy San Francisco is a program designed to make health care services available and affordable to uninsured San Francisco residents. It is operated by the San Francisco Department of Public Health. The program is available to all San Francisco residents regardless of immigration status, employment status, or pre-existing medical conditions — but they must first meet all of the requirements:

  • Living on a combined family income at or below 500% of the Federal Poverty Level. Find out if you meet the income requirements.
  • A San Francisco resident who can provide proof of San Francisco residency
  • Uninsured for at least 90 days
  • Not eligible for public insurance programs such as Medi-Cal or Medicare
  • Age 18 or over

Take a look at HealthySF’s covered medical services and quarterly participant fees.


Your Turn

Now think about how your own access to health care might be affected by your family’s income and where you live.

Write down any questions you have, connections you make, or personal experiences that touch on this idea.

For those of you who are considering careers in healthcare or are currently in the field, what are some considerations you might take with you? How might enhanced knowledge about the social justice issues of health care access and quality inform you?

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Click here to access a list of references and works cited.

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