Social determinants of health, according to the World Health Organization (WHO), are the conditions in which people are born, grow, live, work and age, as well as the health system. These determinants give rise to spread of disease in poor communities with large unmet health needs and large gaps in health and socioeconomic indicators across borders.
Second year occupational therapy student Sara Atkinson realized on a mission trip to Nicaragua with Palmetto Medical Initiative (PMI) that taking things like culture, socio-economic status and environment into consideration during diagnoses is important in further understanding—and overcoming—barriers to treating patients in low-income countries.
“We saw a pediatric patient who had trouble rolling over and other activities that she should have been able to perform at her age,” said Atkinson, a 2015 MUSC Center for Global Health trainee travel grant recipient. “After exploring cultural contributing factors, the group of students and I took into consideration that the environment is much different in rural Nicaragua than where we are from. There is dirt everywhere, even in some homes, so mothers may not feel comfortable putting their children down. This could contribute to a lack of exploration and motor development for these children.”
The simplicity in which diagnoses are dubiously portrayed in popular culture is unrealistic. The outcome usually comes by way of an unrelated series of tangential events and hence, a diagnosis of a sometimes rare but very treatable condition. This feeds unreasonable expectations and misguided perceptions about the healthcare profession.
Atkinson found that in low- and middle-income countries even medical or health professional students were expected to perform as a seasoned practitioner would.
“The Nicaraguans looked to us for answers we, as students, could not give no matter how bad we wanted to help them,” said Atkinson. “This is why most of the students would like to come back once our skills mature.”
Getting to the point where care is provided—after considering all factors contributing to ill health— is far more complex than what is generally perceived by those not in the healthcare field.
Atkinson believes practitioners should consistently do more to work through constraints in providing the best care to all patients. Not considering the full scope of determinants of health may prove financially and physically costly in the end.
“Sometimes you have to adapt and change a treatment as you learn about the patient,” said Atkinson. “We were lucky enough to have a diverse team of healthcare professionals working to discern what nonmedical issues were impacting the patient’s health.”
It did not take traveling to Nicaragua for Atkinson to realize the glaring differences in access to resources from country to country. It is well known that needed supplies are scarce in low-and middle-income countries. Atkinson, however, remained optimistic. Atkinson and her colleagues worked with what was available to them allowing the group to become inventive out of necessity.
One of the most important lessons Atkinson brought back to the US was a profound one. Although students who travel abroad are quick to apply what they have learned in the classroom and are encouraged to do so by clinicians, she had the realization that the best available equipment in the US is not necessarily the most appropriate in all cultures. Atkinson noted specifically the use of wheelchairs in an area with smaller homes, no sidewalks, and rough terrain. As all these factors need to be considered, supervisors work with students and early-career practitioners to ensure that patients receive the best care and the equipment that they need.
From the environment to the per capita income in the clinic’s catchment area, Atkinson feels these social determinants of individual and population health are important in diagnosing and providing care for all patients.
“I have learned, first and foremost, to be culturally sensitive no matter where I am geographically,” remarked Atkinson. “More importantly, I do not believe we should assume anything about patients. Sometimes you try to box in a certain diagnosis and think everything is going to be clear cut—that is not always the case. We should treat considering all things that could impact the patient’s health.”