Talking Social Determinants of Health with Ralph DiClemente

Ralph DiClemente

Ralph DiClemente

Healthy Teen Network is committed to using the social-ecological health promotion frame (more information in our 2013-2016 Strategic Plan), incorporating the social determinants of health to build collaboration beyond our field and achieve results across diverse populations, including pregnant and parenting teens. But what are the social determinants of health and how do they affect adolescent sexual and reproductive health? Recently I had a conversation with distinguished Professor and Researcher, Dr. Ralph DiClemente, to hear his take on this subject.

For the benefit of those who are not familiar with the concept, how would you define the social determinants of health?
Ralph DiClemente: I would define the social determinants of health as factors that affect people’s health behavior. They generally refer to any factor or influence external to the adolescent that resides in their community or society. So, you can refer to them as extrinsic factors.

So how would one address these extrinsic factors or social determinants of health in their work?
RD: There are a couple of ways. First, you have to decide at what level these factors are operating. For example, an extrinsic factor could operate at a dyadic or partner level. You could try to develop programs that either get partners into treatment, for example for STDs, or you may do partner interventions. We bring in a young woman and her male partner—this is a dyadic-level intervention.

Other extrinsic factors may operate at the peer network level. So another thing you might try then is community level interventions where you target the entire network of young people and try to change (peer) network norms and perceptions, which leads hopefully to changing network behaviors.

A third level may operate at an organizational level, for example health departments or clinics, in which case you would want to work in those clinics to develop adolescent friendly centers or have adolescent friendly times when only young people are going to be in the clinic… Another opportunity is to move the clinic into the community, for example, mobile vans. We can go to where young people are because, it is less stigmatizing than going to the clinic and young people may not have the means—cars, transportation, money, etc.—to get to clinics. So let’s bring the clinic to them—reduce that barrier—the accessibility.

Another level may be at the broader societal level. These are issues such as poverty, discrimination, both racism and sexism, media influences—how does the media portray adolescents, how does it portray minority youth, how does it portray female minority youth. So there, you may want to engage in media literacy training in schools, get the schools involved in dispelling myths. You can also do social marketing approaches at the broader societal level.

There are a lot of social determinants—you need to determine where they are emanating from, and once you have decided that, then you can target your intervention to that level.

Do you personally target all these different levels of social determinants—partner, peer network, organizational, and societal—in your work?
RD: Well, we try to. And because we are doing research projects, we don’t have unlimited resources, which certainly is a constraint. However, we certainly do try to target all these social determinants. For example, in a more recent study, we developed expedited partner treatment for young women testing positive for an STD, in which case they could actually bring medication to three of their male sex partners. So the male sex partners did not have to go to the clinic.

In doing so you addressed a huge barrier.
RD: Exactly! The barrier of time, cost, and the argument that often ensues from young women telling a boyfriend, “You gave me an STD.” Instead they say, “It may not have been you, it may have been you, but here’s some medication. If I have got this, you may have it as well since we had unprotected sex.” So they get treated, it’s good for them, it’s good for the couple, and it reduces the potential spread through the rest of the network. That’s one example of a dyadic approach.

Another example of our approach is the use of media in our interventions. We roll in the media literacy piece in our interventions by playing for example rap music or music videos that show young African American girls in less than a positive light and we critique the lyrics. Many young girls say them, but they haven’t thought about what the lyrics mean. [The lyrics] are misogynistic. But until they read them…and we go through them, they don’t really know what they mean…So we sensitize them to the lyrics and [ask] how does that make you feel to be called this, that, and the other thing. So again, we want to target across multiple levels, because multiple levels are essentially influencing their behavior, creating a fertile ground for risk behavior. The solution we feel is to target multiple levels with interventions we think will benefit young women. And young men for that matter as well.

Would you say the potential for greater impact is why it is so important for the field of adolescent sexual and reproductive health to address the social determinants of health?
RD: Yes, it is clear that by focusing only on young people—young boys and young girls—we are missing a really key piece of the equation, which is the environment in which they exist, the social context in which they exist. No one exists in a vacuum. All of us are influenced to some degree by what we see around us, what our friends and family tell us, how we model other’s behavior whether it’s actual real life behavior of friends or modeling what we see on the TV or internet. So the issue becomes, if all those issues are coalescing to affect our behavior, we need to be able to target those influences to optimize our effects.

For people who are currently implementing, for example, an evidence-based intervention, what are three concrete ways they may be able to address the social determinant of health if they are not already doing so?
RD: Well the first way is to understand those determinants. They may want to ask their young clients to identify sources of influence. So before you can develop an intervention, you really need to do an assessment of the primary sources of influence. (Assuming of course that you do not have unlimited resources…) Once you have identified what those sources are then the next step is to either address those sources in your intervention or address those sources directly—one way is to directly change them.

For example, accessing teen clinics is not easy. Well, you can directly address that by providing young people with transportation resources or having the clinic hold special days for young people or having a mobile van …That would be an easy approach—the direct approach to the social determinant. An indirect approach would be working with the team. Maybe they could touch base with friends, family, etc., to see about getting transportation…. So again, you can directly address these issues–and if you can that’s perfect, or you can try to indirectly address them, or in fact do both.

These are great recommendations and I am sure our readers will benefit greatly from your insight, Dr. DiClemente. Is there anything else you would like to add? Perhaps a question I have not asked you or what we should be thinking about in terms of the social determinants of health?
RD: Well, I think we need to think broadly. We often think about individuals. We have to get out of that mindset and realize that individuals, young people, only exist in a social context. So, understanding that social context is critical. And unfortunately it is a lot easier to focus on the individual and put all the responsibility and burden on them, but that’s not fair. It’s eminently unfair and what we need to do is recognize that we are dealing with young people who have a different maturational level, a different cognitive level, and different resources both cognitive a well as financial.

We need to stop the blame game.
RD: It is a blame game. “You should be doing this!” “You should know better!” Everyone knows better. Adults smoke. They know better. Adults don’t exercise. They know the risk for heart disease and stroke. Adults don’t eat well. Do we blame them? But we blame girls when they get pregnant. We blame kids when they get an STD. I don’t understand the dualism here.

This year at our annual conference Healthy Teen Network is proudly awarding you with the Douglas B. Kirby Researcher of the Year Award.
RD: I’m flattered! That’s major!

Would you please share Doug Kirby’s contribution to the field of the social determinants of health and his legacy?
RD: Well, I think it I hard to quantify what Doug meant to this field in a very short period of time. He was clearly an exemplar of a researcher and how a researcher could be sensitive to the community and work collaboratively with the community. (He was a) very rigorous methodologist, but also sensitive to the needs of people. He wasn’t designing laboratory studies: he was working in people’ homes and communities. He developed a set of guiding principles for effective programs; his reviews are cited repeatedly. For example “No easy answers” is often cited in terms of addressing these issues. He was fair, eminently fair in his evaluation of research, and he was certainly an advocate for young people. [He was a] strong advocate that was beneficial in having programs developed and implemented for young folks. I am delighted, proud, and privileged.

One last question. What do you think we should look forward to seeing and hearing at the conference next month?
RD: I think it is always great to go to a conference with like-minded folks…like-minded not necessarily in solutions, but like-minded in their advocacy and their interest. We want diversity in terms of solutions. We want creativity. We want innovation. Everyone at the conference will have an interest and focus. And that’s great! The feeling, the energy that emanates from that room will be palpable.

How do you address or consider social determinants of health in your work? How have you used media in your interventions? Leave your comments below!

Mousumi Banikya-Leaseburg

Mousumi Banikya-Leaseburg

Mousumi Banikya-Leaseburg, MD, MPH, CPH is a Program Manager at Healthy Teen Network.

10 Minutes with Dan O’Connor

Dan O'Connor

Dan O’Connor

Dan O’Connor, PhD, is a member of the Core Faculty of the Johns Hopkins Berman Institute of Bioethics. He was for many years the Head of Research at RMM, a digital and social media strategy consultancy in London, UK. His research focuses on the ethical issues that arise from the use of social media to create and share health information.

Dan will be delivering the opening keynote at Embracing Innovation: Combining Science with Creativity to Improve Adolescent Health, Healthy Teen Network’s 34th Annual National Conference, this October in Savannah, GA. We recently caught up with him by phone to ask him a few questions about the social determinants of health.

For the benefit of those who are not familiar with the concept, how would you define the Social Determinants of Health?
Dan O’Connor: Basically, being poor makes you sick… I realize that’s perhaps a very trite way of putting what is a very complicated, serious framework…but I think it also gets right to the heart of the matter. There are certain things outside of biology and physiology, certain external factors, that have massive impacts on people’s health.

How do you address social determinants of health in your work?
DO: My work has primarily been in looking at social networks, online social networks particularly, and the ways in which people are able to leverage social media and internet technology—like Facebook, Twitter, online forums, that sort of thing—to exchange information with other people who have similar health conditions. One group I’ve looked at particularly and am hoping to publish [about] in the future are people with cancer who use Facebook and Twitter to reach out to other people in similar situations to not discuss necessarily the science or professional diagnosis, but the kind of every day lay experience of living with disease. And the marvelous thing about online social networks is that they allow people who previously might not have been able to talk to someone else in a similar situation, to reach out and form sort of a sense of community. Because one of the social determinants of health is connectiveness—being connected into a community, having a network available to you to discuss and talk about the experience of living with diseases. So my particular interest is in the way that social media and online social networks are sort of their own social determinant of health and the more access people have to these social networks and the more skilled they are at using them, potentially the better health outcomes people have.

Going back to your initial answer of “being poor makes you sick,” do you think that people’s financial situations and lack of access to the internet have an impact on their health outcomes?
DO: Yes, absolutely, but it’s not necessarily financial poverty—you might call it sort of a lack of social capital, which is about having the education and the access to the Web…and these are definitely social determinants of whether you are able to make the most of the opportunities afforded to you by social media for discussing and exchanging health information. So, there is a clear divide in terms of who is able to have reliable internet access—which is a poverty issue, a sort of economic social determinant—but there’s also the kind of educational and intellectual social determinants. Who has the social capacity to make the most of those opportunities? You know, if you’re very well educated, if you have a sort of base understanding of your disease, if you understand how social networks work, if you’re able to parse good health information from bad health information online, you have an advantage over people who perhaps lack that kind of level of social capital…. Being able to make the most of that access is, I think, a social determinant.

Why do you think it’s important for Healthy Teen Network, and fellow professionals and organizations in the field of adolescent sexual and reproductive health (ASRH), to address the social determinants of health?
DO: It’s not just you and your field—it’s everyone in the health field—if we don’t understand the social determinants of health, we’ll never achieve what we’re looking for, which is better public health outcomes, in total. If we constantly focus purely on biological and physical causes, we’ll constantly be merely treating people, rather than preventing. Improving the social determinants of health means that we get to prevent potential negative health outcomes.… I think that’s a positive way to go forward.

Addressing the social determinants of health is nothing new, but there seems to be an increased focus of late in the way people are talking about them and considering them in their work. Do you find this to be true?
DO: [For example] thinking about obesity [and] the obvious links that it has to poverty…. There’s an increased understanding that access to fresh foods and things like that is a clear social determinant of obesity, and that [understanding is] great and it’s very positive, but what I am slightly concerned about is that sometimes that focus shades into almost a blaming of the people who have got those poor social determinants. And I think that is something to be very careful that we ought to guard against…. [People who have] social determinants that are negative—or stacked against them—it’s not necessarily their fault. These things are socially embedded. So, while there has perhaps been some increased focus on social determinants, what that has to go along with is an understanding that people are not to blame for their social situations.

What ways do you recommend the field of ASRH incorporate social determinants into our work?
DO: I think I’m preaching to the choir, but one obvious key social determinant for adolescent sexual health is reliable information and being within a social environment—whether it’s a physical family and friends environment or an online social network—where you have access to reliable sexual health information…. And, speaking as a gay man, [I’d say] that one of the other social determinants of health is acceptance or a lack of stigma toward alternative sexuality. We know that there are a lot of mental health issues, particularly among LGBTQ teenagers and adolescents and that is primarily socially determined because of rejection and stigma, and that might be an area that could be a focus [for ASRH field].

Anything you’d like to add?
DO: I’m really pleased that Healthy Teen Network has got this focus on the social determinants of health because I think it’s something that gets slightly swept under the carpet, particularly in American public health…. Social inequality does lead to bad health outcomes—and they’re not just bad health outcomes for one person, they’re bad outcomes for the whole system.

How do you address or consider social determinants of health in your work? Do you agree that the role social determinants of health play sometimes gets “swept under the carpet?” If so, what can we do to change this? Leave your comments below!

Kelly Connelly

Kelly Connelly

Kelly Connelly is the Marketing and Communications Manager at Healthy Teen Network.

Teen Birth Rates Down: Let’s Continue this Trend by Addressing Social Determinants

Friday, September 6, 2013, the Centers for Disease Control’s (CDC) National Center for Health Statistics (NCHS) released preliminary birth data for 2012. State-specific data tables are also available.

Some key highlights from the CDC NCHS report on preliminary birth data for 2012[1]:

Teen Birth Rates

  • The birth rate for teens 15-19 years was down 6% in 2012 (29.4 births per 1,000 teens 15-19 years), yet another historic low for the nation, with rates declining for younger and older teens and for nearly all racial and Hispanic origin groups. 
  • Since 2007, the teen birth rate has dropped almost one third (from 41.5 births per 1,000 teens 15-19 years)and more than half in the years from 1991 (61.8) to 2012 (29.4).
  • The number of births to teens 15-19 dropped 7% during 2011-2012, to 305,420, the fewest since the end of World War II.
  • The 2012 total births to teens was almost one-third fewer than in 2007 (444,899) and less than half the total in 1970, the all-time peak year for the number of teen births (644,708).

Younger Teen Birth Rates

  • Consistent with recent trends, the rate for younger teens fell more during 2011-2012 than the rate for older teens, 8% compared with 5%.
  • The birth rate for the youngest teens, aged 10-14 years, remained at 0.4 births per 1,000 in 2012. Because the female population in this age group declined very slightly, the number of births to under 15-year-olds declined as well during 2011-2012 to 3,674, the fewest since 1946.

Young Adult Birth Rates

  • The birth rate for women in their early twenties, 20-24 years, declined in 2012, to a new record low of 83.1 births per 1,000 women. 
  • The birth rate for women 20-24 years has declined steadily since 2007 at nearly 5 percent annually.

Birth Rates among Racial and Ethnicity Groups

  • Among racial and ethnicity groups, declines from 2011 to 2012 for teens 15-19 years ranged from 3 percent for American Indian/Alaska Native (AIAN) teens to 5 to 7 percent for non-Hispanic white, non-Hispanic black, Asian and Pacific Islander (API) and Hispanic teens.
  • The largest decline for any population group since 2007 was reported for Hispanic teens, down 39 percent, to 46.3 per 1,000 in 2012.

(*As another related resource, Child Trends posted a helpful analysis on the birth rate data and closing the gap between racial and ethnic groups.)

The continued downward trend in the teen birth rate is promising news. Positive health outcomes are the result of reduced sexual risk-taking behaviors, such as increased correct and consistent use of condoms and contraception, reduced frequency of sex, and delayed initiation of sexual activity.  In comparison to previous sexual behaviors, the CDC notes, “While reasons for the declines are not clear, teens seem to be less sexually active, and more of those who are sexually active seem to be using birth control than in previous years.”

Drilling down to identify the factors causing these positive behavior changes is a bit less straightforward. There is a vast field of research demonstrating that evidence-based programs can reduce sexual risk-taking behaviors. We also know that there are over 500 risk and protective factors influencing sexual risk-taking behaviors, with some of those factors having more influence or a higher amenability to change through programs and services.

President Obama’s Teen Pregnancy Prevention Initiative (TPPI) supports the implementation of these evidence-based programs, in an effort coordinating funding and activities across agencies, including the U.S Department of Health and Human Services, Office of Adolescent Health (OAH) and the Centers for Disease Control and Prevention (CDC) Division of Reproductive Health (DRH) and Division of Adolescent and School Health (DASH).

While the latest report is encouraging, the data also signal the need for constant and continued effort to empower youth to lead healthy sexual, reproductive, and family lives. When we consider that health disparities persist, and U.S. rates are still higher than all other industrialized nations, the rising HIV and sexually transmitted infection (STI) rates, the changing demographics of the country, and the persistent gaps in rates across racial/ethnic and socioeconomic groups, there is still much to be done, and new, innovative approaches are needed.

Figure 1[2]

teen_birth_rate

Current realities—

  • the persistent health disparities among marginalized youth;
  • the rising and disproportionate HIV and STI rates among youth;
  • the United States’ lagging progress behind other industrialized nations; and
  • the many, many risk and protective factors influencing sexual risk-taking behaviors—

indicate a need to increase our impact, despite the reduction in birth rates for 2012.

With these realities in mind, Healthy Teen Network developed its 2013-2016 Strategic Plan, a Road Map for the Future of Adolescent Sexual and Reproductive Health. Healthy Teen Network promotes a social-ecological health promotion frame because it supports communities to recognize, explore, and address the social and environmental factors—the social determinants of health—that influence citizens’ health and learning, particularly as they relate to risk-taking behaviors.

Figure 3[3]

Social-Ecological Health Promotion Frame

soc_hecol_model

The social-ecological health promotion frame changes our way of thinking about what we do and what young people need to thrive, such as addressing issues of housing, food, education, employment, and more, as these social determinants impact the health and well-being of young people.

Using the ecological frame can help build collaboration beyond our field and achieve better outcomes for youth across diverse populations.

Evidence-based programs, such as those funded through Obama’s Teen Pregnancy Prevention Initiative have contributed greatly to the continued downward trend in teen birth rates, and Healthy Teen Network believes in the critical importance of these evidence-based programs. However, as a national community, we must explore new methods to address the needs of populations not addressed within the current repertoire of evidence-based programs, as well as those populations who need attention on a range of social determinants, beyond health education. And so, Healthy Teen Network promotes research-based approaches, innovative programs, and new partnerships.

We believe, with this attention to research-based and innovative approaches, new partnerships, and populations of need, we can increase our impact, continuing the promising downward trend, while also addressing health disparities. Society has an obligation to all adolescents and young adults, including teen parents, to have access to these opportunities in order to lead healthy and fulfilling lives.

How do you work to incorporate social determinants in your work with youth?

How can we work to collaborate with new and diverse partners, to address social determinants?

Gina Desiderio

Gina Desiderio

Gina Desiderio is the Director of Marketing and Communications at Healthy Teen Network


[1] Hamilton B.E., Martin J.A., Ventura S.J. Births: Preliminary data for 2012. National vital statistics reports; vol 61 no 5. Hyattsville, MD: National Center for Health Statistics. 2012. Available from: http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_03.pdf

[2] Centers for Disease Control and Prevention. 2010 Sexually Transmitted Diseases Surveillance. http://www.cdc.gov/std/stats10/adol.htm. Retrieved April 30, 2013.

Planning a National Conference: Behind the Scenes

Rita Lassiter

Rita Lassiter

Have you ever wondered what goes into planning the Healthy Teen Network Annual National Conference—or any national event for that matter? While the bulk of the planning a national conference takes place just six to eight months preceding the event, there are many “i’s” to dot and “t’s” to cross before registration opens: it is truly a year-long process. There are various elements that go into planning a successful conference.

The first step is to determine a theme and set of objectives that address the pertinent issues of the moment, are innovative, and serves the needs of your audience. In fact, depending on those you serve, perhaps a step before setting the theme/objectives may be assessing your audiences to identify their needs. Once the theme and objectives are established, the content planning team creates a program, addressing the theme and objectives, through a host of keynote and plenary sessions, to include experts in the field and will motivate attendees but seek to challenge conference attendees to be creative in providing solutions for addressing the needs of their constituents. An extensive Call for Proposals process vets out the best workshops and roundtable sessions, offering tangible skills for attendees to apply to their work with regard to programs, policy, research, and capacity-building. While the conference program provides many professionals with the opportunity to shine a light on their work through presentations, discussions, and roundtable sessions, we also devote time to recognize those individuals and organizations that have contributed so much to the field, through awards.

Now, what’s a conference without some outside fun? A conference planning team makes every attempt to make sure attendees are well informed on the “Who, What, Where, When, and Why” in their conference host city. This is where a reliable and knowledgeable host hotel staff and contact with the local convention/visitors bureau (CVB) come into play. Every attendee should be equipped with a “to do” list; sites to see, places to shop, and of course, places to savor a taste of the local cuisine.

Throughout the planning for the program and the logistics, the marketing and fund development team coordinate details to support the conference. Staff network and reach out to potential donors to secure sponsorships to support sessions and luncheons, as well as scholarships to support attendance. The marketing team plans to secure exhibitors and advertisers for the program, markets the conference program to potential attendees, and designs the various conference materials, such as the save-the-date, preliminary brochure, and program.

From programmatic and content details to marketing and sponsorship to logistics and contracts, it takes the collaboration of numerous individuals to ensure that the event will run smoothly. For many of these tasks, forming an active conference planning committee can be extremely valuable. From suggestions for potential speakers, presenters, and exhibitors to conference funding and media/local outreach, these are local team members who have their eyes and ears on the ground of the local host city from day one of planning.

Want to know how to register for an event? Where the annual event will take place? How to get from point A to point B? What is included on the schedule of events? Your event planning staff is the “go to” for all things conference related and will develop an FAQ listing for any inquiry that comes their way. Internally, it is their duty to make every process as seamless as possible for all involved. Are there hiccups along the way? Absolutely. However, any event planner will learn to learn from those hiccups and develop protocols and best practices to apply to any event/meeting moving forward. And the reward at the end? A fabulously executed conference for all to enjoy!

Healthy Teen Network’s 34th Annual National Conference celebrates “Embracing Innovation” to address adolescent sexual and reproductive health and the needs of parenting teens. Healthy Teen Network will showcase innovative strategies and research focused on adolescent sexual health, pregnant and parenting teens, and building the capacity of youth-serving organizations to sustain themselves for years to come. Helping youth make healthy, responsible decisions about how they live out their sexuality and care for their families requires examining the aspects of their lives that impact how they make those choices. The conference preliminary brochure contains all the information you need about Embracing Innovation.

This year’s conference will be hosted at the Hyatt Regency Savannah, on the riverfront in beautiful and historic downtown Savannah. Reserve your room online and receive the conference discount, but don’t delay–this room block is likely to sell out! Picked by Conde Nast Traveler as a Top 10 U.S City to Visit, Savannah offers visitors a wide variety of food, shopping, history, and sites to explore. For things to do and see while you’re in town, check out www.VisitSavannah.com.

We hope to see you in Savannah!

Rita Lassiter is the Meeting and Event Planner at Healthy Teen Network.

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