From the macro level of statistical data, we can readily demonstrate and appreciate that larger forces are at play in determining the health and welfare of groups and individuals, but translating that understanding about the Social and Environmental Determinants of Health down to the micro level of interactions with patients or families sitting in our waiting and examination rooms is a challenging endeavor.  This article will be one of a series of discussions about approaches and interventions that may serve to promote efforts to address and ultimately ameliorate these risk factors in our patients lives and communities.

For starters it is evident that this is not an easy task, as for the most part, as healthcare providers, we work at the micro level, often doing and experiencing the wonder and satisfactions of our one-on-one interventions with patients to address acute and chronic physical and emotional health concerns.  We know that much of what we see in the office has roots in various environmental factors, but as healthcare providers, we typically have little influence of these external factors and we are limited in our capacity to assess, measure and intervene with larger social and environmental concerns.

Of course, sometimes we can individually and collectively have influence and see impacts – for example, with organized public health immunization efforts we may note the consequential reduction of children presenting with measles infection and, following broad educational campaigns, we may see increased numbers of babies being breast fed or see examples of how screening and patient education can reduce the impact of the quiet killers: obesity, hypertension, and metabolic disorders.

How might individual primary care providers have greater impact in their day to day work?

A first step, of course, is to recognize that innumerable adverse non-medical factors have enormous impact on health outcomes.   These factors are multiple and complex and include the social, legal, environmental, and commercial conditions in which people and families live their daily lives.  To name a few: poor access to healthcare, food and housing insecurity, traumatic exposure to family and/or community violence, exposure to environmental toxins, commercial promotion of unhealthy behaviors, access/exposure to substances of abuse, deficiencies in educational services, institutional and sociocultural bias because of racial, ethnic, gender/sexual and other minority identity factors, and, and , and … the list goes on (see V Codes and Z Codes link, below).

A second step is to identify the presence of these adverse determinants in the lives of our patients as a component of our overall health and health risk appraisal of patients.  Within the psychiatric community, where medicine meets society and culture more directly than in other areas of healthcare, this has been recognized.  While this recognition is far from optimal, these factors are brought into the diagnostic and treatment planning process by the designation of V Codes within the DSM (and the comparable Z Codes in the ICD 10) diagnostic systems.

While not recognized as primary mental health disorders and generally not reimbursable per se, V and Z Code conditions are included to identify “other conditions that may be a focus of clinical attention”.   The rationale being that interventions to ameliorate any of these conditions may often have significant impact on a patient’s overall mental health status and functionality.  While V and Z Codes do not address underlying causes of health problems, they can be used to identify the panoply of concerns that can impair functionality and wellness and they are a systematic vehicle to get social issues reflected in the psychiatric and medical chart.

V Codes (DSM-5) & Z Codes (ICD-10)

• • Primer
  • V Codes (DSM-5)
    • Relational
    • Educational and Occupational
    • Housing and Economic
    • Social Environment
    • Crime and Legal System
    • Other Health Service Encounters
    • Other Psychosocial, Personal, and Environmental Circumstances
    • Circumstances of Personal History
    • Abuse and Neglect
    • No Diagnosis
  • Z Codes (ICD-10)
    • Education and Literacy
    • Employment and Unemployment
    • Housing and Economic
    • Social Environment
    • Negative Life Events in Childhood
    • Problems Related to Upbringing
    • Problems Related to Primary Support
    • Psychosocial Circumstances
    • Other Psychosocial Circumstances
  • Resources

Recognizing V and Z Code conditions as potential negative determinants of health in primary care arguably makes sense, as recognition of these conditions, along with consideration of potential interventions could be of obvious benefit for many patients both acutely and ongoing through their lifespan.

Clearly, the challenge of finding and activating relevant resources to assist individuals with these complex problems is a significant one, but the recognition of these conditions and consideration of potential interventions, typically through referral to social agencies or other support networks seem appropriate considerations.

Provider consultation with and referral of patients to SmartCare program staff should be considered as a potential resource for providers and patients seeking supports and other interventions in the V and Z Code arena.

2-1-1 San Diego is another resource that can take the time to understand each individual’s situation and link those in need with those who can best help. A free, 24 hour, confidential phone service and searchable online database, 2-1-1 connects people quickly, confidentially and effectively to community, health, and disaster services. Available in over 200 languages, 2-1-1 provides information about more than 6,000 resources.

To paraphrase the public safety messaging about potential threat situations, it may be appropriate to adopt a “See Something, Say Something” approach— acknowledging relevant life stress issues and suggesting that patients “Do Something” that may improve a their life situation and, ultimately, their long term health status.

References:

1. Compton, M. T., & Shim, R. S. (2015). The social determinants of mental health. Focus, 13(4), 419- 425.
2. CENTER FOR THE STUDY OF SOCIAL POLICY. (n.d.). About strengthening families and the protective factors framework. About-Strengthening-Families. Retrieved January 24, 2022, from https://cssp.org/wp-content/uploads/2018/11/About-Strengthening-Families.pdf
3. Psych DB Listing of V Codes and Z Codes: https://www.psychdb.com/teaching/dsm-v-icd-z-codes#relational
4. SmartCare E-Weekly:  An Important Community Resource 211 San Diego http://www.smartcarebhcs.org/an-important-community-resource-2-1-1-san-diego/

“Racism is a social determinant of health and affects health and well-being along the developmental spectrum beginning in pregnancy and extending throughout all periods of early child development” . (our italics)

Recent literature has explored the sequelae of racism and the mechanism of impact. In addition to structural or institutional racism (for example in legal or educational systems), the authors highlight the impact of racism that a child may experience in day to day life, described as “personally mediated racism”.

“Personally mediated racism can …have deleterious effects on both maternal and infant mental health…[and] includes experiences of stereotypes and prejudices about an individual’s ability, motives, or intent on the basis of their race….[this] can be expressed implicitly (unconscious) or explicitly (conscious), and can be experienced directly or indirectly (vicariously). Examples of vicarious exposures include listening to a parent/caregiver describe unfair treatment at work, witnessing discriminatory behaviors towards a caregiver in a store, or reading about an event of a loved one from the news or social media”

According to a review of evidence over the past five years, the impacts of the racism can include,

• Increased rates pre-term birth
• Decreased access to high quality hospital care
• Adverse impacts on care-giver well-being, which may impact early dyadic experiences
• Increased separation challenges
• Higher rates of post-partum depression
• Decreased infant sleep duration
• Increased rates of school age sleep problems, anxiety, depression, suicide risk, low self-esteem and disruptive behaviors

Some approaches to consider (among many others)

• Create a culturally-safe medical home where the providers acknowledge and are sensitive to the racism that children and families experience by integrating patient and family-centered communications and evidence-based screening tools that incorporate valid measures of perceived and experienced racism into clinical practice.
• Promote programs that increase access to care for members of underserved communities.
• For patients who report experiencing racism, empathically assess for associated mental health conditions, including signs of posttraumatic stress, anxiety, grief, and depressive symptoms, using validated screening tools and a trauma-informed approach to make referrals to mental health services as needed”
• Conduct quality-assurance assessments that include analyses of quality of care and patient satisfaction by race, and respond accordingly
• Encourage policies to foster interactive learning communities that promote cultural humility and provide simulation opportunities to ensure that both senior and junior pediatricians are competent in delivering culturally appropriate and patient and family-centered care.
• Attend to issues of bias at individual, team, organizational, economic and other levels, and explore opportunities to address the negative impacts of conscious and unconscious bias on health care delivery and outcomes.

Berry OO, Londoño Tobón A, Njoroge WFM. Social Determinants of Health: the Impact of Racism on Early Childhood Mental Health. Curr Psychiatry Rep. 2021 Mar 12;23(5):23. doi: 10.1007/s11920-021-01240-0. PMID: 33712922.

Trent, M., Dooley, D. G., Dougé, J., & On, S. (2019). The Impact of Racism on Child and Adolescent Health, 144(2). Policy Statement American Academy of Pediatrics.