*Corresponding Author:

Peggy B Smith, PhD, MA,

Professor and CEO, Population Program, Baylor College of Medicine, One Baylor Plaza, Houston, TX, USA, Tel: 1-713-557-9987; E-mail: Peggys@bcm.edu

ABSTRACT

Over the last fifty years various schools of thought have begun to consider factors that determine not only health but also behavioural wellness for disadvantaged communities. Historically, bench science focused on biomedical findings which, through translation endeavours, contributed to lifesaving applications in clinical care. Contemporary investigations in public health, however, suggest that a second paradigm, nonmedical factors, may exert a broader influence on physical and behavioural wellness than targeted medical strategies. Some [1] posit that this emerging body of research suggests that social factors have a significant impact on the physical and mental wellness of populations. This does not deny that medical care influences health; rather, it indicates that medical care is not the only influence and suggests that it effects may be more limited than commonly thought, particularly in determining who becomes sick or injured in the first place. Authors [2] continue to elaborate that current medical intervention strategy to reduce health disparities do not typically take a “life-course perspective” and tend to be disease-specific, often targeting individual and health systems factors without addressing social or behavioural influences. Shifting from a medically driven paradigm, Social Determinants of Health (SDOH) are generally broad based and diverse with drivers such as socioeconomic status, education, employment, gender, and race/ethnicity. While all are significant, major academic sector suggests that employment has the most potential for positive health outcomes that are not medically driven.

To qualitatively evaluate the execution of the social determinant of employment, we present a case of an individual who participated in project Ascend, a job training portal for inner city opportunity youth that is embedded in a medical setting. The significance of our findings is discussed in the context of the importance of such a platform which uses clinical settings as a portal to address non-medical and behavioural challenges to economic advancement of underserved populations. Such a portal provided significant social support and therapeutic sessions which were critical to program continuation and ultimate employment success.

Key words: Social determinants of health, risk reduction, behavioural health, medical employment portals, job training, underserved youth.

INTRODUCTION

Social Determinants of Health (SDOH) are defined [3] as “the circumstances, in which people are born, grow up, live, work and age, and the systems put in place to deal with illness.” These systems are further shaped by “economics, social policies, and politics” on the national and local levels leading to societal hierarchy and health inequities. Social determinants are intimately connected to non-medical factors that influence the health outcomes of many individuals. For example, limited access to education limits work opportunities leading to low income and poverty which is associated with lack of employment.

The scope of the issue is significant for underserved youth; for example, in Texas it is estimated that 111,000 youth and young adults (ages 16-24) remain disconnected from both school and the labour market. These young people disproportionately come from communities of colour and live in low-income households. The SDOH platform, project Ascend targets, young adults 18-24 who have a high school diploma or GED and are disconnected from both school and the labour market. The program aims to reconnect these young adults, providing them with the tools needed for economic, physical, and emotional well-being. Components of this platform are embedded in a clinical setting and offer a variety of activities which include comprehensive online workshops and mentoring which teach resume writing, cover letter writing, financial literacy, professionalism, study skills, and job searching. Participants have weekly check-ins with Ascend professionals and 24/7 access to a dedicated staff member and program therapist. Clinical components include primary care, reproductive health, and mental health services offered free of charge through the program’s medical portal. In addition, each participant is assigned a mentor and they also receive counselling as needed from the program’s a behavioural health specialist. Support for job search is also provided including resume writing, mock interviews, and networking with local healthcare employers.

This initiative focuses on certifications in five medical careers: Certified nurse’s aide, medical business office professional, phlebotomist, telemetry technician, community health worker or electrocardiography technician. The program covers all participants’ expenses including stipends for living costs, such as transportation, housing, and food during their training program. Plus Ascend participants have access to wrap around services from their medical home.

CASE REPORT

Brianna was just nineteen when she connected with the Baylor Teen Health Clinics and learned about Ascend. She had recently graduated high school, but like many young women from her neighbourhood, the path forward was unclear. Poverty shaped her life from the start. She lived in an apartment with family members where bills were split between whoever could contribute. At one point, she wrote on her intake form that her “top three priorities” were simply “working, schooling, and mental health/family.”

She had always been interested in healthcare, and one of the clinic staff told her about the Ascend program. In her first email she wrote: “I was told by one of the Baylor Clinic staff… that if I were interested in going into healthcare this opportunity would be an option to investigate. Not only but that you’re fantastic to work with and overall, a good person to talk with about this. Again, I am just looking for some more information as to how I can start and maybe apply for grants!” That message captured where she was at the time — hopeful, but also aware she could not afford this path without outside support.

Her home life was deeply unstable. Both of her parents struggled with substance use, and early in her time with Ascend they overdosed together on the same night. Brianna later wrote: “My mother and father both overdosed last night. I was trying to find my younger sister with all this mess. I will be a bit behind because of this situation, and I’m trying to catch up as soon as possible. My mother and father are fine but they did OD and I was just needed to make sure my sister was safe.” At nineteen years old, she was left responsible for her little sister’s well-being, forced to act as both sister and parent in a household where the adults could not be relied upon. One of her key emotional challenges was to balance being both a caregiver and a sibling while living in a dysfunctional family. Each role periodically was in conflict. In addition, being a young caregiver led to significant stress from providing support and managing responsibilities. Financial issues were significant. Accessing resources like healthcare and educational support through Ascend and the clinics were vital to Brianna’s success.

Poverty compounded these struggles. After the overdose, her mother’s car was totalled and impounded, leaving Brianna without transportation. Getting to class, lab, or a doctor’s appointment became a barrier she couldn’t solve on her own. Time and again she had to arrange rides through relatives or ask for Ubers and Lyfts to be covered so she could keep up. For Brianna, a simple ride wasn’t convenience — it was survival within the program.

Housing and food insecurity were constants. When a storm knocked out power for four days, Brianna lost all of the food in her refrigerator. She reached out saying: “Due to the storm I’ve been without power for the last 4 days. It’s been terrible, we’ve lost all our food. I don’t have money to buy any food because of work being cancelled as well! It’s been me and my little sister, we’re fine in the heat but really could use foods and we don’t have any means of transportation either to make it to food banks or other places offering food services.” Later she admitted: “I spent my last few dollars yesterday on a $6 pizza. I wasn’t sure what we were going to eat tonight.”

Her environment made even studying a challenge. At one point, her apartment was broken into, and her laptop and books were stolen. Without them, she couldn’t prepare for exams. For most students, these would be setbacks; for Brianna, they were threats to her entire future. The Ascend program provided her with a new set of books and a Chromebook, ensuring she could continue her studies without interruption.

Throughout all of this, she carried the added weight of being a young Latina woman from a poor family — facing the prejudices and lowered expectations that come with her gender, ethnicity, and class. Her emails and texts reveal someone constantly apologizing for being late, for asking for help, for needing food, for needing a ride. She often shouldered blame that didn’t belong to her, as if struggling in poverty were a personal failure rather than the product of systems stacked against her.

This was Brianna’s reality when she came to the Baylor Teen Health Clinics and Ascend. She was not simply a student seeking a career; she was a teenager carrying adult responsibilities, navigating generational poverty, addiction in her household, unstable housing, food insecurity, transportation barriers, and the unspoken weight of prejudice and sexism that told her she shouldn’t expect more.

DISCUSSION

Research has shown that our inner-city minority population as seen in this case report is associated with higher rates of poverty, unemployment, homelessness, substance use, psychological distress, and overall mental illness [4]. It is possible that the social determinant of employment for this cohort is more important in influencing health than traditional known factors, and when these factors negatively influence health and mental stability.

Our client in the case presentation finished high school but did not have the resources to enroll in higher educational institutions. In the 2017 cycle of the Youth Risk Behavioural Survey, a significant number of individuals in grade 9-12 across ten states and nine large urban school districts in the United States identified similar barriers to higher education which by default reduced their employment opportunities and exposed them to low-paying jobs and financial instability. Family of origin instability was present in client situation. Housing was an essential prerequisite for any job training program and housing insecurity such as described above could have prematurely ended the desired career path.

In addition to adverse personal consequences, homelessness is also associated with health risks such as HIV in the United States which complicates job training and employment acquisition and it is a strong predictor of poor health outcomes [5]. Some of these possible health barriers to job success were avoided by our clients’ access to Ascend’s medical portal along with the program therapist which provided access at no charge to quality health care. Unfortunately, our minority population experiences higher rates of substance use and the need for behavioural health services is critical.

CONCLUSIONS

Several factors contribute to and correlate with positive employment outcomes of opportunity youth. Through the in-depth examination of this case report, several significant SDOH suggest an integrated relationship of employment in urban youth population. First, lack of higher education completion, unemployment, and housing instability found in our participant were critical determinants impacting job training and employment acquisition. Second, impaired family of origin networks in the form of abandonment and substance abuse were fundamental social determinants with significant negative behavioural health impacts. Finally, maladaptive coping strategies, if unaddressed directly predispose participants to future failure in the absence of appropriate ancillary and ongoing services. It is vital to acknowledge successful employment can reduce health disparities and promote health equity among this population in urban areas, especially when paired with a medical home. Moreover, understanding the prevalence and impact of unemployment, education, housing insecurity, substance use and discrimination on this population is critical if barriers to economic independence are to be overcome.

Acknowledgements: Funding for this project was provided in part by The William Stamps Farish Foundation, The McGovern Foundation and The Madison Charitable Foundation.

REFERENCES

1. Braveman P, Gottlieb, L. The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 2014 Jan-Feb; 129 Suppl 2, 19-31.

2. Thornton R.L.J, Greiner A, Fichtenberg, C.M, Feingold, B.J, Ellen J.M, Jennings, J.M et al. Achieving a healthy zoning policy in Baltimore: Results of a health impact assessment of the transform Baltimore zoning code rewrite. Public Health Reports, 2013, 128 (Supplement 3): 87-103.
PubMed: 24179284

3. World Health Organization (WHO). Social determinants of health: key concepts. 2013. https://www.who.int/news-room/questions-and-answers/item/social-determinants-of-health-key-concepts

https://www.who.int/news-room/questions-and-answers/item/social-determinants-of-health-key-concepts

4. James S.E, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. Washington, DC: National Center for Transgender Equality; 2016. The Report of the 2015 U.S. Transgender Survey.

5. Buchanan D, Kee R, Sadowski L.S, Garcia D. The health impact of supportive housing for HIV-positive homeless patients: a randomized controlled trial. American Journal of Public Health. 2009; 99 Suppl 3:0–80.

PEER REVIEW

Not commissioned. Externally peer reviewed.

1. Braveman P, Gottlieb, L. The social determinants of health: It’s time to consider the causes of the causes. Public Health Reports, 2014 Jan-Feb; 129 Suppl 2, 19-31.

2. Thornton R.L.J, Greiner A, Fichtenberg, C.M, Feingold, B.J, Ellen J.M, Jennings, J.M et al. Achieving a healthy zoning policy in Baltimore: Results of a health impact assessment of the transform Baltimore zoning code rewrite. Public Health Reports, 2013, 128 (Supplement 3): 87-103.
PubMed: 24179284

3. World Health Organization (WHO). Social determinants of health: key concepts. 2013. https://www.who.int/news-room/questions-and-answers/item/social-determinants-of-health-key-concepts

https://www.who.int/news-room/questions-and-answers/item/social-determinants-of-health-key-concepts

4. James S.E, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. Washington, DC: National Center for Transgender Equality; 2016. The Report of the 2015 U.S. Transgender Survey.

5. Buchanan D, Kee R, Sadowski L.S, Garcia D. The health impact of supportive housing for HIV-positive homeless patients: a randomized controlled trial. American Journal of Public Health. 2009; 99 Suppl 3:0–80.