Social Determinants of Health, Part 2: Access to care, health literacy and patient engagement.

by Dr. Randall Williams, MD

Readers of this blog know that the most basic actions influence health in powerful ways. Some of these simple but profound health actions include:

  • eating nutritious food;
  • being physically active;
  • avoiding high-risk behaviors (like smoking);
  • receiving recommended immunizations and screenings;
  • and scheduling an appointment with a provider when needed.

Yet, while we know these things, for various reasons many of our patients (and sometimes even we ourselves) do not do these things consistently or at all. The challenges are so deep-seated and the behavior is so antithetical to our aspirations as a society that the federal government created an initiative called Healthy People 2020. One of its primary organizational goals for this decade:

“To create social and physical environments that promote good health for all.”[1]

Healthy People 2020 has identified five focus areas within the broader social determinants of health:

  1. Economic stability
  2. Education
  3. Social and community context
  4. Health care access and literacy
  5. Neighborhood and built environment

Although many of these critical components stretch well beyond the reach of healthcare provider organizations, I think you’ll agree that healthcare access and health literacy fall directly into the lap of organizations committed to being accountable for the health and healthcare of populations.

First, a few facts on healthcare access.

  • Only 59% of target adults receive guideline-based colorectal cancer screening
  • Only 49% of adults with hypertension have their disease under control
  • Only 21% of diabetics have their disease under control
  • Only 68% of children receive the recommended childhood immunizations

Recognizing that you can’t expect to receive proper preventative care unless you have access to a physician, and that having “access” to a primary care provider does not necessarily guarantee that this care will be delivered, here are some additional sobering facts about healthcare access:

  • As of 2011, only 77.3% of Americans had a usual primary care provider. Nearly a quarter of Americans did not.
  • The story gets more concerning as you look at groups based on insurance status. While nearly 82% of Americans insured through public sources (Medicare, Medicaid, VA, Tricare) had a primary care doctor, that number falls to 80% with private insurance and dips to only 42% of the uninsured. (View the infographic here.)
  • Just like real estate, healthcare access is about location, location, location. According to the CDC, locally, physicians per 100,000 individuals varies widely from zero to 508, with generally lower rates in rural areas and in the south.



Graphic originally published at (

While I’m not advocating for a mandatory redistribution of physicians, I do think there are ways, especially given modern communications technologies, that we can begin to bridge the gaps created by geographic differences. More on that topic in a future post.

 Now, a few facts on health literacy.

Healthcare literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions[1]

According to, persons with limited or poor health literacy/skills:

  1. Are more likely to skip recommended preventative care such as mammograms or flu shots.
  2. Are more likely to have chronic diseases and are less able to manage them effectively. Studies have found that persons with high blood pressure, diabetes, asthma, or HIV/AIDS who have low health literacy have less knowledge of their condition and how to manage it.
  3. Are associated with increased rates of avoidable hospitalization. Studies have also shown higher utilization rates for ER and inpatient admissions.
  4. Have been shown to utilize healthcare services normally aimed at treating complications of illness and less likely to utilize services aimed at preventing complications of illness.
  5. Are more likely to report their own health as poor.

Lower health literacy contributes to poor health, inability to self-manage chronic conditions effectively, increased usage of inappropriate care, increased inpatient and ER utilization, and increased costs.  According to the National Assessment of Literacy, only 12% of American adults have proficient health literacy.  In other words, roughly 9 out of 10 of your population may lack the necessary understanding of their health needs to adequately manage their condition and prevent disease exacerbations.

Bridging the gaps: leveraging technology for healthcare access and health literacy.

Over the years, my colleagues and I have worked with ACOs and health systems across the country, many of who practiced in remote, rural and/or healthcare “access challenged” areas. These providers have used telehealth and other simple communications technologies, like mobile phones, to provide their populations with the kind of care support that might otherwise be delivered in person, or worse, not at all. Using technology as a bridge across distances and in-between visits has allowed these organizations to:

  • care for more patients;
  • follow up more closely with those needing frequent care;
  • and increase the scale of their care coordination efforts, while improving health outcomes and reducing costs of care.

(You can download and read more about one such organization who used a technology-enhanced care model here.)

Technology is also an effective way to address health literacy challenges. Patient engagement technology helps providers detect problems in health literacy within large populations. Screening for patient confidence and patient activation allows care coordinators to identify which patients lack the necessary knowledge to succeed with their self-care. Once these patients have been identified, care coordinators can take the next step to educate them and improve their health management skills.

Daily patient engagement technology also addresses heath literacy with “just in time education”. In this model, patient education is delivered in small, bite-sized, easy-to-consume messages each day while the patient is already thinking about their care and receptive to new learning.  This approach complements care coordinator interactions and coaching sessions with patients by reinforcing key educational messages customized to their individual patient’s needs.

To deliver value-based care, you need to understand the challenges around access and literacy. You also need to build a care model that addresses these social determinants of health. In the third part of this series, I’ll be exploring how an individual’s living environment contributes to their health—and why providers need to be keyed into this piece of the puzzle as well.

(Just a quick reminder – you can download the report on using patient engagement technology for a rural, medically underserved population by clicking the button below.)

Download the free report


[2] U.S. Department of Health and Human Services. 2000. Healthy People 2010. Washington, DC: U.S. Government Printing Office.

Dr. Randall Williams, MDSocial Determinants of Health, Part 2: Access to care, health literacy and patient engagement.

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