Jornadas de Medicina Social: un núcleo colaborativo de educación para promover la acción sobre los Determinantes Sociales de la Salud en sectores comunitarios de la Alaska rural / Social Medicine Grand Rounds: A Collaborative Education Hub to Promote Action on Social Determinants of Health Across Community Sectors in Rural Alaska

Lucas Trout Trout, Kristine Salters, Rob Inglis, Matthew Tobey, Jennifer Kasper

Resumen


TRASFONDO: La estratificación de la carga de morbilidad en EEUU a partir de diferencias sociales, económicas y raciales apunta a la necesidad de formatos de educación y práctica médicas que vinculen el análisis interdisciplinario de las desigualdades sociales a intervenciones sociales y estructurales concretas como parte del ámbito esencial del cuidado clínico. Esta lectura del proyecto de la medicina social - en la cual se une el suministro de servicios de salud a una agenda de equidad pragmática y operativizada - resulta particularmente relevante en sistemas de salud tribales, en los cuales la población de los pacientes asume una carga dispar de lesiones y enfermedades, en los cuales fuerzas sociales e históricas juegan un papel importante en la producción y mantenimiento de estas disparidades sanitarias, y en los cuales fuerzas económicas y sociales limitan la disponibilidad, accesibilidad y eficacia de los servicios de salud.

OBJETIVOS: Este artículo describe el marco conceptual y materiales educativos de un programa de medicina social Jornadas en un sistema de salud tribal en Alaska Septentrional, dirigido hacia el desarrollo de capacidades clínicas, organizacionales, y comunitarias para abordar los determinantes sociales de la salud. Lideradas por la División de Medicina Social de la Asociación Maniilaq y en conjunto con colaboradores de la Escuela de Medicina de Harvard y el Hospital General de Massachusetts, los Jornadas de medicina social unen a los equipos de cuidado clínico de hospitales y pueblos con trabajadores de servicio social y tribal y con miembros de la comunidad para estudiar y aplicar perspectivas de la medicina social al suministro de servicios de salud en 12 pueblos circumpolares indígenas de Alaska. El modelo utiliza un currículo basado en el cuidado médico para impulsar la colaboración clínico-comunitaria y el análisis crítico de retos en la prestación de servicios de salud enfocado en cuatro áreas de prioridad establecidas por los dirigentes tribales: salud materna e infantil, enfermedades crónicas, salud mental, y enfermedades infecciosas.

MÉTODOS: El programa Jornadas de medicina social fue puesto a prueba en abril del 2017 y será formalmente inaugurado en noviembre del 2017. Los investigadores usarán un enfoque de métodos combinados, uniendo el análisis de datos de expedientes médicos electrónicos con entrevistas a participantes y datos de encuestas pre y post para investigar cambios en los patrones de prácticas de proveedores relacionados a determinantes sociales de la salud, alianzas comunitarias e intersectoriales, y revisiones a políticas y protocolos del sistema de salud durante un año de programación. Encuestas pre, durante y post recolectadas antes de que comience el programa, a los seis meses, y después de un año de programación servirán para evaluar el nivel de conocimiento, disposición, y acción de los participantes para abordar determinantes sociales de la salud. Un protocolo de evaluación de la necesidades sociales administrado en la clínica ambulatoria evaluará las necesidades satisfechas e insatisfechas de los pacientes, y un rango discreto de resultados sanitarios será monitoreado usando registros de pacientes del expediente médico electrónico.

DISCUSIÓN: Proponemos la hipótesis de que al traer los determinantes sociales de la salud a la esfera de preocupación moral de los trabajadores de salud; al subrayar la relevancia clínica y utilidad de la teoría y análisis social; al fortalecer alianzas comunitarias que vinculen la atención médica primaria a servicios sociales y tribales; y al fomentar habilidades prácticas entre los trabajadores de salud para incluir intervenciones sociales y estructurales como parte del repertorio clínico de base, las Jornadas pueden contribuir a la mitigación de los impactos de la estratificación social sobre la situación sanitaria en el noroeste de Alaska.

CONCLUSIÓN: Las Jornadas de medicina social examinan cómo fuerzas sociales, históricas, y estructurales se encarnan como enfermedades y lesiones en individuos, así como las maneras en que estas fuerzas dan forma a la eficacia médica, la experiencia de la enfermedad, y al estándar de cuidado. El modelo sirve para construir comunidades inter-profesionales de práctica para el aprendizaje, la deliberación, y la acción sobre los determinantes sociales de la salud en el noroeste de Alaska, así como para construir y potenciar la infraestructura compartida clínica, educativa, y de entrenamiento con colaboradores académicos para expandir el alcance del programa y reducir las desigualdades de salud.

Palabras clave: medicina social, indígena de Alaska, disparidades de salud, determinantes sociales de la salud, equidad en salud, estratificación social, salud tribal


Abstract

Background: The stratification of America’s disease burden along social, economic, and racial lines suggests the need for forms of medical education and practice that link interdisciplinary analysis of the impacts of social inequities to practical social and structural intervention as part of the essential purview of clinical care. This reading of the project of social medicine—to wed health care delivery to a pragmatic and operationalized equity agenda—is particularly relevant to tribal health systems, where patient populations bear a disparate burden of injury and disease, where social and historical forces play a large role in the generation and maintenance of these health disparities, and where social and economic forces constrain the availability, accessibility, and efficacy of health care.
Objectives: This paper describes the conceptual framework and educational materials from a social medicine grand rounds program in an Alaskan arctic tribal health system, aimed at building clinical, organizational, and community capacity to address social determinants of health. Led by the Maniilaq Association Division of Social Medicine with partners at Harvard Medical School and Massachusetts General Hospital, social medicine grand rounds bring together hospital and village clinic-based care teams, social and tribal service workers, and community members to study and apply social medicine perspectives to health care delivery across 12 circumpolar Alaska Native villages. The model utilizes a case-based curriculum to drive clinical-community collaboration and critical analysis of health care delivery challenges focused on four priority areas established by tribal leadership: maternal and child health, chronic disease, mental health, and infectious disease.

Methods: The social medicine grand rounds program was piloted in April 2017 and will be formally launched in November 2017. Researchers will utilize a mixed methods approach, pairing analysis of electronic health record data with participant interviews and pre-post survey data to investigate changes in provider practice patterns relating to social determinants of health, community and cross-sector partnerships, and revisions to health system policies and protocols over one year of programming. Pre-mid-post surveys collected before the program begins, at the six-month mark, and after a year of programming will assess participants’ knowledge, readiness, and action to address social determinants of health. A social needs assessment protocol administered in the outpatient clinic will evaluate patients’ met and unmet needs, and a discrete range of health outcomes will be tracked using patient registries in the electronic health record.

Discussion: We hypothesize that by maneuvering social determinants of health into the sphere of moral concern of health workers; by underscoring the clinical relevance and utility of social theory and analysis; by strengthening community partnerships linking primary care to social and tribal services; and by building a practical skill set among health workers to include social and structural interventions as part of the core clinical repertoire, grand rounds may contribute to the mitigation of the impacts of social stratification on health outcomes in Northwest Alaska.
Conclusion: Social medicine grand rounds examine how social, historical, and structural forces are embodied as illness and injury in individuals, as well as how these forces shape medical efficacy, illness experience, and standard of care. The model serves to build inter-professional communities of practice for learning, deliberation, and action on social determinants of health in Northwest Alaska, and to build and leverage shared clinical, education, and training infrastructure with academic partners to expand the reach of the program and reduce health inequities.

Keywords: social medicine, Alaska Native, health disparities, social determinants of health, health equity, social stratification, tribal health.

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