Study of the Week -- Mind the Health Gap

Drs Camilla Alderighi and Raffeale Rasoini cover the Study of the Week

Doctors have to pass medical exams. Correct answers on these tests aren’t always the correct answers in the real world. That’s because, in real life, social situations can influence success far more than any prescription.

Sensible Medicine’s wife and husband team of Camilla Alderighi and Raffeale Rasoini show us how typical cookie-cutter medical recommendations can fail, and then they explore two trials that studied unique ways to overcome social barriers to successful healthcare delivery.

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Mrs. G. is 41 years old, but her forehead is furrowed with many wrinkles that she hides under diligent makeup. She lost her job months ago. With two small children and a husband who struggles with a poorly controlled bipolar disorder, Mrs. G. is on edge. She started eating unhealthy food and resumed smoking. Her headaches worsened, and a check at the pharmacy found increased blood pressure, which prompted her to schedule a doctor’s appointment.

If we performed a guideline-driven evaluation and dismissed Mrs. G. with a recommendation to quit smoking, lose weight through diet and physical activity, and return in three months to assess the need for BP drugs, we wouldn’t really have provided her with a care service.

The textbook advice for Mrs G to change her unhealthy behaviors is unlikely to work. The obvious reason: her socioeconomic and psychological factors are the stronger determinants of her health choices.

The more likely outcome at three-month follow-up is that Mrs. G. would not have stopped smoking or changed her diet. Neither would she have embarked on any physical activity. And, with unchanged blood pressure, we may end up prescribing drug therapy.

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“Why treat people and send them back to the conditions that make them sick?” asks Michael Marmot, director of the University College London Institute of Health Equity, in his book The Health Gap.

Marmot has accumulated evidence from populations worldwide on the existence of a social gradient in health: the lower a person is on the socioeconomic scale, the worse their health and the shorter their life.

The role of doctors and health systems to help reduce these health gaps seem much less clear.

According to Marmot, public health interventions should take better account of the social context of the individuals they are aimed at.

We agree and would like to describe two examples from health research.

First is the LA Barbershop Blood Pressure Study, a cluster randomized trial published in NEJM in 2018 that addressed blood pressure management among non-Hispanic Black men in Los Angeles.

The idea behind this study reveals a deep understanding of the social context of many Black communities in the US. Men in these communities have high death rates related to the consequences of high blood pressure and, on average, tend to have few contacts with the healthcare system.

This study’s authors randomized 52 barbershops, serving 319 Black patrons with high blood pressure, to an intervention group in which the barbers actively promoted meetings in the barbershops with pharmacists trained in hypertension management or a control group in which barbers only gave advice on lifestyle changes and on attending medical encounters.

This results showed a huge decrease in blood pressure in the intervention group. The BP reduction exceeded that observed in the mainstream trials of blood-pressure-lowering drugs.

Our second example is the Changzhi Reporters Trial, published in PLOS ONE in 2021. Trial authors recruited 66 newspaper journalists in Changzhi to conduct a randomized trial on the blood pressure lowering effect of a salt substitute versus usual diet. Make no mistake, recruitment of the study participants, administration of the salt substitutes, and blood pressure measurements were all carried out by trained journalists.

The researchers found significant blood pressure reduction in the salt substitute arm, and these positive results were promptly shared with the participating journalists at the end of the trial.

The most surprising results were that journalists’ active participation in a successful trial itself became an educational intervention with the journalists themselves. An analysis of the local newspapers’ articles found a substantial increase in the number of articles about the health effects of salt substitutes soon after the trial, which had lasting effects over the four years of follow-up. Moreover, the results of surveys on random citizens before and after the trial showed that knowledge and awareness about salt intake and health had improved.

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We appreciate these studies because they inspire hope. And they relieve, albeit mildly, the sense of inadequacy that we feel when we apply a reductive biomedical approach to the intricacies of human suffering.

While there’s general agreement on the need to recognize and take action on the social determinants of health, we currently lack substantial data about how to do it effectively.

As a starting point, health interventions could be thought of as fitting gently into the social contexts of their recipients.

We believe these two novel study designs help point us in the right direction.