A Picture Is Worth a Thousand Words

Abstract

Teaching students about the intricacies of how social determinants of health (SDOH) influence individual and community health requires instructor creativity. This article offers an innovative strategy for engaging millennials, those born after 1982, in learning about the SDOH. The teaching approach uses engaging techniques, community engagement, and graphic information systems to reach students. This activity is best facilitated through four different sessions: (1) class session: introduction and explanation of SDOH; (2) small group discussions; (3) homework assignment: students physically collect and store the primary data and the instructor assimilates the data and creates a map; and (4) class session: visual analysis and discussion of data and resulting maps. At the end of the implementation of this teaching strategy, students should be able to list and describe each of the SDOH; collect, record, and classify primary data (e.g., address, photograph, service type) on physical assets that both positively and negatively contribute to individual health in a specific community; and evaluate and discuss how geographic location of resources influences individual health.

Keywords

mapping millennials social determinants of health SDOH

Generally, most undergraduate and graduate students understand that taking care of themselves by eating well and staying active, not smoking, getting enough sleep, getting recommended immunizations and screening tests, and seeing a doctor when sick all influence individual health (HealthyPeople.gov, 2015). However, many undergraduates may not grasp the concept that

health is also determined in part by access to social and economic opportunities; the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships. The conditions in which we live explain in part why some Americans are healthier than others and why Americans more generally are not as healthy as they could be. (HealthyPeople.gov, 2015)

Social determinants of health (SDOH) are often used to provide a conceptual framework for students to learn about the complexity of individual and community health (Solar & Irwin, 2010). In order to teach students that health does not occur in isolation, faculty often illustrate SDOH in a cycle (see Figure 1).

Figure 1.

Social determinants of health (SDOH).

Figure 1 communicates how health differs greatly depending on where someone is born and the neighborhood where someone lives, plays, and grows up (Marmot, Friel, Bell, Howeling, & Taylor, 2008). While the graphic is a helpful visualization of the influencers of health, teaching undergraduate students may require a shift in teaching strategies to more dynamic methods. Because of their digital, web-based, interactive, and visual media habits, teaching millennials, those born after 1982, requires instructors to include more engaging and interactivity in the classroom (Monaco & Martin, 2007; Norcini, 2003; Roehl, Reddy, & Shannon, 2013).

This article is designed to present a method for instructors to facilitate student learning on the significance of SDOH in influencing health. The strategy utilizes several teaching approaches specifically designed to engage millennial students including actual physical community exploration and mapping.

Objectives

At the end of the implementation of this teaching strategy, students should be able to the following:

List and describe each of the SDOH.

Collect, record, and classify primary data (e.g., address, photograph, service type) on physical assets that both positively and negatively contribute to individual health in a specific community.

Evaluate and discuss how geographic location of resources influences individual health.

Target Population

Although this activity is designed for undergraduate and graduate students, the strategy can be applied to any public health or health promotion course.

Materials and Resources Needed

Computer or laptop and printer

Pen, note pad, and dry erase markers

Microsoft Excel and PowerPoint software

Mapping software (free and downloaded from the Internet)

Projection screen

Whiteboard

Mapping Software

A mapping system (also called a geographic information system or GIS) generally integrates hardware, software, and data for capturing, managing, analyzing, and displaying all forms of geographically referenced data and information (Maguire, 1991). This system allows one to input, integrate, analyze, model, interpret, and visualize spatial data in ways that reveal relationships, patterns, and trends in the form of maps, reports, and charts. A mapping system helps answer questions, solve problems, and even market new research ideas by observing spatial data in a way that is easily understood and shared. In addition, new mapping apps are also being developed for ease of use in the field using smart phones.

Open source mapping software can be easily downloaded from the following:

Mapline: https://mapline.com/

EasyMapMaker: http://www.easymapmaker.com/

Batchgeo: http://en.batchgeo.com/features/map-excel-data/

Maptive: https://www.maptive.com/

These programs allow the user to easily upload an Excel spreadsheet and create a map. An example of a map created using a combination of Excel and mapping software is illustrated in Figure 2.

Figure 2.

Sample map of community health assets around Sam Houston State University campus generated by students for class discussion.

Procedure

This activity is best facilitated through the following four different sessions: (1) class session: introduction and explanation of SDOH; (2) small group discussions; (3) out of class assignment: through physical exploration and personal observations of local neighborhoods students collect and store the primary data and the instructor assimilates the data and creates a map; and (4) class session: visual analysis and discussion of data and resulting maps.

Session 1: Class Lecture and Practice Session (Introduction and Explanation of SDOH)

The instructor will begin with a lecture on the concept of SDOH. The lecture will discuss the process in depth and provide examples of all five determinants of health (see Figure 1). The instructor will explain how each determinant can be either a positive or a negative contributing factor to individual and community health. In addition, the instructor will provide examples of both positive and a negative assets influencing individual and community health. The lecture should take approximately 30 minutes.

Session 2: Small Group Discussion

Next, the instructor will break the class into small groups of no more than four students for discussion purposes. The groups will be assigned the task of identifying two to three examples of physical assets that contribute to each determinant of health and how that asset affects health. Table 1 illustrates an example of how these data can be collected. It provides the students the SDOH category, an example of an asset contributing to the SDOH, as well as an example explanation of how the asset contributes to health. This exercise should take 20 to 25 minutes.

Table 1.

SDOH Assets and Contributions to Health.

SDOH	Asset example	How the asset contributes to health
Neighborhood and Built Environment	Affordable housing, full-service grocery stores, fast-food restaurants, convenience stores, public parks, green spaces, transportation, and so on	Full-service grocery stores—Allow people to have access to healthy foods. Healthy eating promotes healthy weight.
Neighborhood and Built Environment		Fast food restaurants—Encourage poor eating habits that contribute to obesity.
1.
2.
3.
Health and Health Care	Physician offices, clinics, hospitals dentists offices, hospitals, and so on	Physician offices—Provides access to healthcare needed to stay healthy.
Health and Health Care		Clinics—No availability of clinics may mean that people have limited options for seeking health care services.
1.
2.
3.
Social and Community Context	Police stations, lack of social order, residential segregation, and so on	Police stations—Presence of police can lead to a feeling of public safety. When there is safety, people are more likely to utilize parks and green spaces for healthy behaviors such as exercise.
Social and Community Context		Lack of social order—Exposure to crime and violence contributes to feeling of stress and therefore mental health issues.
1.
2.
3.
Education	High schools, elementary schools, preschools, and so on	Schools—Access to education has been shown to be linked to healthy behavior choices.
Education	High schools, elementary schools, preschools, and so on	Preschool—Limited access to preschool education may negatively influence high school graduation rates. This affects health as high school graduation has been linked to better health.
1.
2.
3.
Economic Stability	Local business, affordable housing, full-service grocery stores, and so on	Local business—Provide employment opportunities. With access to employment may come health insurance. Health insurance allows access to doctors so that people can maintain health.
Economic Stability		Full-service grocery stores—Full-service grocery stores may not set business in a neighborhood that they feel will not be profitable. Without access to healthy food choices, people may make bad choices that result in obesity or high blood pressure.
1.
2.
3.

Note. SDOH = social determinants of health.

Each group will turn in one copy of the assignment to the instructor and keep one copy for the group. The instructor will then review each group’s document. As a class, the students and the instructor will discuss each SDOH, asset, and what affect that asset has on health. The discussion should take approximately 20 to 25 minutes.

Session 3: Out of Class Assignment (Field Data Collection)

Student tasks

The instructor will divide students into small groups of no more than four students (Carini, Kuh, & Klein, 2006; Sanders, 1995). In order to encourage the sharing of knowledge, the groups should be different from the groups used for the in-class exercise. Groups will meet at a central point as defined by the instructor. The instructor will provide groups the address and general neighborhood of the meeting point. The groups will have 1 hour (from beginning to end) to walk no more than a 1-mile perimeter from the central point. As they walk, they will record the names, addresses (street address, city/town, and zip code) of all potentially health-relevant physical assets that they locate and to which category of SDOH that asset belongs. Students will utilize previous knowledge about physical assets that contribute to each determinant of health and how that asset affects health from the class lecture and exercise to complete this assignment. On completion of their community exploration exercise, the group will transcribe their notes into an Excel spreadsheet and send it to the instructor.

Instructor tasks

The instructor will take the student-submitted Excel spreadsheets and aggregate them into one spreadsheet. Then, using Excel spreadsheets and mapping software, the instructor will generate a map for class discussion (see Figure 2). The following definitions are associated with the specific assets that students were to map: “central point”—the point at which the students met to begin the community exploration project; “transportation”—bus stations or bus stops; “physical activity”—green spaces and public parks; “liquor store”—sell only alcohol; “housing”—apartment complexes and dorms; “food/alcohol”—convenience stores; “fast food and restaurant”—sell food that can prepared quickly and taken away; and “child care”—day care centers.

Session 4: Class Discussion (Visual Analysis and Discussion of Data and Maps)

The final piece of this exercise is a class discussion of student findings following their community exploration. While the discussion might take many forms, it should be centered on data collected and an analysis of the resulting map created from the data.

Figure 2 illustrates an actual example of this class exercise carried out in a freshman-level college course, Introduction to Health Education and Careers in Health Education, in the summer of 2015 with a class of 20 students. The map depicts the scale of exposure to negative influencers of health for the students. The radius of the inner circle is approximately one quarter of a mile, the radius of the middle circle is approximately one half a mile, and the radius of the outer circle is one mile. Standard walking speed for a stroll is about 17 minutes for mile (Williams & Thompson, 2013). As seen in Figure 2, from a central point outwards, students are bombarded with close access to fast food and alcohol. Eight of the nine fast food outlets noted are in the inner two circles and are between approximately 4 and 8 minutes from the central point. Four of the six areas for physical activity are outside the largest circle and would range from 20 to 30 minutes to walk. One area for physical activity would require a walk of about 17 minutes, while the closest to the center would be about a 12-minute walk. Thus, the more positive influencers of health, such as sites for physical activity, are much further out from the central point than are the negative influences, such as fast food and restaurant, liquor, and food/alcohol. The positive influences are even farther from housing. In addition, in order to get to sites for physical activity, major intersections and highways would have to be crossed, which is daunting in a largely sidewalk less environment and particularly threatening in a summer environment in which the heat index regularly crosses 100 (Lees, Clark, Nigg, & Newman, 2005; Mayo Clinic, 2015; Tappe, Duda, & Ehrnwald, 1989).

With each new data set and/or center point location of the classroom exercise, the center point on such a map will most probably differ. Consequently, access to both positive and negative resources will also shift. As the center point changes, the instructor will then need to adjust the class discussion based on the resulting map.

Assessment Techniques

Several ways exist for the instructor to assess student learning from this teaching methodology based on Millers Pyramid (Norcini, 2003). At the lowest level, the instructor can develop quiz and/or test questions assessing students’ understanding, or what they know, of SDOH and the influence that access to various assets has on health. Second, instructors can assess student learning, or how knowledge is employed, using class participation and discussion. Last, instructors can assess class understanding of how physical assets shape individual and community health by reviewing the spreadsheets turned in. The more comprehensive the list(s), the deeper the class understanding and student demonstration of competence.

Conclusion

The presentation of information regarding the SDOH in a visual format is a powerful way to educate students. The display of assets, both positive and negative, on a map can demonstrate to students how physical location contributes to individual health. Additionally, this bird’s eye view concisely demonstrates how positive assets, for example, parks and green spaces, and negative assets, for example, fast food restaurants and liquor stores, contribute or detract from individual and community health.

Not only is an asset map a helpful way to visualize the influencers of health, but mapping the SDOH transforms and updates lecture-based teaching methodologies. Creating asset maps from student-collected data can be a more dynamic teaching strategy. It offers the instructor additional ways in which to engage millennial students.

Footnotes

Acknowledgements

The authors would like to thank the Office of Research and Sponsored Programs, GIS Center, at Sam Houston State University for their support and contribution to this project.

Authors’ Note

In-kind staff support to conduct the mapping task was provided by the Office of Research and Sponsored Programs, GIS Center, Sam Houston State University, Huntsville, Texas.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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