Social Determinants of Health: A Framework for Communicating with Health Care Professionals and Policy Specialists about the Work of the Organized Blind Movement

by Justin Salisbury

From the Editor: In the National Federation of the Blind, we do not consider blindness to be primarily a health problem. On the other hand, we want very much for those who treat people who are experiencing changes in their eyesight to refer their patients to us, especially at the point where further medical intervention is either impossible or undesirable. We also often find ourselves needing to communicate our concerns to people who view blindness primarily through the healthcare lens, including legislators and members of the media. Justin Salisbury, a dedicated Federationist now residing in Minnesota who always seeks to apply what he learns to achieve practical and positive results, believes that he has found a way to explain our movement to these audiences that is worth trying. Here is what he says:

For many years, I had learned to argue that blindness was not a healthcare issue, but I am now open to more possibilities. I would like to share a framework that will be new to some readers, and I will explain how I think this framework is useful for communicating with healthcare professionals and health policy specialists.

As many readers know, each year, the National Federation of the Blind gathers in Washington, DC, for our annual Washington Seminar, where we put our heads together and visit our federal legislators to advance the legislative agenda of blind Americans. In some of those congressional appointments, I have found myself assigned to a legislative aide who specialized in healthcare issues, even at times when I was not there to discuss a bill as directly about health care as the Medical Device Nonvisual Accessibility Act. If I went there to talk about ending disability-based subminimum wages, I still may have found myself talking to a health policy specialist. I suspect that this phenomenon may come from the idea that what blind people want and need might be healthcare to try to heal our eyesight. This is not the case for many of us, but the conversation does not need to end just because we find ourselves in the presence of a healthcare professional or health policy specialist.

In 2017, in the Hawaii State Legislature, there was a bill that would have harmed blind people. Proponents of the bill were moving it through the legislature by using low expectations of blind people to justify what they wanted to do. This bill would have added blindness to the list of qualifying disabilities for handicapped parking placards in the State of Hawaii. The proponents argued that it was terrifying to walk through a parking lot as a blind person and that this bill was absolutely necessary to ensure our safety. The National Federation of the Blind opposes the issuance of such placards to the blind pursuant to Resolution 85-22, which observes that ‘the unnecessary use of such parking spaces by blind persons casts doubt on our assertion that blindness does not render us helpless and immobile.” In other words, it is a manifestation of low expectations of blind people, specifically our ability to move freely and safely through the world. As a cane travel instructor with a National Orientation and Mobility Certification, I have taught blind people how to travel confidently so that blindness is not a reason to need handicapped parking. Our fear was that the routine services offered to newly blind people would include handicapped parking placards.

While I was working for the vocational rehabilitation agency, one of my supervisors called me into their office and told me about the bill purely for my information. I quickly found myself pulling together a team of witnesses to go into a joint senate committee hearing and testify against the bill. I took the time to investigate the chairs of each of the two committees, and I was disappointed to learn that one of them was a medical doctor. Here we go again, I thought, but we made our case. Somehow, the medical doctor really understood what we were saying. He killed the bill for us. He also asked us what other bills were on our wish list so that he could help us with them, and he became the first sponsor of our first parental rights bill. He fought for us, and I decided to help him with his primary campaign for lieutenant governor. During a campaign event, I asked one of his fellow doctors about why this network of physicians seemed to understand what I was talking about. He told me that they really believed in addressing the social determinants of health (SDOH), and he explained the SDOH framework. Today, the medical doctor/state senator who introduced our parental rights bill, Joshua Green, is the governor of Hawaii.

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. I borrowed this definition from Healthy People 2030, a nationwide initiative aimed at improving the health and well-being of all Americans by the year 2030. The Affordable Care Act (also known as Obamacare) and other public policies have encouraged health care organizations to focus on SDOH. Several codes of ethics across different health care professions—including the American Public Health Association (APHA) Code of Ethics, the American Medical Association (AMA) Code of Medical Ethics, and the National Association of Social Workers (NASW) Code of Ethics—encourage health care professionals to consider and address SDOH.

Different entities have organized SDOH into different category lists, just like there are many ways you can cut up a pizza before you eat it. I will stick with the system from Healthy People 2030. In this system, SDOH are organized into five domains: (1) economic stability, (2) education access and quality, (3) health care access and quality, (4) neighborhood and built environment, and (5) social and community context.

For economic stability, the goal is to help people earn steady incomes that allow them to meet their health needs. Blind people who get involved in the National Federation of the Blind are more likely to have higher incomes than blind people who do not, according to data from a 2018 study by doctors Edward Bell and Arielle Silverman. This should not be much of a surprise, since the Federation was initially organized to confront threats to the financial well-being of blind people. We have worked for many years to promote the employment, wages, and expectations of blind people in the workforce. We also advocate for policies and programs that support the economic stability of blind people. We often advocate for adequate funding for vocational rehabilitation programs and minimum wage laws that do not exclude workers with disabilities. We also advocate for changes to Social Security Disability Insurance benefits to eliminate the harsh earnings cliff that stops all benefits if a blind person earns one dollar over the substantial gainful activity threshold.

For education access and quality, the Healthy People 2030 goal is to increase educational opportunities and help children and adolescents do well in school. I think that education access and quality are important across the lifespan, including for children and adolescents. In the National Federation of the Blind, we help support students to succeed in school, partly through the skills and confidence that we give each other, partly through advocating with specific educational programs and institutions to ensure that they are serving blind students well, and partly through advocating for legislation that supports education access and quality for blind students. We may advocate for government grant programs to support the training of people, blind or sighted, who want to become a Teacher of Blind Students (TBS), cane travel instructor, or rehabilitation teacher. These professionals help enhance the educational futures of blind students. We may also advocate for the improved accessibility of medical office and laboratory equipment, which helps create opportunities for blind students to study medicine and related professions.

For health care access and quality, the goal is to increase access to comprehensive, high-quality health care services. This domain is pretty directly connected to our advocacy and easily understood. If we have better access to quality health care services, we will be likely to have better health outcomes. Sometimes, we approach this by advocating for better accessibility of medical devices or medical information systems, such as online patient portals, health applications, and check-in kiosks at health care facilities. Sometimes, the National Federation of the Blind does end up being a place where people learn more about how to manage their health, even though it is not about their eye health, at least directly. For example, I have friends who have learned a lot about how to manage their diabetes as a blind person through the Federation’s Diabetes Action Network. I have enjoyed Jessica Beecham’s fitness breaks during national convention, as well as the programming of our Sports and Recreation Division to help blind people to pursue our fitness and recreational goals. Federationists recently fought for, and got, an extension of Medicare telemedicine benefits, which assist blind people who struggle with transportation to medical appointments. And although I have not heard much about this as a formal NFB initiative, there are some discussions in statewide health care policy spaces to address the shortage of health care providers accepting Medicaid or to improve medical transportation programs funded through Medicaid. Many blind people need to use these programs and resources to seek health care.

For neighborhood and built environment, the goal is to create neighborhoods and environments that promote health and safety. Local chapters in the National Federation of the Blind have advocated for changes in the built environment and sometimes for neighborhood safety. Sometimes, chapters have advocated for accessible signals at crosswalks or advocated for how they should be designed. Other times, chapters have advocated for removal of barriers in the build environment. I was once involved in an advocacy effort to remove an anchor bolt that had once been attached to a telephone pole and was sticking out at an odd angle on the sidewalk near an agency serving the blind. I bashed my shin on it once. It created an environmental hazard and served no functional purpose, so we worked together to get it removed. Some chapters have advocated to remove traffic signs, much like deer crossing signs, that warn drivers that blind people may be crossing the street at particular intersections. These are occasionally installed near agencies serving the blind, but they are pieces of our built environment that undermine the health and safety of blind people by lowering expectations. Low expectations can lead to carelessness, and they can also lead a blind person to conclude that their cane travel skills are good enough when they could be improved significantly.

For social and community context, the goal is to increase social and community support. Quite simply, the National Federation of the Blind is a source of social and community support. In the Federation, we also encourage and support blind people to go out and be part of other networks in their lives so that blindness is not a barrier to social integration. Through the NFB, I have met blind people in leadership or other roles in their homeowners’ associations, churches, fraternities or sororities, and many other spaces where people find social and community support. Some specific objectives in Healthy People 2030 for this goal include increasing voter participation, deinstitutionalizing people with disabilities, and helping to keep children from being separated from their parents, which have been longstanding Federation priorities.

Sometimes, local chapters of the National Federation of the Blind will undertake outreach campaigns to eye doctors’ offices to advocate for our brochures to appear in the waiting rooms of eye clinics and for eye doctors who find that a patient is becoming blind to tell that patient about the National Federation of the Blind. I think this is a great thing that we do, and I think we should keep doing it. It is also possible that we could connect more comprehensively with those eye doctors by explaining to them that participating in the National Federation of the Blind can help to improve the social determinants of health for their patients and thereby improve health outcomes. I have tried this and found mixed results; some eye doctors cannot remove themselves from the compulsion to try to help their patients see. But some of them understand, so I think this approach is worth continuing. I have also learned from my conversations with many health care professionals that the best place to sell this message is to the primary care physicians, who largely function as a case manager of a person’s health care. Health insurance companies also employ case managers for their customers. If we can get the attention of these professionals who hold case manager roles, we may find that many of them end up referring blind people to the National Federation of the Blind.

When I talk to health care professionals or health policy specialists about an initiative of the National Federation of the Blind, or if I am explaining what Structured Discovery adjustment-to-blindness training can do for blind people whose lives they can influence, I now have a way to speak their language. If I can explain the initiative and the ways it fits into the social determinants of health (SDOH) framework, I may be able to connect with them better than I did ten years ago. Even if they do not hold the power to do what I want at the moment, building that understanding with them could help to recruit them as a powerful ally who may walk with me to meet the person who can. You can do it, too. As long as our initiative improves the well-being of blind people, which will certainly be our intent, then it will improve our social determinants of health.

References

Bell, E. C., & Silverman, A. M. (2018). Rehabilitation and Employment Outcomes for Adults Who Are Blind or Visually Impaired: An Updated Report. Journal of Blindness Innovation and Research, 7(1). Retrieved from https://nfb.org/images/nfb/publications/jbir/jbir18/jbir080101.html. doi: http://dx.doi.org/10.5241/8-148

Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved January 1, 2025, from https://odphp.health.gov/healthypeople/objectives-and-data/social-determinants-health