5.2 Social determinants of health

Social determinants of health shape our well-being from birth. They include where we live, work, and play. These factors go beyond individual choices, influencing health outcomes and quality of life for entire communities.

Understanding social determinants is key to improving public health. By addressing issues like education, income, and environment, we can reduce health disparities. This approach requires teamwork across different sectors to create lasting positive change.

Social Determinants of Health

Definition and Explanation

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• 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
• SDOH encompass the social, economic, and physical conditions that influence individual and group differences in health status and health outcomes
• The concept of SDOH emphasizes that health is not solely determined by individual behaviors or access to healthcare, but is significantly shaped by the broader social, cultural, and environmental contexts in which people live
• SDOH operate at multiple levels, including individual, interpersonal, community, and societal levels, and interact in complex ways to influence health outcomes across the life course
• Addressing SDOH is critical for improving population health, reducing health disparities, and promoting health equity

Importance and Impact

• SDOH play a crucial role in shaping the health and well-being of individuals and communities
• Understanding and addressing SDOH is essential for developing effective public health interventions and policies that promote health equity
• Recognizing the impact of SDOH helps shift the focus from individual-level factors to the broader social, economic, and environmental determinants that influence health outcomes
• Addressing SDOH requires collaboration across sectors, including healthcare, social services, education, housing, and transportation, to create comprehensive and sustainable solutions
• Investing in strategies that target SDOH can lead to long-term improvements in population health and reduce the burden of chronic diseases and health disparities

Major Social Determinants

Socioeconomic Factors

• Socioeconomic status (SES), including income, education, and occupation, is a key determinant of health
  • Lower SES is associated with poorer health outcomes, higher mortality rates, and limited access to resources that promote health (healthcare, healthy food, safe housing)
  • Higher SES is linked to better health outcomes, longer life expectancy, and greater access to health-promoting resources (preventive care, health education, recreational facilities)
• Economic stability, including employment, job security, and financial resources, can impact access to healthcare, healthy food, and safe living conditions, ultimately affecting health outcomes
  • Unemployment and job insecurity are associated with increased stress, mental health problems, and limited access to health insurance and healthcare services
  • Financial strain can lead to housing instability, food insecurity, and reduced ability to afford health-promoting resources (medications, preventive care, health education materials)

Social and Community Context

• Social and community context, including social cohesion, social capital, and exposure to discrimination and social stressors, can impact health behaviors, mental health, and overall well-being
  • Social cohesion and social capital, which refer to the strength of social relationships and networks within a community, are associated with better health outcomes and increased access to health-promoting resources (social support, information, resources)
  • Exposure to discrimination and social stressors, such as racism, sexism, and poverty, can lead to chronic stress, mental health problems, and adverse health behaviors (smoking, substance abuse, unhealthy eating)
• Education, including early childhood education, school quality, and educational attainment, is linked to health literacy, health behaviors, and long-term health outcomes
  • Higher levels of education are associated with better health outcomes, increased health literacy, and adoption of health-promoting behaviors (regular exercise, healthy eating, preventive care)
  • Early childhood education and high-quality schools can provide a foundation for lifelong learning, social-emotional development, and health literacy skills

Physical Environment

• Neighborhood and built environment factors, such as housing quality, access to healthy food, transportation, and exposure to environmental toxins, can influence health behaviors and outcomes
  • Poor housing quality, including exposure to lead, mold, and overcrowding, can lead to respiratory problems, injuries, and mental health issues
  • Limited access to healthy food options and an abundance of fast food outlets in a neighborhood can contribute to poor dietary habits and increased risk of obesity and chronic diseases
  • Lack of safe and reliable transportation can limit access to healthcare services, employment opportunities, and health-promoting resources (parks, recreational facilities, healthy food outlets)
  • Exposure to environmental toxins, such as air and water pollution, can increase the risk of respiratory problems, cancer, and other chronic health conditions

Healthcare Access and Quality

• Health and healthcare access, including the availability, accessibility, and quality of healthcare services, as well as health literacy and healthcare-seeking behaviors, play a significant role in shaping health outcomes
  • Limited access to healthcare services, due to factors such as geographic location, transportation barriers, and lack of health insurance, can lead to delayed or foregone care and worse health outcomes
  • Poor quality of healthcare services, including inadequate patient-provider communication, cultural insensitivity, and medical errors, can result in suboptimal care and adverse health outcomes
  • Low health literacy, which refers to the ability to obtain, process, and understand basic health information and services, can impact healthcare-seeking behaviors, adherence to treatment plans, and self-management of chronic conditions
  • Healthcare-seeking behaviors, such as regular check-ups, preventive screenings, and timely treatment for acute and chronic conditions, can influence health outcomes and prevent the progression of diseases

Social Determinants vs Health Inequities

Relationship between Social Determinants and Health Inequities

• Health inequities are the unjust and avoidable differences in health status and outcomes between different population groups, often resulting from the unequal distribution of social determinants
• Social determinants interact and accumulate over the life course, creating complex pathways through which they influence health outcomes and contribute to health inequities
  • For example, children born into low-income families may have limited access to high-quality education, leading to lower educational attainment and employment opportunities, which in turn can impact their access to healthcare, healthy food, and safe living conditions, ultimately resulting in poorer health outcomes and widening health inequities
• The intersection of multiple social identities, such as race, ethnicity, gender, and socioeconomic status, can lead to compounded disadvantages and exacerbate health inequities
  • For instance, Black women from low-income backgrounds may face multiple forms of discrimination and barriers to accessing health-promoting resources, resulting in disproportionately higher rates of chronic diseases and maternal mortality compared to their White, higher-income counterparts

Structural and Systemic Factors

• Structural and systemic factors, such as racism, discrimination, and unequal distribution of power and resources, shape the distribution of social determinants and perpetuate health inequities
  • Systemic racism, which refers to the policies, practices, and norms that create and maintain racial inequalities, can lead to unequal access to education, employment, housing, and healthcare, ultimately contributing to racial health disparities
  • Discrimination in healthcare settings, such as implicit bias among healthcare providers, can result in differential treatment, misdiagnosis, and suboptimal care for marginalized populations, exacerbating health inequities
• Health inequities are not only a result of individual choices or behaviors but are deeply rooted in the social, economic, and political structures that create and maintain unequal opportunities for health
  • Addressing health inequities requires a focus on the upstream determinants of health, such as policies that promote equal access to education, employment, and housing, rather than solely relying on individual-level interventions
  • Promoting health equity necessitates dismantling the structural and systemic barriers that perpetuate inequalities and creating more just and inclusive social, economic, and political systems that provide equal opportunities for health and well-being

Strategies for Health Equity

Policy and Program Interventions

• Implementing policies and programs that improve access to quality education, stable employment, and livable wages can help reduce socioeconomic disparities and promote health equity
  • Investing in early childhood education programs, such as universal pre-kindergarten and high-quality childcare, can provide a strong foundation for lifelong learning and health
  • Implementing living wage policies and job training programs can improve economic stability and access to health-promoting resources for low-income populations
• Developing community-based interventions that foster social cohesion, build social capital, and address social stressors can promote mental health and well-being
  • Implementing community-wide initiatives that promote social connectedness, such as neighborhood events and social support groups, can enhance social cohesion and improve mental health outcomes
  • Establishing community-based organizations that provide resources and support for individuals facing social stressors, such as violence prevention programs and immigrant support services, can mitigate the impact of adverse social determinants on health
• Improving access to affordable, quality healthcare services, including preventive care and mental health services, can help reduce health disparities and improve health outcomes for disadvantaged populations
  • Expanding Medicaid coverage and implementing policies that promote healthcare affordability, such as subsidies for health insurance premiums, can increase access to healthcare services for low-income populations
  • Integrating mental health services into primary care settings and increasing the availability of community-based mental health resources can improve access to mental healthcare and reduce disparities in mental health outcomes

Community Engagement and Empowerment

• Engaging communities in the planning, implementation, and evaluation of health interventions can ensure that strategies are culturally appropriate, responsive to local needs, and effective in promoting health equity
  • Involving community members in the development of health promotion programs and policies can help identify local priorities, cultural values, and social norms that influence health behaviors and outcomes
  • Establishing community advisory boards and partnerships with community-based organizations can facilitate the implementation of health interventions that are tailored to the unique needs and strengths of specific communities
• Empowering communities to advocate for their health needs and participate in decision-making processes can foster a sense of ownership and sustainability in health promotion efforts
  • Providing training and resources for community members to develop leadership skills and engage in advocacy efforts can help build capacity for community-driven change
  • Supporting community-based participatory research and evaluation can generate evidence on the effectiveness of health interventions and inform the development of more equitable and sustainable health promotion strategies

Addressing Structural and Systemic Factors

• Advocating for policies that address structural and systemic factors, such as racism and discrimination, and promote social justice and equal opportunities for health can create more equitable and sustainable improvements in population health
  • Implementing anti-discrimination policies in healthcare settings, such as cultural competency training for healthcare providers and diversity initiatives in healthcare institutions, can help reduce disparities in healthcare access and quality
  • Advocating for policies that address the root causes of health inequities, such as housing policies that promote affordable and stable housing, can create more equitable living conditions and improve health outcomes for disadvantaged populations
• Promoting intersectoral collaboration and partnerships between health, social services, education, housing, and other sectors can help address the complex and interconnected nature of social determinants of health
  • Establishing cross-sector partnerships, such as collaborations between healthcare providers and housing agencies, can help coordinate services and resources to address the multiple social determinants that influence health outcomes
  • Developing comprehensive and integrated approaches to health promotion, such as place-based initiatives that address multiple social determinants in a specific geographic area, can create more sustainable and equitable improvements in population health