Social Determinants of Health

"Our zip code may be more important than our genetic code" (1)

What are the social determinants of health?

The social determinants of health are the conditions, in which children, youth, and families are born; grow up, live and work, in addition to the health care infrastructure (Shern, Steverman, Ahmed, & Shea, 2011). Where you live can be a significant indicator of how well you live as well as how long you live. Such non-medical factors influence health and well-being, including health-related knowledge, attitudes, beliefs, or behaviors. (2) Socioeconomic inequalities in health have been widening for decades. In the United States the data consistently show that the poor, and particularly the non-white poor, bear a disproportionate burden of exposure to unhealthy environments and are at greater risk for mental and behavioral health-related condition. (3) In addition to health literacy, gender, education, sexual orientation and geography; culture, acculturation, language, race, ethnicity, socioeconomic status, and social exclusion significantly influence overall health status as well. (4) These factors tend to be interrelated and contribute to disparities among as well as within groups.

Why address the social determinants of health?

A social determinants of health framework can provide a more complete picture of why people become ill initially, and moreover, what it will take to restore their health. It recognizes the value of equity and social justice and considers them to be essential to staying healthy and accessing quality health care. Policy changes to alleviate the social determinants of health such as poverty, racism, violence, and access to resources can have a far reaching impact on improving the health of a community, state or county. Addressing only the symptoms of illness and ignoring its root cause will not improve population health.

Facts at a glance

Approximately 3.5. million individuals are homeless in America. (5)
In the U.S., 44 million people are living in poverty and 41.3 million are using food stamps. (6)
Children living in poverty are seven times more likely to have poor health than children in higher income households. (7)
With a prison population of 2.3 million, we now have the highest rate of incarceration in the world. (8)
Approximately 30 percent of LGBT youth report having been physically abused by family members because of their sexual orientation, gender identity or expression. (9)
LGB individuals had a 1.5 times higher risk for depression and anxiety disorders over a period of 12 months or a lifetime than heterosexual individuals. (10)
African Americans are 30% more likely to report having serious psychological distress than Non-Hispanic Whites. (11)
In 2007, Hispanics were 3 times more likely to be uninsured than non-Hispanics. (12)
American Indians and Alaska Natives have an infant death rate 40 percent higher than the rate for Caucasians. (13)
American Indian/Alaska Native adults were 2.3 times as likely as white adults to be diagnosed with diabetes. (14)
In 2006, adults with less than a high school degree were 50% less likely to have visited a doctor in the past 12 months compared to those with a bachelor's degree. (15)
Only 33% of disadvantaged fourth-graders are proficient readers at grade level. (16)
Poor Mexican-American children ages 2 to 9 have the highest proportion of untreated decayed teeth (70.5 percent), followed by poor non-Hispanic black children (67.4 percent). (17)

Who should address the social determinants of health?

Policymakers
State Health Directors
Communities

Policy Makers

Lawmakers should consider the impact of social determinants of health as a framework when developing policies.
Public policies should be developed that promote equitable access to important social and material resources.
Policies that promote social inclusion and acceptance of diverse communities should be pursued.
Consider the social determinants of health as a guide for the development of policies for behavioral health prevention that call for multi-agency partnerships or collaboration.
Key decision-makers can use this information to coordinate with foundations and other stakeholders in identifying solutions.

State Health Directors

Encourage state public health departments to partner with their state behavioral health program directors to guide implementation of evidence-based programs using the social determinants of health (e.g., parks, other recreational areas, the Good Behavior Game, et al).
Incorporate behavioral health into a broader public health state plan using social determinants of health to guide the drafting of the plan. The social determinants can be used as a frame of reference to get behavioral health folded into broader public health goal(s) of states.
To facilitate and provide support to the state health directors working with other agencies to be cognizant regarding the impact of the social determinants of health.
Address unequal access to health care in all aspects of policy including:
a. Location of clinical facilities
b. Culturally appropriate outreach to populations who are known to underutilize health care
c. Assure that lower income first time mothers have access to a visiting nurse service
Educate political leadership regarding the importance of addressing problems of poverty, racism and social exclusion for the health and productivity of the population.
Reach out to the leadership of other components of state government to address the multiple social determinants (education, safe housing, healthful food) known to drive population health.

Communities

Raise awareness of the importance of the social determinants of health and their impact on individuals and communities.
Pursue policies to assure that healthful food, safe housing and living wages are available to everyone in the community.
Support community activities to build social networks among individuals who represent differing racial or ethnic groups.

Key Messages for Everyone

Social determinants of health are the primary determinants regarding whether individuals stay healthy or become ill
The larger the gap in health disparities, the more the overall health status of entire populations is reduced
The larger the difference in health status between the healthiest and least healthy in a community the lower the overall health status of the population.
Assess the community with the community using a community-based participatory approach (community engagement)
Significant health inequalities persist among and within minority groups
Equity & social justice are the cornerstones of health

Language of Social Determinants

Health - a state of complete physical, mental, and social well-being and not just the absence of illness
Social exclusion - a multidimensional process of progressive social rupture, detaching groups and individuals from social relations and institutions and preventing them from full participation in the normal, normatively prescribed activities of the society in which they live
Oppression - the exercise of authority or power in a burdensome, cruel, or unjust manner
Acculturation - cultural modification by an individual, group or community by adapting to or borrowing traits from another culture
Social gradient - the extent of the difference in wealth and opportunity between those with the most and those with the least
Structural racism - Institutional racism is the differential access to the goods, services, and opportunities of society .Generally, there is no sole, true identifiable perpetrator; when racism is built into the institution, it appears as the collective action of the population
Social capital - the fabric of a community and the community pool of human resources available
Income inequality - unequal distribution of household or individual income across the various participants in an economy
Health Inequity - a difference or disparity in health outcomes that is systematic, avoidable, and unjust
Health disparities - differences in health outcomes between groups that reflect social inequalities
Health literacy - whether a person can obtain, process, and understand basic health information and services that are needed to make appropriate health decisions; also requires complex group of reading, listening, analytical, and decision-making

Robert Wood Johnson Foundation. http://www.rwjf.org/vulnerablepopulations/product.jsp?id=42029
WHO (2010). Social determinants of health. Retrieved from http://www.who.int/social_determinants/en/
Evans, G., & Kantrowitz, E. (2002). Socioeconomic status and health: The potential role of environmental risk exposure. Annual Review of Public Health, 23, 303-31.
Situational Analysis: Issues of Relevance in Designing a National Strategy to Promote Mental, Emotional, and Behavioral Health and to Prevent/Reduce Mental Illness and Substance Use Disorders. D. Shern, S. Steverman, E. Ahmed, & P. Shea. National Association of State Mental Health Program Directors, 2011. Page 6.
National Coalition for the Homeless. (2009). How many people experience homelessness? Retrieved from http://www.nationalhomeless.org/factsheets/How_Many.html
DeNavus-Walt, C., Proctor, B.D., & Smith, J.C. (2010). Income, poverty, and health insurance coverage in the United States: 2009. U.S. Census Bureau, Current Population Reports, P60-238. Washington, DC: U.S. Government Printing Office. Retrieved from http://www.census.gov/prod/2010pubs/p60-238.pdf
Situational Analysis: Issues of Relevance in Designing a National Strategy to Promote Mental, Emotional, and Behavioral Health and to Prevent/Reduce Mental Illness and Substance Use Disorders. Op. cit.
Ibid. Page 7.
http://minorityhealth.hhs.gov/
http://books.nap.edu/openbook.php?record_id=13128&page=206
http://minorityhealth.hhs.gov/
http://www.cdc.gov/nccdphp/dach/chhep/index.htm
http://minorityhealth.hhs.gov/
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=3&lvlid=26
http://www.cdc.gov/nccdphp/dach/chhep/index.htm
http://www.cdc.gov/nccdphp/dach/chhep/index.htm
http://www.ahrq.gov/research/dentalcare/dentria.htm