Social Determinants of Health: What They Are and Why We Need Them in Public Health
As reported in a 2014 Public Reports article, a large and compelling body of evidence has accumulated, particularly during the last two decades, that reveals a powerful role for social factors—apart from medical care—in shaping health across a wide range of health indicators, settings, and populations. This evidence does not deny that medical care influences health; rather, it indicates that it is not the only influence on health. Moreover, research suggests that medical care may be more limited than commonly thought, particularly in determining who becomes sick or injured in the first place.
Consider the following example from a 2019 Time magazine article about research that showed your zip code's influence in terms of your longevity. Researchers from the New York University School of Medicine used data from NYU Langone Health's City Health Dashboard to find that 56 of the 500 largest U.S. cities are home to people who can expect to live at least 20 fewer years than those in other neighborhoods, even if they're just blocks or miles away. Where you live directly affects your health in several ways, from exposure to air pollution and toxins to accessibility of healthy food and medical care.
It is also a more subtle indicator of socioeconomic factors inherent to health and longevity, including race and income. For example, the cities with the widest gaps in life expectancy were those that were most segregated by race and ethnicity, with predominantly minority neighborhoods often facing obstacles. Obstacles include poverty, untenable housing costs, unemployment, and subpar social services—that did not affect majority-white neighborhoods to the same degree.
This research study underscores the importance and influence of Social Determinants of Health (SDoH) in public health and calls for its inclusion in studies that solely focus on individual behavior.
The World Health Organization (WHO) and the U.S. Department of Health and Human Services (HHS) have developed definitions for SDoH.
The WHO defines SDoH as "the conditions in which people are born, grow, work, live, and age and the wider set of forces and systems shaping the conditions of daily life. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels." They state SDoH are primarily responsible for health inequities—the unfair and avoidable differences in health status seen within and between countries.
Similarly, HHS Healthy People 2030 defines SDoH as "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."
Healthy People 2030 uses the framework below to organize domains of SDoH. A project is listed under each category to provide an example that aligns with that domain.
#1: Economic Stability
This domain explores the connections between income, cost of living, socioeconomic status, and health. Key issues include poverty, employment, food security, and housing stability.
Example: Association of Socioeconomic Status with Eye Health Among Women With and Without Diabetes
#2: Healthcare Access Quality
This domain explores access to and understanding of health services. Key issues include access to healthcare, primary care, health insurance coverage, and health literacy.
Example: Characteristics and Current Clinical Practices of Opioid Treatment Programs in the United States
#3: Social and Community Context
This domain explores community cohesion, civic participation, discrimination, issues in the workplace, and incarceration.
Example: A housing mobility program's impacts on teen and young adult parenting
#4: Education Access and Quality
Key issues include high school graduation, enrollment in higher learning, language and literacy, and early childhood development.
Example: Linking studies to assess the life expectancy associated with eighth-grade school achievement
#5: Neighborhood and Built Environment
Key issues include quality of housing, access to transportation, availability of healthy foods, air and water quality, and neighborhood crime and violence.
Example: Local Government Retail Incentives for Healthier Food Retailers in the USA, 2014
Health in All Policies
Health in All Policies (HiAP) recognizes that health is created by a multitude of factors beyond healthcare and, in many cases, beyond the scope of traditional public health activities.
Together, people who work in public health, healthcare, and non-health fields can take actions that target SDOH. HiAP is a collaborative approach that integrates health into policy-making across sectors to improve the health of all communities and people. The HiAP approach may also be effective in identifying gaps in evidence and achieving health equity.
Hopefully, you see the benefit of SDoH in public health and will incorporate it in your next research project.
Research and materials for this article were compiled, written, and distributed on behalf of the National Public Health Information Coalition. The views and opinions expressed in this blog are those of the various authors and do not necessarily reflect the official policy or position of the National Public Health Information Coalition or its members.
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