Social determinants of health

In 2008, the WHO Commission on Social Determinants of Health published a report entitled "Closing the Gap in a Generation", which aimed to understand, from a social justice perspective, how health inequity could be remedied, and what actions could combat factors that exacerbated injustices.[8] The work of the commission was based on development goals, and thus, connected social determinants of health discourse to economic growth and bridging gaps in the healthcare system.^[8] This report made three broad recommendations regarding social determinants of health that needed to be addressed.^[8] The first imperative was to improve daily living conditions, including work and home physical environments, early childhood development and education, and social protection across the lifespan. The second recommendation was to disrupt the distribution of power, money, and resources, including social inequities such as gender disparities; this recommendation involves a more active role on the part of government. Third, the report calls for a global acknowledgement of the problem so as to take its full measure, as well as assess the impact of any planned interventions.^[9]

The 2010 Affordable Care Act (ACA) established by the Obama administration in the United States, embodied the ideas put in place by the WHO by bridging the gap between community-based health and healthcare as a medical treatment, meaning that a larger consideration of social determinants of health was emerging in the policy.^[10] The ACA established community change through initiatives like providing Community Transformation Grants to community organizations, which opened up further debates and talks about increased integration of policies to create change on a larger scale.^[11]

The 2011 World Conference on Social Determinants of Health, in which 125 delegations participated, created the Rio Political Declaration on Social Determinants of Health.

The United States Centers for Disease Control and Prevention (CDC) defines social determinants of health as "life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care, whose distribution across populations effectively determines length and quality of life."^[15] These include access to care and resources such as food, insurance coverage, income, housing, and transportation.^[15] Differences in rates of occupational injuries and illnesses are closely linked with demographic, social, cultural, economic, and/or political factors. Although many advances have been made to rectify gaps in occupational health within the past half century, still many persist due to the complex overlapping of occupational health and social factors.^[16]

According to a report by the Center for Migration Studies of New York, the different social determinants of health are strongly correlated. People living in an area with one identified determinant also tend to be affected by other determinants.^[17] Social determinants of health influence health-promoting behaviors, and health equity among the population is not possible without equitable distribution of social determinants among groups.^[15]

A commonly used model that illustrates the relationship between biological, individual, community, and societal determinants is Whitehead and Dahlgren's model originally presented in 1991 and subsequently adapted by the CDC.^[18] Additionally, within the United States, Healthy People 2030^[19] is an objective-driven framework which can guide public health practitioners and healthcare providers on how to address social determinants of health at the community level.^[20]

In Canada, these social determinants of health have gained wide usage:

The list of social determinants of health can be much longer. A 2019 article identified several other social determinants, including culture or social norms; media, stigma, and discrimination; immigration; religion; and access to broadband internet service.[23] Additional research indicates that social determinants of health can be directly tied to degrees of health literacy.^[24] Unfortunately, there is no agreed-upon taxonomy or criteria as to what should be considered a social determinant of health. In the literature, a subjective assessment—whether social factors impacting health are avoidable through structural changes in policy and practice—seems to be the dominant way of identifying a social determinant of health.^[23] The increase of artificial intelligence (AI) being used in clinical care raises numerous opportunities for addressing health equity issues, yet clear models and procedures for data characteristics and design have not been embraced consistently across health systems and providers.^[25]

Gender

Economics

"Economic stability is a social determinant that significantly impacts employees because it is an aspect of wellness that intersects with so many others.^[41]" Economic stability within households is essential for the health and well-being of families, neighborhoods and for local and national economies.^[42] "Economic security is having stable, sufficient income to meet basic needs while economic insecurity is living in a household with incomes below 200 percent of the federal poverty level.^[42]" According to Child Welfare League of America (CWLA), Economic stability is described as the ability to obtain the resources that is necessary to one's life and well-being.^[3]

Maintenance of good health through the utilization of proper healthcare resources can be quite costly and therefore unaffordable to certain populations. According to the

Housing is another critical aspect of economics as a social determinant of health. In a 2020 housing study in which millions of court records on renter evictions were analyzed, the evidence on racial and gender demographics were dramatic.^[47] Black and Latino tenants experienced significantly higher eviction rates than their white counterparts. And housing instability plays a critical role in health outcomes: when families have to spend a disproportionately high percentage of income (30% or more) on housing, there are insufficient funds remaining for essentials such as healthy foods, consistent health care, and medications.^[48] Racial disparities in eviction rates correspond to negative health outcomes, including depression.^[49]

Food security—meaning consistent availability and affordability of food that promotes well-being and prevents disease—is another important social determinant of health linked to economics.^[50] Food insecurity increases in neighborhoods where access to healthy food is limited because of travel distance to supermarkets and lack of transportation.^[51] Families living in poverty struggle with consistent access to sufficient healthy food, and suffer negative health outcomes as a result; food insecurity has been demonstrated to correlate with many health issues, including chronic disease and obesity.^[52]

As one's job or career is a primary conduit for both financial and social capital, work is an important, yet under represented, factor in health inequities research and prevention efforts.^[53] There are many ways that a job can affect one's health, such as the job's physical demands, exposure to hazards, mechanisms of employment, compensation and benefits, and availability of health and safety programs. In addition, those who are in steady jobs are less likely to face poverty and its implications and more likely to have access to health care.^{[53][54][55][56][57]}

Work

Work is a defined social determinant of health, meaning that the conditions at work are a key aspect in determining the health of an individual.^[58] This was demonstrated notably during the COVID-19 pandemic when members of the essential workforce were exposed to a much higher risk of the disease by the necessity of being at work.^[59] Other examples include the relatively higher risk of injury in construction jobs or the relatively higher risk of toxic substances in many industrial jobs.

Because many of the jobs associated with higher health risks are essential to society, it is important to implement policies to mitigate the inequities experienced by these workers. A "good job" is defined by the CDC as one that is safe and healthy; has sufficient income and benefits; allows for work-life balance; provides employment security; considers employees' voices in decision-making; offers opportunities to gain skills; and has positive employment-related relationships.^[58]

Ongoing debates

Steven H. Woolf [Wikidata] of the Virginia Commonwealth University Center on Human Needs states, "The degree to which social conditions affect health is illustrated by the association between education and mortality rates."^[60] Reports in 2005 revealed the mortality rate was 206.3 per 100,000 for adults aged 25 to 64 years with little education beyond high school, but was twice as great (477.6 per 100,000) for those with only a high school education and three times as great (650.4 per 100,000) for those less educated. Based on the data collected, the social conditions such as education, income, and race were dependent on one another, but these social conditions also apply to independent health influences.^[60]

Marmot and Bell of the University College London found that in wealthy countries, income and mortality are correlated as a marker of relative position within society, and this relative position is related to social conditions that are important for health including good early childhood development, access to high quality education, rewarding work with some degree of autonomy, decent housing, and a clean and safe living environment. The social condition of autonomy, control, and empowerment turns are important influences on health and disease, and individuals who lack social participation and control over their lives are at a greater risk for heart disease and mental illness.^[61]

Early childhood development can be promoted or disrupted as a result of the social and environmental factors affecting the mother, while the child is still in the womb. Janet Currie's research finds that women in New York City receiving assistance from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), in comparison to their previous or future childbirth, are 5.6% less likely to give birth to a child who is underweight, an indication that a child will have better short term, and long term physical, and cognitive development.^[62]

Several other social determinants are related to health outcomes and public policy, and are easily understood by the public to impact health.^[23] They tend to cluster together – for example, those living in poverty experience a number of negative health determinants.^[22]

International health inequalities

Even in the wealthiest countries, there are health inequalities between the rich and the poor.

The materialist approach offers insight into the sources of health inequalities among individuals and nations. Adoption of health-threatening behaviors is also influenced by material deprivation and stress.[75] Environments influence whether individuals take up tobacco, use alcohol, consume poor diets, and have low levels of physical activity. Tobacco use, excessive alcohol consumption, and carbohydrate-dense diets are also used to cope with difficult circumstances.^[76][75] The materialist approach seeks to understand how these social determinants occur.

The neo-materialist approach is concerned with how nations, regions, and cities differ on how economic and other resources are distributed among the population.^[77] This distribution of resources can vary widely from country to country. The neo-materialist view focuses on both the social determinants of health and the societal factors that determine the distribution of these social determinants, and especially emphasizes how resources are distributed among members of a society.

The social comparison approach holds that the social determinants of health play their role through citizens' interpretations of their standings in the

Life-course approaches emphasize the accumulated effects of experience across the life span in understanding the maintenance of health and the onset of disease. The economic and social conditions – the social determinants of health – under which individuals live their lives have a cumulative effect upon the probability of developing any number of diseases, including heart disease and stroke.[80] Studies into the childhood and adulthood antecedents of adult-onset diabetes show that adverse economic and social conditions across the life span predispose individuals to this disorder.^[81][82]

Hertzman outlines three health effects that have relevance for a life-course perspective.^[83] Latent effects are biological or developmental early life experiences that influence health later in life. Low birth weight, for instance, is a reliable predictor of incidence of cardiovascular disease and adult-onset diabetes in later life. Nutritional deprivation during childhood has lasting health effects as well.

Pathway effects are experiences that set individuals onto trajectories that influence health, well-being, and competence over the life course. As one example, children who enter school with delayed vocabulary are set upon a path that leads to lower educational expectations, poor employment prospects, and greater likelihood of illness and disease across the lifespan. Deprivation associated with poor-quality neighborhoods, schools, and housing sets children off on paths that are not conducive to health and well-being.^{[84][citation needed]}

Cumulative effects are the accumulation of advantage or disadvantage over time that manifests itself in poor health, in particular between women and men.^[85] These involve the combination of latent and pathways effects. Adopting a life-course perspective directs attention to how social determinants of health operate at every level of development – in utero, infancy, early childhood, childhood, adolescence, and adulthood – to both immediately influence health and influence it in the future.^{[86][87][citation needed]}

Chronic stress and health

The direct relationship between stress and health outcomes is the effect of stress on human physiology. The long term stress hormone, cortisol, is believed to be the key driver in this relationship.^[89] Chronic stress has been found to be significantly associated with chronic low-grade inflammation, slower wound healing, increased susceptibility to infections, and poorer responses to vaccines.^[88] Meta-analysis of healing studies has found that there is a robust relationship between elevated stress levels and slower healing for many different acute and chronic conditions^[90] However, it is also important to note that certain factors, such as coping styles and social support, can mitigate the relationship between chronic stress and health outcomes.^[91][92]

Stress can also be seen to have an indirect effect on health status. One way this happens is due to the strain on the psychological resources of the stressed individual. Chronic stress is common in those of a low socio-economic status, who are having to balance worries about financial security, how they will feed their families, housing status, and many other concerns.^[93] Therefore, individuals with these kinds of worries may lack the emotional resources to adopt positive health behaviors. Chronically stressed individuals may therefore be less likely to prioritize their health.

In addition to this, the way that an individual responds to stress can influence their health status. Often, individuals responding to chronic stress will develop potentially positive or negative coping behaviors. People who cope with stress through positive behaviors such as exercise or social connections may not be as affected by the relationship between stress and health, whereas those with a coping style more prone to over-consumption (i.e. emotional eating, drinking, smoking or drug use) are more likely to see negative health effects of stress.^[91] Vape shops are also found more in low socioeconomic status areas. The owners target these areas in particular to gain profit. Since people with low-income status are not highly educated, they are more prone to make poor health behavior choices. Socioeconomic status also has a huge impact in lives of people of color. According to Kids Count Data Center, Children in Poverty 2014, in the United States 39% of African American children and adolescents, and 33% of Latino children and adolescents are living in poverty (Kids Count Data Center, Children in Poverty 2014).^[94] The stress these racial groups with low socioeconomic status face, is higher than the same race group from a high-income community.^[95] According to the research done on socioeconomic disparities in vape shop density and proximity to public schools, the researchers found that vape shops were located a lot more in the areas with schools where African-Americans/Latinos/Hispanic students were in higher population than the areas with schools where White population was more.^[96]

The detrimental effects of stress on health outcomes are hypothesized to partly explain why countries that have high levels of income inequality have poorer health outcomes compared to more equal countries.

A landmark study conducted by the World Health Organization and the International Labour Organization found that exposure to long working hours, operating through psychosocial stress, is the occupational risk factor with the largest attributable burden of disease, i.e. an estimated 745,000 fatalities from ischemic heart disease and stroke events in 2016.^[98]

Improving health conditions worldwide

Reducing the health gap requires that governments build systems that allow a healthy standard of living for every resident.

Interventions

Three common interventions for improving social determinant outcomes as identified by the WHO are education, social security and urban development. However, evaluation of interventions has been difficult due to the nature of the interventions, their impact and the fact that the interventions strongly affect children's health outcomes.^[99]

1. Education: Many scientific studies have been conducted and strongly suggests that increased quantity and quality of education leads to benefits to both the individual and society (e.g. improved labor productivity).^[100] Health and economic outcome improvements can be seen in health measures such as blood pressure,^[101][102] crime,^[103] and market participation trends.^[104] Examples of interventions include decreasing size of classes and providing additional resources to low-income school districts. However, there is currently insufficient evidence to support education as a social determinants intervention with a cost-benefit analysis.^[99]
2. Social Protection: Interventions such as "health-related cash transfers", maternal education, and nutrition-based social protections have been shown to have a positive impact on health outcomes.
   Cochrane Collaboration Review of the health impact of unconditional cash transfers in low- and middle-income countries found a large body of evidence that these cash transfers clinically meaningfully reduce in the likelihood of being sick (by an estimated 27%), may also improve food security and dietary diversity, and may also reduce extreme poverty and improve school attendance, as well as increase healthcare spending.^[107][108]
3. Urban Development: Urban development interventions include a wide variety of potential targets such as housing, transportation, and infrastructure improvements. The health benefits are considerable (especially for children), because housing improvements such as smoke alarm installation, concrete flooring, removal of lead paint, etc. can have a direct impact on health.[109] In addition, there is a fair amount of evidence to prove that external urban development interventions such as transportation improvements or improved walkability of neighborhoods (which is highly effective in developed countries) can have health benefits.^[99] Affordable housing options (including public housing) can make large contributions to both social determinants of health, as well as the local economy,^[110] and access to public natural areas -including green and blue spaces- is also associated with improved health benefits.^[111][112]

The Commission on Social Determinants of Health made recommendations in 2005 for action to promote health equity based on three principles: "improve the circumstances in which people are born, grow, live, work, and age; tackle the inequitable distribution of power, money, and resources, the structural drivers of conditions of daily life, globally, nationally, and locally; and measure the problem, evaluate action, and expand the knowledge base."^[113] These recommendations would involve providing resources such as quality education, decent housing, access to affordable health care, access to healthy food, and safe places to exercise for everyone despite gaps in affluence. Expansion of knowledge of the social determinants of health, including among healthcare workers, can improve the quality and standard of care for people who are marginalized, poor or living in developing nations by preventing early death and disability while working to improve quality of life.^[114]

Challenges of measuring value of interventions

Many economic studies have been conducted to measure the effectiveness and value of social determinant interventions but are unable to accurately reflect effects on public health due to the multi-faceted nature of the topic. While neither cost-effectiveness nor cost-utility analysis is able to be used on social determinant interventions, cost-benefit analysis is able to better capture the effects of an intervention on multiple sectors of the economy. For example, tobacco interventions have shown to decrease tobacco use, but also prolong lifespans, increasing lifetime healthcare costs and is therefore marked as a failed intervention by cost-effectiveness, but not cost-benefit. Another issue with research in this area is that most of the current scientific papers focus on rich, developed countries, and there is a lack of research in developing countries.^[99]

Policy changes that affect children also present the challenge that it takes a significant amount of time to gather this type of data. In addition, policies to reduce child poverty are particularly important, as elevated stress hormones in children interfere with the development of brain circuitry and connections, causing long term chemical damage.^[115] In most wealthy countries, the relative child poverty rate is 10 percent or less; in the United States, it is 21.9 percent.^[116] The lowest poverty rates are more common in smaller well-developed and high-spending welfare states like Sweden and Finland, with about 5 or 6 percent.^[116] Middle-level rates are found in major European countries where unemployment compensation is more generous and social policies provide more generous support to single mothers and working women (through paid family leave, for example), and where social assistance minimums are high. For instance, the Netherlands, Austria, Belgium and Germany have poverty rates that are in the 7 to 8 percent range.^[117]

Within clinical settings

Connecting patients with the necessary social services during their visits to hospitals or medical clinics is an important factor in preventing patients from experiencing decreased health outcomes as a result of social or environmental factors.^[118] This can take the form of community health workers who can support patients with their care plans developed in conjunction with their primary care physicians.^[119]

A clinical study done by researchers at the University of California San Francisco, indicated that connecting patients with the resources to utilize and contact social services during clinical visits, significantly decreased families social needs and significantly improved children's overall health.^[120]

In addition, within the clinical setting, it was noted that in order to better health outcomes for the patients in any clinical setting, a collection of SHD data should be documented. This helps maintain the connection between healthcare systems and organizations that address these needs that were documented.^[121]

Public policy

The Rio Political Declaration on Social Determinants of Health embraces a transparent, participatory model of policy development that, among other things, addresses the social determinants of health leading to persistent health inequalities for indigenous peoples.^[68] In 2017, citing the need for accountability for the pledges made by countries in the Rio Political Declaration on Social Determinants of Health, the World Health Organization and United Nations Children's Fund called for the monitoring of intersectoral interventions on the social determinants of health that improve health equity.^[122]

The United States Department of Health and Human Services includes social determinants in its model of population health, and one of its missions is to strengthen policies which are backed by the best available evidence and knowledge in the field.^[123] Social determinants of health do not exist in a vacuum. Their quality and availability to the population are usually a result of public policy decisions made by governing authorities. For example, early life is shaped by availability of sufficient material resources that assure adequate educational opportunities, food, and housing among others. Much of this has to do with the employment security and the quality of working conditions and wages. The availability of quality, regulated childcare is an especially important policy option in support of early life.^[124] These are not issues that usually come under individual control but rather they are socially constructed conditions which require institutional responses.^[125] A policy-oriented approach places such findings within a broader policy context. In this context, Health in All Policies has seen as a response to incorporate health and health equity into all public policies as means to foster synergy between sectors and ultimately promote health.

Yet it is not uncommon to see governmental and other authorities individualize these issues. Governments may view early life as being primarily about parental behaviors towards their children. They then focus upon promoting better parenting, assist in having parents read to their children, or urge schools to foster exercise among children rather than raising the amount of financial or housing resources available to families. Indeed, for every social determinant of health, an individualized manifestation of each is available. There is little evidence to suggest the efficacy of such approaches in improving the health status of those most vulnerable to illness in the absence of efforts to modify their adverse living conditions.^[126]

A team of the Cochrane Collaboration conducted the first comprehensive systematic review of the health impact of unconditional cash transfers, as an increasingly common up-stream, structural social determinant of health. The review of 21 studies, including 16 randomized controlled trials, found that unconditional cash transfers may not improve health services use. However, they lead to a large, clinically meaningful reduction in the likelihood of being sick by an estimated 27%. Unconditional cash transfers may also improve food security and dietary diversity. Children in recipient families are more likely to attend school, and the cash transfers may increase money spent on health care.^[107]

One of the recommendations by the Commission on the Social Determinants of Health is expanding knowledge – particularly to health care workers.^[114]

Although not addressed by the WHO Commission on Social Determinants of Health, sexual orientation and gender identity are increasingly recognized as social determinants of health.^[127]

With all the different health inequities and differences in quality of care addressed in social determinants of health, the American Hospital Association created the Value Initiative project which helps make healthcare more affordable to people of all types. It does this four different ways:

1. It frames issues regarding the healthcare system and its pricing and affordability.^[128]
2. It provides knowledge, resources, and tools for hospitals to supply affordable healthcare and increase value^[128]
3. The initiative collects data of hospital experiences to develop new federal policy solutions^[128]
4. Builds a platform for the American Hospital Association to discuss with policymakers to find solutions to the lack of affordable care.^[128]

This initiative educates the public and makes sure there is transparency in pricing of hospital bills, making sure patients are not billed more than they should be. It also addresses the cost drivers in the healthcare system, and urges for legislators to take action to make healthcare affordable and to prioritize health over profit.^[129] This organization asks congress to control the rising costs of pharmaceuticals by encouraging competition between manufacturers, and improving transparency in drug pricing.^[129] In this value initiative, they have started the Affordability Advocacy Agenda (AAA) which improves the ongoing policy and advocacy activities. With the Covid-19 pandemic health care spending increased and there was a rise in hospitalizations and therefore a rise in demand for health care providers. The price for care has increased and there aren't enough workers to meet the demand for care.^[130] The AAA and congress are working together to provide relief from the pandemic in order to make healthcare more affordable to all.

As of January 1, 2022 there are regulations placed for healthcare providers about no surprise billing. This is the "No Surprises Act" of division BB of the Consolidated Appropriations Act, 2021 and this rule was made by the Biden-Harris administration.^[131] Patients should not be billed more than they expected to pay, it is often noticed with emergency services and this rule will stop patients from getting worried about any bills out of their budget, and they will be able to get the proper care they need for their health with peace of mind. The act was passed by congress at the end of 2020 and offers protection against insured Americans getting surprise bills from out-of-network providers.^[132] They struggled to find an amount that an insurer should pay to the out-of-network provider, but eventually found an amount and the law is now in effect as of January 2022.^[132] When it comes to out-of-network providers, patients often rely on these services in an emergency and then get stuck with the bill afterwards.^[133] Air Ambulance bills are a big problem for consumers, not just because they are out of network and cost a lot, but also for their lack of billing transparency.^[133] Since the Airline Deregulation Act, which allows air ambulance to make their own prices, federal solutions to this increasing cost of emergency care is needed.^[134] A possible solution is to allow air ambulance services to be administered and financed in a way that combines competitive bidding and public utility regulation.^[133]

See also

Notes and references