Social determinants of health (SDOH)—the circumstances in which people are born, grow, live, work, and age that affects health and quality of life—are strongly connected with disparities in health status and life expectancy.
There is no single, universally accepted definition of social determinants of health. Social determinants of health (SDOH) are defined by the World Health Organization as the conditions in which people are born, grow, live, work, and age. Despite this elaborate and nuanced description of SDOH, the phenomena are often represented solely by socioeconomic indicators, such as income and education. In the last twenty years, a transfer of focus has occurred in public health to concentrate on population health. This includes SDOH.
Research has found that individual behavior, often driven by social determinants, accounts for up to 40 percent of the risk of premature death. These findings helped establish the Commission on Social Determinants of Health by the World Health Organization (WHO) in 2005. The Commission’s responsibilities require that they assemble, collate, and synthesize global data on SDOH and its impact on health inequity and make recommendations for action to address that inequity. The goal of the Commission is simple: to foster a global movement on social determinants of health and health equity. The Commission’s first report in 2006 stated ‘the link between people’s health and their surrounding can no longer be ignored.’
The Urgency of Addressing Social Determinants of Health
Focusing on three key principles of action, the 2020 Commission report on SDOH explicitly calls for closing the health gap in a generation. These principles include 1) improving the conditions of daily life, 2) tackling the key drivers of the conditions of daily life, such as the inequitable distribution of power, money, and resources; and 3) systematically measuring the problem, evaluate an action plan, and expand the knowledge base of SDOH. According to healthypeople.gov, there are five key areas of social determinants of health. These areas include 1) Economic Stability, 2) Education, 3) Health & Health Care, 4) Neighborhood & Local/Regional Environment, and 5) Social & Community Context. These five areas of determinants are just the ecosystem in which social determinants are housed.
Examples of social determinants include:
- Socioeconomic conditions (i.e., concentrated poverty and the stressful situations regularly experienced with poverty)
- Access to mass media and emerging technologies (i.e., cell phones, internet access, and social media)
- Availability of resources to fit daily needs (i.e., safe housing and local food markets)
- Access to educational, economic, and job opportunities
- Access to health care services
- Quality of education and job training
- Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
- Transportation options
- Public safety
- Social support
- Social norms and attitudes (i.e., discrimination, racism, and distrust of government)
- Exposure to crime, violence, and social disorder (i.e., presence of trash and lack of cooperation in a community)
- Residential segregation
Closing the Health Gap
Since 2018, health systems in the U.S. have publicly committed approximately $2.5 billion toward directly addressing social determinants of health, such as job training, food security, and housing. First and foremost, we must admit there is a problem. Acknowledging that there is a problem and assuring that health inequity is measured – within countries and globally – is a necessary platform for action. Once we can all agree on this, it is then necessary to develop a digital infrastructure that integrates social care into the healthcare delivery model. This will also require a workforce that’s able to integrate social care into health care delivery.
Health and health equity may not be the intention of all social policies, but they will be fundamental. The conditions in which we live explain why some Americans are healthier than others and why Americans more generally are not as healthy as they could be. The building blocks of good health have their foundation in social and emotional skills learned during early childhood.
Health Literacy and Access to Information
Health literacy is the extent to which individuals can obtain, process, and understand basic health information needed to make suitable health decisions. Patients who lack health literacy may have difficulty understanding clinical information and may not correctly follow directions for prescription drugs or other treatments. There are multitudes of reasons for low health literacy, ranging from low educational skills and cultural barriers to healthcare providers using words that patients don’t understand.
You cannot tell someone’s literacy level just by looking at them. An effective way to decrease miscommunication is to simplify communication with patients and confirming they understand the health information discussed. Using a universal health literacy precaution approach, healthcare organizations and professionals can structure care delivery as if everyone has limited literacy. A best practice is to use simple, clear language to avoid any likelihood of misinterpretation.
What strategies could all of us adopt to minimize barriers and misunderstandings for low literacy patients? It is important to remember that patients with low literacy tend to ask fewer questions. Healthcare professionals should translate the conversation from medical terminology to plain language while limiting the information provided to 3-5 key points.
The Digital Health Transformation
Innovation starts with insight and seeing challenges in a new way. Concentrating on SDOH, globalization of the marketplace has brought new opportunities for equitable health. These benefits come in the form of new technologies, goods and services, and improved living standards. It can also generate negative conditions. The accelerated progressions and adoption of digital health technologies for both consumers/patients and health systems have greatly impacted healthcare delivery in the U.S., especially in rural and other remote areas that lack access to health care services.
The digital evolution has moved healthcare into a more marketplace-centric mindset, with health systems shifting their strategies to create a more consumer-driven experience, creating a more active patient engagement environment. While the future of healthcare is digital, lack of access to digital technologies is one barrier to health care in the U.S. Even with access to technology and digital health tools, misinformation online is also an obstacle to the receipt of high-quality care. Efforts should be made to make digital health services more natural for those with low health literacy to use and design programs that can promote health and digital literacy. Having internet access is inadequate; health literacy and digital literacy are essential parts of collecting health information.
The Impact of COVID19
Even as the COVID-19 vaccine roll-out is accelerating across the country, the public health and economic effects of the pandemic continue to affect the well-being of many Americans. Not everyone has been affected equally by the pandemic—social determinants of health affect who gets sick and everyone in the community during this unprecedented time. The pandemic is exacerbating the impact of these inequities, particularly for communities that are already under-resourced and experiencing barriers.
Ignoring Social Determinants of Health
Too many healthcare stakeholders aren’t talking about social determinants. Only 43 percent of respondents to a PwC Health Research Institute (HRI) June 2019 global consumer survey said their doctor has even raised the subject with them. Other health workers, such as nurses, pharmacists, and dietitians, are talking about it at a much lower level, highlighting the opportunity to involve healthcare workers more broadly. SDOH is much more complex than simply rich versus poor.
Social determinant factors have a significant impact on how patients engage with their health. It is vital to remember that SDOH is not the result of any natural law, nor do they exist in a vacuum. Health equity is an issue within all countries worldwide and is influenced significantly by the global economic and political system. Within the U.S., the design, implementation, and evaluation of effective policies at the local, state, and federal levels to improve health outcomes can be improved through a deeper understanding of the complexities of social and economic disparities.