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Social Determinants of Health: Breaking Down the Barriers

Community members painting mural

The social determinants of health—defined by the World Health Organization as the conditions in which people are born, grow, live, work and age—can influence nearly 70% of your health outcomes. These factors are also a driving force behind many health disparities that are occurring today worldwide.

Health People 2020 breaks down the social determinants of health into five categories:

  1. Economic stability
  2. Education
  3. Social and Community Context
  4. Health and Healthcare
  5. Neighborhood and Built Environment

Healthy People Social Determinants of Health

Source: Healthy People 2020 

More specific examples include access to social and economic opportunities, resource availability, quality of education, workplace safety, healthy eating options and nature of social interactions or relationships.

In a HIMSS Innovation That Sticks podcast episode, Jeff Fritz, CEO of Revel Health, shared his take on the social determinants of health, or what he calls social barriers. These barriers, he explained, can prevent an individual from obtaining the resources they need to achieve better health outcomes and improved quality of life.

The term population health is one topic that’s closely intertwined with discussions centered on the social determinants of health. Population health evolved as part of the movement to study health outcomes across specific groupings of individuals, or “the community that makes up a population that the healthcare provider system views as a unit they want to make healthier,” Fritz explained. Within a specific population, the social barriers preventing individuals from improving their health or receiving care contributes to a decrease in overall health of that population as a whole. “A social barrier is something where if you removed it, you would see an increase in the health of that population.”

Social Barriers and Health Disparities

Thanks to the wealth of information evolving on the topic of social determinants of health, societies are becoming more informed than ever about the existence of social barriers and how to tackle them. The three cases below, all based on U.S. population data, connect different health outcomes with specific patterns observed in challenges facing many individuals. By looking at these three different angles, we can begin to understand just how much power the social determinants of health have over our lives.

Case #1

Adverse Childhood Events and Individual Stability

Adverse childhood events (ACEs) can have a permanent impact on the future of an individual’s social and economic stability. The original ACE study, a collaboration between the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente, looked at categories of ACEs occurring within a child’s home life.

This research focused on three different categories related to adversity:

  1. Witnessing and/or being a victim of abuse—including emotional, physical and sexual
  2. Neglect—physical or emotional
  3. Other household challenges like substance abuse, mental illness, violence, divorce, incarceration or death of a family member

Compared to individuals reporting no ACEs, individuals with six or more died nearly 20 years earlier.

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ACEs can be connected to toxic stress, a term coined by the National Scientific Council on the Developing Child. Being subjected to toxic stress consistently as a child has been proven to negatively impact brain development—as cited by in a study conducted by the The National Center for Biotechnology Information, which explored long-term effects on the structure and function of the brain.

“Compared to participants with no ACEs, those with higher ACE scores were more likely to report high school non-completion, unemployment, and living in a household below the federal poverty level,” research states. “This evidence suggests that preventing early adversity may impact health and life opportunities that reverberate across generations. Current efforts to prevent early adversity might be more successful if they broaden public and professional understanding of the links between early adversity and poverty.”

Case #2

Food Security and Ethnicity

The Behavior Risk Factor Surveillance System (BRFSS) is an ongoing surveillance system used to measure behavioral risk factors across the non-institutionalized adult population in the U.S., for individuals aged 18 years or older. Two questions related to the social determinants of health were added to the assessment, with a goal of uncovering facts about food and housing security.

The survey incorporates the perspectives of over 95,000 Americans living in 15 different states—representing approximately one third of the U.S. population. Well over half of these respondents reported being worried or stressed in the last year about if they had enough money to eat nutritious food. The research found this lack of food security was most prevalent among African Americans (69%) and Hispanics (65%). Less than 20% of non-Hispanic whites faced this same hardship. A similar pattern of racial/ethnic disparities occurred in other parts of the BRFSS, including data collected on education levels and housing security.

A report from Feeding America estimated that one in eight Americans are food insecure; that’s 40 million people, which includes over 12 million children. Food and housing are social determinants of health that are considered actionable, the report stated. “Establishing farmers’ markets, farm stands, and community gardens in disadvantaged neighborhoods can improve food security by increasing access to affordable healthy foods at lower cost or with alternative payment options (e.g., electronic benefits transfer discounts) and alleviating the costs associated with traveling to obtain these foods.”

Case #3

Suicide and Geographic Location

A 17-year study by the CDC determined over 600,000 people in the U.S. died by suicide (from 1999 to 2015), marking historically high rates that continue to grow. Research has also stated that over half of individuals who died by suicide had no diagnosed mental health conditions.

One study looked at suicide rates occurring across urban and non-urban populations in the U.S., focusing on six different county urbanization classifications. The study confirmed a connection between less urbanized areas and higher rates of suicide. Less urbanized areas face limited access to mental healthcare, which is heightened more by a shortage of behavioral health providers in non-urban areas.

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The report also stated that males were four times more likely than women to die by suicide. “All communities might benefit from strategies that enhance coping and problem-solving skills, strengthen economic support during times of financial hardship, and identify and support persons at risk for suicide,” the research report noted.

Resources for Tackling Social Barriers

There are a wealth of resources out there that can help shed light on the impact of the social determinants of health. Here are just a few recommended by the CDC which can help address and prevent future health inequities, including policy resources to help U.S. citizens activate change in their community and beyond.

  • 10 Essential Public Health Services: This list, developed by The Core Public Health Functions Steering Committee, addresses a variety of different public health activities that should be prioritized in addressing the social determinants of health.
  • Community Preventative Services Guide: Understanding the importance of prevention in addressing the social determinants of health, the Community Preventive Services Task Force created this guide, which details potential health intervention approaches and other resources addressing health inequities.
  • Violence and Abuse Prevention Infographic: This visual resource looks at violence as a public health issue and explores different prevention methods.
  • The Prevention Status Reports (PSRs): Highlighting policies and practices in the U.S. which address public health concerns, this resource drills down by each individual state and shows how they each use evidence-based practices to address social determinants of health.
  • A Practitioner’s Guide for Advancing Health Equity: This guide provides an overview of improvement strategies practitioners can reference in order to reduce disparities identified in chronic disease.
  • Health Equity Resource Toolkit: Obesity is defined as a leading health disparity in the U.S. affecting individuals across all demographics. This toolkit outlines a six-step process that will help you to plan, implement and evaluate community programs committed to reducing obesity rates.
  • Policy Resources: Perhaps the biggest step to taking action involves advocating for health policy which addresses or incorporate preventative measures related to the social determinants of health. This resource from the Journal of Public Health Management and Practice explores different approaches.

More Social Determinants of Health Policy Resources from the CDC:

Brownfields/Land Reuse Action Model
Chronic Disease State Policy Tracking System
Health in All Policies: Achieving National Prevention Strategy and Healthy People 2020 Goals

If we want to build a better, healthier future for all populations, it is integral that the social determinants of health, or social barriers leading to health disparities, are addressed. Awareness needs to be amplified from the individual level to the community level and beyond to activate reform. Through collective understanding and community action, interventions can have a lasting impact on society, leading to improved health outcomes universally.

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Originally posted June 18, 2019