What are social determinants of health?
Social determinants of health are conditions in the places where people live, work, learn, and play that affect physical and mental health. A social determinant of health can be anything from the food we eat to the quality of housing. These are some of the causes of diseases that are known to be linked to SDOH: malnutrition, obesity, heart disease, stroke risk factors (e.g., smoking), or lack of education or resources for medication management (e.g., prescription drug prices).
The SDOH approach was first developed in 1992 at a United Nations conference on development in China; it has since been adopted by other international organizations and governments around the world as an approach to tackling problems associated with poverty and inequality within a specific country or region. The World Health Organization (WHO) has published an implementation guide: “A social determinants approach to public health.” Based on this guide, SDOH have been integrated into the UN’s Sustainable Development Goals and, in 2017, the WHO launched a Global action plan for the promotion of health-based interventions addressing both health needs and social determinants.
The WHO defines social determinants of health as including:
These variations can influence a person’s susceptibility to illness and their ability to effectively manage their own health over the course of their lives.
SDOH have become a key tool in the development of health care projects and interventions in low- and middle-income countries. The WHO has also developed Global recommendations for SDOH, which aim to provide guidance on how to design, implement and evaluate SDOH initiatives.
Social determinants of health are seen by some as more important than biomedical interventions because they address the person’s context rather than just the individual. Sociologists and other social scientists view these factors as largely outside of an individual’s control, but other studies have shown that there is great variability between individuals within each “social group” (e.g. education, income, or occupation).
For example, smoking rates across populations in different countries and socio-economic circumstances vary greatly. In the United States, there is a strong demographic correlation between smoking rates and income; however, there is a large percentage of Americans who were born into poverty with parents who smoked; these people are still at greater risk for smoking than other Americans, even if they are not poor. This is because social groups develop norms of behavior that can override individual control and prevent change. The SDOH approach recognizes these differences so that resources can be spent where they will yield the best results.
SDOH have been used to understand health inequalities, as well as for social inclusion, particularly in the area of mental health.
The focus on SDOH shifts the attention from individual-based interventions to a more holistic approach that includes social factors.
Social determinants of health lead to a greater understanding of how certain populations are less able to be included or excluded from society because they are low-income and often hold positions that are considered undesirable by the dominant culture. The SDOH approach allows these people to identify what they need and develop interventions that will be effective based on their needs, rather than those who feel they “need” them. This allows integration of SDOH in the planning, implementation and evaluation of health support services.
The SDOH approach has also been used to provide better education with a focus on the social contexts in which people learn by examining the effect of their environment on learning. Implementation of SDOH may have better results than those based solely on biomedical interventions.
SDOH are particularly useful for assessing the overall political and economic context to improve policy formulation, project design and evaluation so that interventions can be designed that reflect the needs and experiences of specific communities, rather than individual countries. They also explain how social conditions affect health when they are not described simply in terms of psychosocial or behavioral factors alone.
SDOH are the conditions in which we are born, grow, live, work and age. They include a wide range of factors ranging from our standard of living, social relationships and life experiences to economic and educational opportunities that can interact with each other to produce health outcomes in people. SDOH also help shape a person’s identity and the values, attitudes and behaviors that affect their lives.
Social determinants of health are not nearly as well documented in countries that have already made great strides towards alleviating poverty and other SDOH concerns such as malnutrition. The lack of documentation may stem from the fact that SDOH have been recognized more recently as important predictors at this time. In 2015, the SDOH approach was described as “an important innovation in health promotion, health research and policy”.
According to a study of the literature on SDOH by the WHO, social determinants appear to affect not only physical health but mental health as well. In developed nations with high SDOH rates, such as those in Scandinavia or England, high levels of depression are seen among individuals with low incomes and poor socio-economic status. Similarly there is an increased prevalence of depression in those who experience both social deprivation and violence. An analysis of the 2005 Health Survey for England showed that 41.7% of those residing in the most deprived areas suffered from depression.
Mental health is a broad term and covers a wide range of psychological disorders that may have different social determinants than those for physical health. For example, an individual who moves to an area with high population density may experience lower quality of life as a result, but this might not affect their physical health. However, it is likely to affect their mental health, which in turn can lead to physical health issues such as stress-related disorders and hypertension.
The social determinants of health also play a role in the mental health and wellbeing of children, especially those living in poverty. A World Vision Report on child poverty stated that for children who live below the poverty line, factors such as poor housing conditions, inadequate nutrition and lack of access to education could cause them to develop anxiety and stress responses that could negatively affect their physical health as well. This is particularly true if these factors are not addressed early on in a child’s life. In fact, according to the report, an estimated 121 million school-aged children were not in school as of 2013 due to poverty.
These SDOH are also important for understanding child development and the success of interventions designed specifically for youth. For example, exposure to violence can cause youth to engage in risky behavior and make them more susceptible to drug use, teenage pregnancy and school drop-out. Exposure to environmental factors also play a role in the development of mental disorders such as major depression, post-traumatic stress disorder or a variety of personality disorders.
SDOH also play an important role in the health of older individuals and their ability to stay independent. A study by the Kaiser Family Foundation on American elderly showed that income security is one of the most important factors for health for this demographic group. In fact, the study revealed that financial security was the top indicator for physical health and among the top indicators for mental health overall.
The benefits of SDOH for children and adults are well known, however social determinants of health also have the potential to help sustain the health of developing countries in accordance with the UN Millennium Development Goals. According to a study by the African Centre for Health Leadership, SDOH can improve the productivity of a country through improving access to education, healthcare and clean water. Furthermore, they can also reduce poverty levels in an area as a whole and increase leaders' capacity to plan accordingly.
Merit Health is a non-profit organization based in Alabama that emphasizes the importance of SDOH for public health. The organization also supports a research network, the Social Determinants of Health Network (SDHN), which was created to "improve the quality, effectiveness and equity of healthcare in the US by shifting our field’s focus to address social determinants of healthcare inequities." The SDHN works with Merit Health and partners to sponsor research on SDOH.
The Bandura's Social Cognitive Theory was originally developed as one of many theories relating to mental, physical and behavioral development over an individual’s lifetime. According to this theory, an individual’s environment is not the only factor in their development; they also take into consideration their own thoughts and actions.
The stress process model describes how people react to SDOH, particularly those that are negative. According to this model, stress occurs when a person is presented with a stressor (an event or condition that negatively impacts their health) and then tries to cope with the situation. This coping could be beneficial in terms of health outcomes or detrimental depending on the circumstances.
The "cumulative disadvantage" perspective was initially used to understand racial inequalities in health however it can also be applied to social inequalities involving other demographic groups such as low-income earners and women. However, this perspective was later applied to other SDOH
In order to explain how SDOH in general affect individuals’ health, the "health inequity" perspective was adopted. According to this perspective, social inequities in health can arise as a result of several factors including genetics, race and socio-economic status. Furthermore, over time these SDOH accumulate and lead to worse health outcomes for individuals or groups as a whole.
The term "social determinants" was first proposed by the World Health Organization in 1996 and it refers to the global forces that play a role in an individual's or society's health status. Some SDOH were described in detail in the 1992 WHO report on Health for All by the World Health Organization. Since then, research has continued and new studies on these SDOH have been published.
In 2015, the World Health Organization released a document describing 10 of the most important SDOH that have been proven to affect individuals’ health. This includes gender inequality, where women are more likely to die due to pregnancy related complications and childbirth than men, as well as income inequality which can hinder access to healthcare and lead to higher mortality rates for low-income earners. Other SDOH listed in the report includes the quality of air, sanitation and water sanitation, violence and injuries, education, healthy life expectancy and social support.
As an example of how SDOH can affect health status in a population, a study by the World Health Organization found that people who have no access to electricity are much more likely to experience depression than those with access to electricity. This is also true for people who do not have access to clean water sources. An additional study by UNICEF found that children who live in poverty are more likely to suffer from illness such as pneumonia or diarrhea due to their living conditions compared to children from wealthier families.
Social determinants of health are also important factors in the lives of older individuals. Factors such as social isolation, disability and disease can lead to worse health outcomes for elderly people compared to younger adults and the burden of caregiving for older adults often falls on their spouses or family members. An individual’s access to a safe environment and healthcare can also affect their health as they age.
The social determinants of health model has been criticized in recent years due to major flaws in its design. Some critics argue that it places too much emphasis on the role played by SDOH while others believe that SDOH should be prioritized over other factors.
Critics of the SDOH model argue that it does not sufficiently account for individual health outcomes. The main argument is that social patterns do not result in an increase in a person's risk for disease but instead cause individuals to become more susceptible to certain diseases. However, studies have shown that social determinants of health have the potential to influence an individual's behavior and cause risks to change over time. For example, research has shown that people who are overweight are less likely to smoke in adulthood than those who remain slim all throughout their lives thus indicating a potential change in behavior as a result of SDOH.
Furthermore, the social determinants of health model has been criticized for not being able to explain how a person's behavior and living circumstances affect their health. For example, while it may be clear that people who have access to clean drinking water have lower risks of contracting diarrheal diseases than those without access, it is less clear as to why this is the case. Without a clear reason or hypothesis as to why this is true, critics argue that the SDOH model should be reconsidered.
Another criticism of the social determinants of health model involves defining what actually determines an individual’s health status. Early studies, such as those conducted by the World Health Organization, centered on physical health as they focused on the effects of a person's age, gender and race. However, with the rapid evolution in health research and technology, it is uncertain if these factors are still relevant in determining an individual’s health.
The "social determinants of health" research is also criticized for being based only on observational studies that use statistical methods to show relationships between social determinants and health outcomes. These studies do not provide any insight into how or why this relationship may exist and critics argue that it is unclear how applicable these findings are to actual populations.
In addition to the criticisms of the SDOH model, some critics argue that the "social determinants of health" research is not valuable or applicable in a global sense. A major criticism of this perspective concerns income inequality. Critics argue that it is unclear how income inequality affects individuals living in countries with high rates of poverty or those living in developed countries because many countries do not have comparative data on income inequality.
An alternative perspective to the social determinants of health is that individuals are more likely to be exposed to SDOH than it is for an individual's health to determine an SDOH’s impact on the individual’s well-being. This perspective is often referred to as social vulnerability and it can be explained by the idea of environmental and social vulnerability. Environmental vulnerability means that an individual's health may be influenced by a change in social determinants of health, such as the quality of air, sanitation or some other aspect of the environment. Social vulnerability, on the other hand, refers to people who face a greater risk for certain SDOHs compared to others.
As an example, people living in impoverished neighborhoods are more likely to suffer from respiratory disease such as bronchitis due to their low socio-economic status (SES), education level or even their specific location compared to residents from wealthier neighborhoods. Furthermore, children whose families have a low SES can be more prone to experiencing certain diseases than children who come from middle class families. This is also true for individuals who live in areas with inadequate access to health care services or those who are socially isolated.
There is also a debate as to whether the relationship between the SDOH and health outcomes is linear or non-linear as this may influence how people respond to certain scenarios or changes in an individual's environment. If the relationship is linear then there will be a direct correlation between social determinants of health and poor health status. However, if it is non-linear then the relationship between social determinants of health and health outcomes will be influenced by other factors such as behavior and genetics.
In addition to the discussion about linearity, some have argued that the impact of social determinants of health on an individual's well-being is not necessarily cumulative. This means that an individual who is exposed to a single SDOH may experience a negative impact on their overall well-being but this change in health status may not affect other areas of an individual's life. The idea behind this perspective centers around the idea that changes in an individual's environment influence his or her behavior rather than SDOH directly affecting the person's health.
Several social determinants of health such as race, education and income have been related to an individual's likelihood for certain diseases. For example, a person who is African American will have a greater probability of having diabetes than someone who is Caucasian. According to the research conducted by Dr. Douglas K. Owens, the likelihood for an African American to develop Type 2 diabetes is 1 in 2 compared to 1 in 11 for a Caucasian individual. Furthermore, lower levels of education or coming from a low-income family has been linked to higher incidence rates of heart disease and cancer among many other health conditions.
A person's SES also plays a major role in whether or not an individual is at increased risk for disease. Low SES is associated with a variety of chronic illnesses such as heart disease, diabetes, cancer, lung disease and HIV or AIDS. However, the relationship between SES and health is dynamic in that it can change over time. A study conducted by Lisa Berkman examined how social networks affect one's risk for poor health outcomes. She found that individuals who participated in social activities had higher levels of self-confidence and other positive emotions which lead to them being more productive members of society. This finding suggests that the presence or absence of friendships, relationships and support networks can have an impact on one's overall well-being.
A life course perspective on health highlights the idea that an individual's pattern of health and well-being throughout a lifetime is shaped by their experiences as well as environmental factors. The pattern of an individual's health and well-being over time may also be influenced by trauma and subsequent mental health issues.
The current focus on preventing chronic disease such as diabetes, heart disease and cancer is often focused on prevention through social interventions such as diet, nutrition, physical activity, smoking cessation and treatment for substance abuse. The focus of preventive care includes the promotion of healthy behaviors which are critical in reducing risks associated with SDOH’s.
Social interventions can range from simple and non-invasive ways to address SDOH such as smoking cessation programs, providing access to affordable health care, increasing access to food and other basic services and developing communities that support individuals in achieving their full potential.
These social interventions are often focused on low income populations in order to promote their health. An example of a social intervention in the field of obesity prevention is the promotion of regular physical activity through organized and integrated programs within schools or community parks. Another approach to addressing SDOH is through class size reduction which has been shown successful in reducing levels of obesity.
There are many ways to mitigate the impact of SDOH on an individual's health. Although it is challenging to identify all of the interventions that can be implemented, there are several examples of how societies can reduce mortality and morbidity rates in their communities by addressing certain SDOHs.
In order to reduce the number of people who smoke, governments have increased cigarette taxes which has resulted in a reduction in smoking rates from 41% in 2008 to only 27% today. As a result, smoking-related deaths have decreased by 10% over the last 20 years as well as a decrease in secondhand smoke exposure for children. In addition, smoking restrictions have also been put in place in public places so as to reduce the number of individuals who are exposed to secondhand smoke.
In order to reduce the negative health effects of poverty, governments have implemented social welfare programs such as food stamps, subsidized housing and cash assistance programs. These programs are implemented to ensure that all individuals have access to the basic necessities in order to maintain good health. Income levels are a critical SDOH since they significantly impact an individual's quality of life. According to a study done by Raj Chetty, a ten percent increase in income results in a nine percent decrease in infant mortality as well as eight percent decrease in homicide rates among other positive outcomes.
People who do not manage their SDOH's (i.e. income) are often at a higher risk for chronic disease such as diabetes, heart disease and various types of cancer. As a result, the government has implemented programs that provide low-income individuals with financial assistance in order to reduce their risk for poor health outcomes. Health care reform has also led to the expansion of healthcare services in rural areas which supports the need for social support that can fill the gap when medical services are not available due to a lack of resources.
