Health is clearly impacted by the environment in which we live. Understanding how other related variables, known as social determinants of health, affect us may be critical to optimizing community well-being. What are the social determinants of health? Consider how socioeconomic status, employment, education, social support networks, physical environment or neighborhood characteristics, and access to healthcare services all may play a role in the risk of developing diseases or medical disorders. Furthermore, explore the public health implications and how public policy may promote community health by addressing these important issues.
A couple runs in the evening
Introduction
The World Health Organization defines the social determinants of health as the conditions in the environment in which people are born, grow, live, learn, work, play, worship, and age that shape health.1 These factors include physical attributes associated with “place” as well as the patterns of social engagement and even one’s sense of security and well-being. Collectively, they affect health, functioning, and quality of life.
The risk for developing certain diseases or medical disorders may depend on a number of factors, some of which are beyond an individual's control. Health is determined by a handful of important contributions.2 Consider the following:
Genetics
Health behaviors (smoking, diet, exercise, etc.)
Social factors
Economic factors
Environmental factors (lack of safety, exposed garbage, substandard housing, etc.)
Healthcare access (preventive care, immunizations, cancer screening, etc.)
Governmental policies
There are complex interactions and feedback loops among these factors. For example, financial hardship due to a lost job may promote unhealthy coping mechanisms, such as substance abuse or overeating of unhealthy foods. Collectively, these health determinants may contribute to discrepancies in the incidence of significant health problems, including obesity, heart disease, diabetes, and depression.
Community and personal resources—those linked to both money and power—may also have an impact on important health-determining variables. Inadequate financial resources may undermine access to safe and affordable housing, education, public safety, and healthy foods. Within a community, there may be a lack of access to sidewalks, parks, playgrounds, recreation centers, libraries, local emergency or health services, and toxin-free environments. As a result, there may be multi-generational impacts that may be linked to these community characteristics.
The social determinants of health may be of particular importance.
Social Determinants of Health
It can be difficult to isolate certain contributions to health as significant overlaps exist among the factors. Nevertheless, the following may be considered broadly under the umbrella of the social determinants of health:
Socioeconomic status
Employment
Education
Social support networks
Neighborhood
Physical environment
Access to health care3
It may be helpful to further characterize each of these with more specific examples, as follows.
Socioeconomic Status
This factor relates to the financial resources an individual may have, largely dependent on employment and income. It may be influenced by access to economic and job opportunities within the community. Higher costs of living, debt, medical bills, and other expenses may strain the available resources. When socioeconomic conditions are poor in a community this may lead to a concentration of poverty and the stressful conditions that accompany it, including higher rates of crime.
Employment
Although employment may improve income and socioeconomic status, it is not without additional potential risks to health. Depending on the nature of the work, there may be workplace safety considerations. If the conditions in the workplace are unsafe, due to physical or even psychological risks of harm, health may be negatively impacted.
Education
Access to educational opportunities, starting with early childhood education and development and extending to enrollment in higher education, may have lifelong impacts on health. The quality of the available schooling may determine literacy, language development, and vocational training. The rates of high school graduation, enrollment in higher education, and overall educational attainment may have wider community effects.
Inadequate education may also directly affect health literacy and may deter overall access to health care. Restricted access to mass media and emerging technologies—including cell phones, the Internet, and social media—may also have an increasing role in education disparities.
Social Support Networks
As the poet John Donne once wrote, “No man is an island.” The same is true in the context of health. Social integration—with all of the attendant relationships, interactions, and support systems—may be a key to optimizing health. Community engagement may promote a sense of inclusion and affirm identity.
Cultural norms and attitudes may be helpful, but the presence of discrimination, racism, segregation, distrust of government, and social stressors may have adverse consequences. High rates of incarceration may wound social networks.
Marriage may be a source of support and promote long-term health, or, in some cases, it may be a source of gender inequity and distress. The right community context may promote favorable social norms, civic participation, inclusivity, and social cohesion—all to the benefits of health.
Neighborhood
This factor impacts housing, transportation, recreation, safety, and even nutrition. It is more than just a zipcode or geography. Adequate housing and utility services are foundational, but there also must be community-based resources in support of community living and opportunities for recreational and leisure-time activities. These resources may include the presence of nearby parks and playgrounds as well as local walkability with adequate pedestrian infrastructure like sidewalks.
Public safety (or a lack thereof) may be reflected in local crime rates, but also includes unreported exposure to violence and social disorder (such as the presence of trash or a lack of cooperation in a community). Residential segregation with limited access to resources may have generational effects.
Finally, it is important to be able to meet daily nutritional needs, including access to local food markets and the availability of nutritious food choices. The absence of these resources may lead to food insecurity, hunger, and health deficiencies.
Physical Environment
This is sometimes referred to as the “built environment,” and includes homes, workplaces, neighborhoods, and communities. The quality and availability of housing can prevent housing instability, especially in the context of a natural disaster. Clean air, water, and food will all have positive health impacts. Crowding conditions may affect the transmissibility of infectious diseases. Toxin-free environments may reduce the risks of certain disorders, such as lead poisoning or asbestos exposure causing a type of lung cancer known as mesothelioma.
Access to Healthcare Services
In order to promote health, it is necessary to have access to primary care providers and specialists who can deliver both preventive care and, when needed, necessary treatments. This may require adequate medical insurance, such as Medicare for older patients, or other health coverage.
Medical providers must be available with both linguistic and cultural competency, paying attention to issues related to health literacy. The quality of care must be adequate to meet the needs of the patient population. This may have important public health implications.
Public Health Implications
What are the public health implications of the social determinants of health? Clearly they have a central role to improve health and reduce longstanding disparities in health and health care. Beyond improving access to health care, attention to public policy may promote community health through the advancement of public interests in allied fields.
Changes are needed within the healthcare system to address these social determinants of health. When ignored, there are certain groups and individuals who face social vulnerability.4 This refers to the resilience of communities when confronted by external stresses on human health, such as natural or human-caused disasters or even disease outbreaks. By reducing social vulnerability, it is possible to decrease both human suffering and economic loss.
By promoting health equity, it is possible to affect a number of important health outcomes, including:
Mortality (the rate of death in a population)
Morbidity (the rate of disease in a population)
Life expectancy
Healthcare expenditures
Health status
Functional limitations
In order to achieve this, advances are needed not only in health care but also in allied fields such as education, child care, housing, transportation, community planning, business, law, media, and agriculture. When attention is paid to the social determinants of health, it is possible to shape policy and practice to influence these diverse sectors and promote the overall vitality of the community.