Why social determinants of health matter, and how to take action

(Cross-posted in a slightly modified form at the Life in Underserved Medicine blog)

Recently, my friend Carmen Gonzalez wrote a post for the Occupy Healthcare site in which she highlighted the state of healthcare inequities in the United States.  Carmen’s post is brief and pointed: our nation has significant differences in healthcare status and outcomes, often as a result of factors that are largely beyond individual control: ethnicity, income, educational attainment, community resources, etc.

These factors are referred to as a group as “social determinants of health (SDOH)”, in that they affect individual health but are not the results of individuals’ decisions.  For example: the fact that low-income neighborhoods often lack easy access to nutritious foods and safe places to exercise, meaning that those living in those neighborhoods will have greater challenges following our medical advice to exercise and eat well…not because they might not want to, but because these resources are not readily available to them.  The important role of SDOH in impacting health means that any individual’s health status is not simply the result of poor personal choices, but rather an interplay of individual risk factors and the social milieu in which one lives.

In the United States, we have the most expensive healthcare system in the world (as % GDP (pdf), and per capita), while performing at a level far below our economic peers:

–37th in this WHO analysis (pdf), including lagging behind in infant mortality and adult mortality.
–In this Commonwealth Fund report, the US scored only 64/100 points due to increased costs, lack of improvement in health outcomes, lack of access to care, and increased health disparities.  This report’s findings showed how much improvement in outcomes and costs could result if the US worked to address failings in our healthcare system.  If the US healthcare system was on par with the best-performing systems in the world we could save up to 84,000 premature deaths and nearly $114 billion per year on administrative costs.
–Also from the Commonwealth Fund, this report shows that in the US over 1/4 of Americans struggled to pay their medical bills and 42% skipped needed care.  The Commonwealth Fund recently reported on U.S. Census Bureau data showing that out-of-pocket healthcare costs are significant burdens for Americans, and threaten to push millions of Americans into poverty.

In a recent article in Health Affairs, Steven Woolf and Paula Braveman discussed the impacts SDOH have on individual and population health outcomes.  The full text of the article is not yet available publicly, but in the article Woolf and Braveman note:

–Income correlates directly with health status: higher income, better self-reported health status.  The Health Affairs article reports that “studies of Americans at all income levels reveal inferior health outcomes when compared to Americans and higher income levels.”  Woolf et al demonstrated that 25% of deaths in Virginia 1996-2002 could have been avoided if the mortality rates of the five most affluent cities and counties applied statewide, demonstrating the clear impact income has on health.  (reference here)
–Education notably influences health outcomes, both of individuals and families.  Braveman has noted that children’s health depends greatly on parents’ educational levels (reference here), while Woolf et al have noted that increasing American’s educational levels could have greater impacts on health outcomes than biomedical advances.  (reference here)
–Education and income levels are associated with behaviors such as smoking and physical exercise, showing the interrelatedness of these issues.
–The Health Affairs article also summarizes the ways in which environment influences individuals’ habits, both in where people live, where they work, etc.  These influences are reviewed in-depth in this article by Bravemen et al. (pdf)

As a result of the roles SDOH play on individual health, Woolf and Braveman call for a broader approach to improve the health of individuals and (by extension) the performance of healthcare systems.  It is not sufficient to focus on one patient–or even one family–at a time.  Although this individual health care is what most of us think about when we discuss healthcare overall, Woolf and Braveman indicate that it might not be the most important factor in affecting overall health.  Although meaningful, affordable, effective individual access to healthcare is of critical importance, it is not sufficient to bend the curve on system-wide performance or on healthcare costs.  After all, more individual healthcare will mean that the system will be paying for more services, meaning that cost savings will be delayed.  Even if better and more-timely care results in fewer complications and fewer preventable deaths, resulting cost savings will not be evident in the short-term.  Therefore, we must not stop at ensuring individual access to care.

As Woolf and Braveman write in Health Affairs, “[t]he leaders who can best address the root causes of disparities may be the decision makers outside of health care who are in a position to strengthen schools, reduce unemployment, stabilize the economy, and restore neighborhood infrastructure.  Policy makers in these sectors may have greater opportunity than health care leaders to narrow health care disparities.”

So: what can we do to target SDOH and improve the health of individuals and communities? How can we take on this task?  A few proposals include:

SDOH affect health through various pathways, and to address their impact we need to work at a level above that of the individual while not neglecting the individual.  This means that we must become involved in our political process.  We must call for accountability, while also ensuring that our voices are heard…otherwise, only the voices of large financial contributors will have influence.  We must remember that this is our government, and we should call on our representatives to represent US.  We can work to fix the shortcomings in our political systems…but we must also work to enact change within the systems that exist.

In the same way that other activists call on us to “think global, act local”, we must “think about social determinants of health, act to care for the individual patient.”  The two cannot be separated, and our duty must be to improve outcomes at all levels: we must make our healthcare system more effective, more efficient, and more affordable.  The status quo is unjust and unsustainable.

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Posted in healthcare, Innovation, public health, Social Determinents of Health
  • http://www.Spherit.com Phil Lawson

    The challenge faced may be a bit more complex.

    I whole-heartedly agree about the role of SDOHs in individual, family, community and a nation’s health.

    I am not sure that politicians (as a group) have a clue what SDOHs are, even if you use the full words and not the acronym. And I am quite certain that there is very little, if any, agreement about the actual role and impact of SDOHs by the governmental powers that be.

    But what concerns me the most is that I have not seen agreement in the healthcare provider community on specifics about what the SDOHs are, beyond broad generalities. Or more importantly some agreement on how SDOHs come together, shaping the health of a person, family, community or nation.

    Until there is at least the start of some agreement on what constitutes the “whole of health” and a way to simply communicate the impact of SDOHs to all parties; first and foremost to the public, to healthcare providers, to educators, to politicians, and to the business executives and boards that run the companies in our country (not just healthcare companies) it will be difficult to make real sustainable transformative progress on this vital issue. No, actually it will be impossible.

    There seems to be two primary elements to this part of the challenge.

    First to get a working outline of what constitutes the whole of health – the essential or primary SDOHs – one that can be modified and updated as needed.

    Second is to communicate both what these are and their role in health, ideally on a single page. While almost no one will read a long report, regardless of how definitive it may be, fewer will understand one.

    It is a bit of a challenge I know. But if we expect or allow politicians and/or business leaders to define what SDOHs are and their role in health, we won’t like the outcome.

    • RichmondDoc

      Phil;

      Very good points. I agree that politicians likely do not fully understand the idea of SDOH, and do not realize the tremendous impact they have on health outcomes. The fact that many health care providers lack this same knowledge is surprising and disappointing: to me, this issue is fairly self-evident, and it is a shame that the healthcare community is not more aware.

      I think you are right: we need to make sure that we are discussing the role of SDOH as health professionals and as citizens; we should be discussing this issue whenever we are able to. For those of us who teach students, we should be communicating these ideas to them, too. Woolf’s article highlights the idea of considering the health effects of all political and policy decisions, and we should encourage our representatives to take this perspective.

      The idea of defining “the whole of health” and essential SDOHs is appealing. You may have helped identify a next step.

      Thanks for reading/commenting.

  • http://www.pursuitofpublichealth.com Vinu Ilakkuvan

    Thanks for calling further attention to the issue of SDOH! I understand the points made in the above comments regarding what constitutes SDOH/communicating their impact on health/etc…

    This WHO report has a pretty comprehensive list of SDOHs split into three categories: http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf

    And RWJF has a great start on some of the messaging work around SDOH: http://www.rwjf.org/files/research/vpmessageguide20101029.pdf

    So while I think pulling this info into a one-pager, modifying/updating it, etc. is useful, I don’t think lack of definition/lack of ability to message is our problem when it comes to addressing SDOH. The problem is that SDOH are an inherently all-encompassing concept – almost anything can affect health: food access, urban planning, education, poverty, the list is endless.

    So what do we do? And where do we start? Some organizations and nonprofits are starting to answer it in their own spheres – I think the next step is to start pulling it all together, categorizing and organizing relevant approaches, start prioritizing, figure out who is doing what and what it’ll take to replicate what works on a larger scale, as well as working to change the mindset/conversation – among public and policymakers – that guides policy formation (health impact assessments may be one concrete way to do this, and movements and blogs like this can play an important role too).

    • RichmondDoc

      Thanks for the resources, Vinu.

      It is true that SDOH are all-encompassing…and that is why they matter so much. The reading I have done suggests that if society were overall more equitable in nearly any way (education, income, etc), our quality of life would be better and healthcare costs would be less. I think the greatest challenge is getting our policymakers and fellow citizens to become aware of this. Woolf and Braverman’s article in Health Affairs recommends an approach to policy that prioritizes health considerations in any policy decision: this would be a major shift, but one that could have great benefits.

      • http://www.Spherit.com Phil Lawson

        Vinu, thanks for the links.

        The perceived complexity of the whole of health is a major barrier to getting buy in and support from politicians, business execs, HC providers and the public.

        What some are professing is “self-evident” with regard to the role and value of SDOHs, these are evident to most because they have literally seen it and experienced it. But in reality this “whole” approach goes against the fundamental beliefs our modern societies (and healthcare) have been built upon, but that is a discussion for another time.

        Our mission, if we choose to accept it, is to break through this “complexity barrier.” A simple easy way to literally show the interdependent role of SDOHs in health and the benefits (to all parties) of recognizing and embracing what they mean is essential.

  • Dave Walker

    Mark,
    Well said. I agree with Phil that knowledge of SDOHs is not widespread, even among healthcare providers. I was fortunate to have trained at a program (Montefiore RPSM) where “social medicine” was the basis for evaluating and treating patients/familes/communities. Great opportunity to spread the word.

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