Social Determinants of Health
Introduction-
When we think of healthcare, we often picture doctors, hospitals, and medications. We also consider diet, exercise, and sleep because they represent choices we make that impact our health. While all of these are undoubtedly crucial components for a healthy lifestyle, a profound influence on our well-being exists that extends far beyond the walls of a clinic or the everyday choices we make. These influences are a complex web of non-medical factors known as the social determinants of health. Although we often may not recognize them or feel their immediate effects, they play a pivotal role in determining our overall health and quality of life.
Social determinants of health are the conditions in which we are born, grow up, live, work, and age; things that may not be easily changed, or may not be under our control at all. This includes:
- Economic Stability-
Our socioeconomic status, income, and access to financial resources are strong predictors of health outcomes. For example, a patient with limited finances may have trouble finding health insurance or affording expensive procedures and medications.1 Consequently, the extent of the patient’s care becomes limited and could result in pain, worsening conditions, or possibly a death that is otherwise preventable. Living in a state of poverty also takes a physiological toll on the body. Children experiencing poverty are at risk of developmental delays, toxic stress, chronic illness, and nutritional deficits,2 and in general, those living in poverty are at a greater risk for mental illness, chronic disease, higher mortality, and lower life expectancy.3,4,5 Many of these issues can arise from food insecurity, poor healthcare, poor living conditions, and other factors directly influenced by economic stability. As you will soon read, one’s socioeconomic status is seemingly interconnected with the other determinants of health, and almost all the social determinants of health can ultimately be traced back to economic stability. It can be argued that this is the most important determinant of all.
- Education-
Education provides us with the knowledge and skills necessary to take better care of ourselves and make informed health decisions. Higher levels of literacy are correlated with better health outcomes, while those with lower literacy are 1.5 to 3 times more likely to experience poor health outcomes.6 Furthermore, individuals with higher levels of education are likely to have better job opportunities and have a lower unemployment rate,7 meaning they are economically stable. The inverse applies to those with lower education levels, leading to economic instability and the adverse effects that come with it. Research also suggests that childhood education is correlated with future health outcomes. A study reviewing the effectiveness of early childhood education programs found improved health and health behaviors among participants in adulthood. These individuals had improved cardiovascular and metabolic health, and lower instances of smoking, compared to control.8 Education can have significant and lasting effects on individuals, and the lack thereof can put them at a greater risk of health problems.
- Neighborhood and Physical Environment-
The neighborhood and environment in which we live profoundly affects our lives. Poor air quality, water quality, and proximity to pollution sources can create health hazards for the residents of affected neighborhoods.9 Low quality housing can also expose residents to lead paint, mold, dust, or infestations, placing them at risk of asthma, allergies, lead poisoning, etc.9,10,11,12 Our built environment, i.e. the infrastructure, transportation, and recreational facilities available to us, also influence our activity and health. The availability of sidewalks, parks, bike paths and scenery can all promote physical activity.13 Increased walking is associated with decreased risks of osteoarthritis, diabetes, colon cancer, and hypertension,14,15,16,17,18 so neighborhoods that promote walking can have a positive impact on our wellbeing. The availability of public transport also improves health by reducing air pollution and promoting physical activity.19 In contrast, poorly developed neighborhoods can be detrimental in various ways, with low-income communities being disproportionately affected. Individuals living in areas with low exposure to green spaces were found to have a significantly higher risk of developing hypertension.20 Neighborhood safety concerns were also related to worse mental health and less physical activity.21 Thus, the role of our living environments in shaping our health and wellness cannot be overstated. Well-planned and safe neighborhoods can promote a healthy life, while unsafe, low-quality living conditions can be detrimental. It is important for health providers to keep these considerations in mind when assessing their patients.
- Healthcare Access-
Disparities in healthcare access and quality have far-reaching implications. As mentioned before, a patient’s access to healthcare may be affected by their insurance, or lack thereof. Individuals who are financially limited may have difficulty in finding health insurance,1 and approximately 1 in 10 people in the United States are uninsured.22 These uninsured individuals are also less likely to have a primary care provider, and may have trouble paying for the services and medications they need.22 Individuals who cannot afford private insurance and thus rely on public insurance programs such as Medicaid face many obstacles to adequate healthcare as well. People on Medicaid are 1.6 times less likely to successfully schedule a visit with their primary care provider, and 3.3 times less likely to see a specialist compared to those on private insurance.23 More alarmingly, a 2015 national survey reported that 94% of the primary care providers surveyed were willing to accept privately insured patients, while only 45% were willing to accept new Medicaid patients.24 By merely having public insurance, a patient’s access to primary care providers is already halved, and it is difficult to even see the doctors they do have access to. To further exacerbate the problem, they may receive subpar care, and can even face discrimination from their providers. A study surveying patients in North Carolina reported that those on Medicaid faced excessive wait times, demeaning attitudes from front-desk staff, and poor treatment from their providers. Patients self-reported feeling rushed, not heard, and being treated as second-class citizens by the provider due to their Medicaid insurance. Many participants also claimed to have had private insurance in the past, and noted a significant drop in care quality after enrolling in Medicaid.25 Insurance is not the only cause for discrimination in healthcare either. Race and ethnicity are infamous progenitors of discrimination in the healthcare scene. A study of ethnic minority patients reports patients being treated in a condescending way that belittles their intellect and dismisses any concerns they have. Patients often felt they were stereotyped as being less educated, poor, drug users, dangerous, and difficult to appease.26 From the opposite perspective, health providers confess being less patient and empathetic towards patients of a different race. They have the tendency to blame their patients for noncompliance, poor behavior, and “playing the race card.”26 For the best possible health outcomes, a provider must do their job passionately and accurately, while the patient must trust and cooperate with their provider. However, the presence of discrimination creates a disconnect between the two. When a provider lets their biases get in the way of proper care, and when a patient cannot trust the provider, the integrity of the profession is degraded. As a result, patients cannot rely on the healthcare system to get the services they need to stay healthy, further propagating disparities in healthcare access, and leading to unnecessary suffering and preventable outcomes.
- Social and Community Context-
Social support is defined by the resources that are available to individuals to deal with stressors present in their lives. This includes our social support networks like friends, family, significant others, neighbors, etc., who are readily available to offer psychological, physical, and financial support when needed. Social support is quantified by parameters like network size and frequency of social interaction, as well as access to emotional support (love and empathy) and practical support (money, assistance, etc.).27 Healthy support networks enhance mental and physical health by reducing the likelihood of risky behavior and depression, improving treatment adherence, and increasing resilience through healthy coping.27, 28 Meanwhile, the lack of a support network can have real, physiological effects on the body. Low social support is correlated with hypertension, tachycardia, and exaggerated neuroendocrine responses to stressors.29 Socially isolated men and women were even found to be 1.9 to 3 times more likely to die from ischemic heart disease, cerebral vascular disease, cancer, and other diseases during a 9-year study.30 The people most vulnerable to isolation are those above the age of 65, low-income individuals, and ethnic minorities, all having higher rates of social isolation from 2003-2019. These trends were further exacerbated by the Covid-19 pandemic in 2020.31 Social isolation during the pandemic also appeared to magnify existing mental health conditions like depression, anxiety, and psychosis.32 In our post-Covid world, social support is more relevant than ever, so it is important to recognize it as a real determinant of health. The support you give to others, either as a provider or in your personal life, can have real, tangible effects on their wellbeing.
The Intersection of Social Determinants and Medicine-
Healthcare professionals are increasingly recognizing the profound impact of social determinants on patient health and outcomes. These social determinants must be addressed not only as part of effective medical practice, but as a matter of social justice. By identifying and mitigating factors such as poverty, lack of education, and unsafe living conditions, healthcare providers can reduce the incidence of preventable diseases and poor outcomes. There are many ways in which the social determinants of health can be addressed. General surveys screening for social determinants may be implemented to give providers an unbiased history of their patient. By understanding what issues a patient may be facing, a provider can better help them by tailoring their diagnosis and treatment to the patient. For instance, a patient with limited access to healthy food may require different dietary guidance than one with ready access to fresh produce. Hospitals and clinics often offer a plethora of programs including mental health services, substance abuse programs, support groups, counseling, and can also have connections to city/state resources like housing assistance, food pantries, employment services, etc. Healthcare providers can serve as advocates for their patients by being knowledgeable about all available resources and referring patients to the proper ones when necessary. Community engagement events can serve as opportunities for healthcare professionals to interact with the community and offer health education. Giving informative lectures, classes, and PSAs can inform people about diseases, help them avoid harmful behaviors, and educate them to take better care of themselves and others. Finally, providers can address their own implicit biases by practicing mindfulness, reflecting upon their patient interactions, and holding themselves accountable for any failure on their part. Cultural education and engagement with a diverse population can further help providers remove any personal biases they may have, instead replacing them with respect and empathy towards people of a different background than theirs. By removing bias from the healthcare scene, providers will be able to practice medicine more effectively while patients will be more trusting and intimate with their providers, therefore making healthcare more accessible to all.
The Role of Future Medical Professionals-
As prospective medical students, we have the opportunity to develop a deep understanding of the social determinants of health through our clinical and non-clinical experiences. We can gain clinical exposure by shadowing physicians, working as EMTs or medical scribes, and volunteering at hospitals. Working alongside healthcare providers will not just acquaint us with the clinical setting or help cultivate our interpersonal and practical skills for medical school. It will also expose us to diverse patient populations with unique needs and challenges. By interacting with patients from different backgrounds, cultures, and socioeconomic statuses, we can better understand the complex interplay between these social determinants and health outcomes. This exposure fosters empathy, cultural competence, and a holistic approach to patient care, essential qualities for aspiring healthcare professionals. Non-clinical experiences are equally as important because we get to witness first-hand the impact of the social determinants on people’s lives. They are opportunities to take direct action and combat these factors to make a difference in the health of our community. By volunteering at a food pantry or soup kitchen for instance, we can make healthy meals accessible to those who otherwise face food insecurity. By volunteering at a nursing home, we can provide vulnerable elderly populations with the care and social support they need. Participating in community outreach events and programs can make health education more accessible, especially to underserved populations that may not have equal access to such education. These and many other volunteer experiences can help us build character and develop a passion for serving others. There is a reason medical schools insist on having both clinical and non-clinical experiences; they want us to prove our commitment to healthcare. We can go above and beyond by showing them our acquired understanding of the real world. We must reinforce our commitment to the field and to our future patients by addressing disparities and advocating for equitable access to care. In doing so, we not only advocate for the wellbeing of our community, but develop ourselves as a new generation of compassionate and socially responsible healthcare professionals.
Conclusion-
Social determinants of health are not peripheral issues in healthcare; they are central to our well-being. Recognizing the profound influence of economic stability, education, living environments, healthcare access, and social context on health is essential for creating a healthier and more equitable society. As future medical professionals, we can play a pivotal role in addressing social determinants of health and promoting a more holistic approach to healthcare that transcends the traditional boundaries of medicine.