March – April 2020

By Sarabeth Lowe, MPH Ms. Lowe is a Communication Specialist at the University of Delaware Disaster Research Center. Welcome to the fourth edition of Health Literacy Highlights, a column that explores topics related to finding, understanding, and utilizing health information. This column is meant to empower you with the skills you need to apply what you already know and use it to maintain and protect your overall health and wellbeing. In this installment of Health Literacy Highlights, I focus on the social determinants of health (SDoH) and their impact on public health.  Health is more than just the absence of disease or injury.1–3 It’s also more than just a matter of your genes and choices. There are a myriad of variables that directly affect our wellbeing, beginning with where we live, work, and play. Upstream factors—the fundamental social, cultural, and political structures and systems in place—are the driving forces behind the health inequities we see every day.4 Efforts to improve health in the United States (US) have traditionally looked to the healthcare system to alleviate these disparities, but this approach often misses the forest for the trees. It’s also largely ineffective. Research and history show that this approach is not working.5–7 Despite being widely recognized and documented for many years, disparities in health and healthcare have persisted and, in some cases, widened over time in the US.8–11 Improving health outcomes and achieving health equity require broader approaches that address social, economic, and environmental factors. This has led many practitioners, researchers, and experts to advocate for a strategy that directly addresses the causes—not the symptoms—of these disparities. In other words, they are calling for going back to basics: social determinants of health (SDoH). What Are SDoH? SDoH are the evolving societal systems, their components, and the resources and hazards for health systems that social systems control, distribute, allocate, and withhold that, in turn, cause health consequences.12 SDoH are also described as:13–17 Nonmedical or nonbiological factors that influence health outcomes, risks, quality of life, and longevity; for example, race itself isn’t a SDoH, but racism and its social manifestations, like a ZIP code’s history of school segregation or redlining, are.18 Conditions and environments in which people are born, grow, work, live, and age. Wider forces and systems that shape the conditions of daily life. Upstream social and economic factors that dictate the health and disease of individuals and populations. In short, SDoH are the “causes behind the causes” of health disparities.13 They describe a simple idea: a person’s health is influenced not just by their behavior or actions, but also by social factors. These factors include a variety of personal, social, and environmental conditions and structures, including economic policies, development agendas, social norms, social policies, climate change, and political structures.14 Notably, many SDoH are out of a person’s control.18 The 5 Domains of SDoH SDoH are one of three priority areas—along with health equity and health literacy—for the fifth and current edition of Healthy People, a federal and decadal initiative that sets goals and objectives to improve the health and wellbeing of people in the US.14,15,17 One of Healthy People 2030’s five overarching goals is specifically related to SDoH: “Create social, physical, and economic environments that promote attaining the full potential for health and wellbeing for all.”19–21 The US Department of Health and Human Services had grouped SDoH into five key areas. Economic stability. This domain refers to the connection between a person’s financial status and their health. It encompasses many factors, including income and expenses, social safety net programs (eg, welfare and food stamps), job stability, employment benefits, socioeconomic status, and the general cost of living.17,18,22,23 All of these factors impact a person’s health. Extensive evidence shows that financially disadvantaged individuals have poorer health outcomes than their wealthier counterparts.24–27 For example, higher wealth and income can lead to better health by providing material and employment benefits that promote good health: safe homes and neighborhoods, paid time off work, health insurance, transportation, education, and more. Having a higher socioeconomic status can also reduce the persistent psychosocial stress associated with not having these material resources, which can lead to chronic disease.24,28,29  Education access and quality. This domain refers to a person’s access to and quality of education, and how well it supports their individual learning needs, including those related to how the brain works.18 It encompasses several factors, such as teacher training, geographic location, school facilities (eg, labs, playgrounds, safe classrooms and buildings), curriculum quality and relevance, material resources, educational infrastructure (eg, leadership, policies, and systems), and access to specialized student programs.30,31 Research shows that education and health are intrinsically linked.32 Education is strongly associated with life expectancy, morbidity, and health behaviors.33 It also increases financial security, stable employment, and social success, playing a critical role in lifting people out of poverty and reducing socioeconomic and political inequalities.32,34,35 Healthcare access and quality. This domain refers to a person’s access to and the quality of health-promoting care and resources, and how well it can meet their physical and mental health needs.18 It encompasses several factors, including affordable and easily attainable care, health literacy, health insurance, regularly visiting a primary care doctor, seeing doctors for illness and injuries, receiving mental and behavioral health services, and responding to medical emergencies.36–38 A number of social and economic issues, such as cost and coverage of care, limited access to providers that accept Medicaid, a shrinking healthcare workforce, and fewer medical services and clinicians in rural areas, take a toll on people’s long-term health and contribute to poor wellbeing outcomes.39–44 Neighborhood and built environment. This domain refers to the place someone lives, including its physical, environmental, and societal conditions and its impact on public health and wellbeing.45–47 These factors are related to your ZIP code and the specific community resources that support your health and safety, such as equitable, affordable, and high-quality housing, sidewalks, low rates of crime and violence, schools, workplaces, places of worship, grocery stores, transportation infrastructure, and green spaces.18,48 This SDoH also encompasses climate change.