3.1 Social Determinants of Health
Katie Baker
Social determinants of health are factors that affect health and are beyond an individual’s control. In 2020, the Centers for Disease Control and Prevention (CDC) launched Healthy People 2030 to address these societal-level determinants through public health initiatives such as access to education, clean water, healthcare, and healthy foods.
Healthy People 2030
Healthy People 2030 divides social determinants of health into five categories:
- Economic stability
- Education access and quality
- Healthcare access and quality
- Neighborhood and built environment
- Social and community context
We will explore some of the Healthy People 2030 goals in each of these categories.
Economic Stability
The goal of this category is to help people earn stable incomes that enable them to meet their healthcare needs. Objectives for improving economic stability include reducing:
- The proportion of individuals living in poverty
- The proportion of families and children experiencing food insecurity
- The proportion of households spending 30% of their income on housing
- The number of workplace injuries
- The number of adults whose arthritis interferes with their work
In terms of employment, objectives focus on increasing employment rates and the number of children who live with at least one parent working full-time while decreasing the number of teens and young adults who are not in school or working (Agency for Toxic Substances and Disease Registry [ATSDR], 2023).
Education Access and Quality
The goal of this category is to expand educational opportunities and help children and adolescents succeed in school. Objectives include:
- Improving high school graduation and college matriculation rates
- Increasing the proportion of fourth and eighth graders with appropriate math and reading proficiency
- Increasing the proportion of young children who participate in early childhood education programs and are developmentally ready for school
- Expanding intervention services for those in need
- Increasing preventive mental health care in schools
- Increasing the proportion of people with disabilities in regular education programs.
These objectives are intended to minimize equity gaps that interfere with many students’ access to higher education, well-paying jobs, and services as they get older (ATSDR, 2023).
Healthcare Access and Quality
The goal of this category is to increase access to comprehensive high-quality healthcare services. Objectives include:
- Reducing emergency room wait times
- Increasing the number of adults, adolescents, and children that use evidence-based preventive care
- Increasing screening rates for lung, breast, colorectal, and cervical cancer, as well as discussions about cancer prevention with healthcare providers (ATSDR, 2023)
Neighborhood and Built Environment
The goal of this category is to create neighborhoods and environments that promote health and safety. Objectives include:
- Reducing adolescent crime
- Improving access to clean water and broadband internet
- Reducing exposures to lead and other environmental hazards
- Improving health and safety discussions in schools
- Affecting building codes to support individuals with mobility issues
- Reducing motor vehicle deaths
- Increasing access to fluoridated water
- Addressing asthma-related initiatives (ATSDR, 2023)
Social and Community Context
The goal of this category is increasing community and neighborhood support. Objectives include:
- Reducing anxiety and depression
- Reducing the number of children whose parents have been incarcerated
- Increasing voter participation
- Expanding education preparation and preventive healthcare for children and adolescents (ATSDR, 2023)
Looking Forward with Healthy People 2030
The goals for Healthy People 2030 are wide-ranging and touch on many different fields and disciplines. To meet these goals, local, state, and federal agencies must collaborate to benefit the most vulnerable members of society. If you work for a public health organization or a large medical group or hospital, you will likely contribute to the Healthy People 2030 mission. This includes incorporating future initiatives into your work and contributing to these nationwide goals. While Healthy People 2030 is a U.S.-based initiative, its underlying principles apply to health across the globe. As we explore the different social and environmental factors that affect health, keep in mind that the same core factors are involved in determining individual health worldwide.
The Effect of Social Determinants on Our Health
Health Literacy
What is health? The World Health Organization (WHO, 2023) defines health as not only lacking illness or injury but being in a state of “complete physical, mental and social well-being.” This might also be referred to as thriving. When someone is healthy, they are supported emotionally and physically by their personal decisions and environment and are free from any infections, diseases, or injuries caused by external factors. Health includes both mental and physical aspects.
Social determinants of health are factors that influence an individual’s health beyond pathogens, injuries and other physical causes that affect physical, mental, and emotional health. Health literacy includes knowledge of healthy and unhealthy behaviors, as well as an understanding of explanations for illness and injury. For example, a patient who takes a full course of antibiotics to treat an infection and prevent antibiotic resistance, instead of stopping antibiotics as soon as they feel better, shows an understanding of their treatment plan and the need to prevent resistance. Recently, there has been increased focus on improving health literacy around bacterial infections and resistance through public health ads and patient education materials.
Personal decisions about our health, such as what foods and drinks we consume, how much exercise we perform, and our choices around tobacco, drug use, and immunizations, can have lasting impacts on our physical and mental health. Maintaining a healthy diet that includes regular meals and limits overconsumption can lead to positive health outcomes. Something as simple as having access to and eating a regular breakfast can have lasting effects on rates of obesity and diabetes and provide the energy and appropriate blood sugar levels to maintain healthy mood and energy levels, especially during school and work.
Choosing a diet rich in fruits and vegetables can have positive impacts on cardiovascular, gastrointestinal, neurological, and mental health, among other benefits (Angelino et al., 2019). Increased intake of orange and yellow vegetables, for example, provides essential nutrients for healthy vision. Choosing a diet high in preserved and smoked foods will negatively impact digestive and cardiovascular health. For example, eating large amounts of smoked meats, such as bacon, and grilled foods leads to the creation of chemicals that increase our risk of developing various types of cancers (National Cancer Institute, 2017). Also, poor blood sugar control from eating highly processed foods can lead to the development of Type 2 diabetes. While some foods linked to poor health outcomes may be enjoyable, their consumption should be limited to reduce health risks.
The amount and type of exercise that we get impacts our mental and reproductive health, as well as the health of our musculoskeletal and cardiovascular systems. Different exercises focus on endurance, flexibility, and cardiovascular health. An exercise routine that includes stretching, weights, walking, and quick bursts of high activity will address all three of these areas. Daily exercise can improve mild depression, premenstrual syndrome, and polycystic ovarian syndrome (Woodward et al., 2020). Daily exercise for 20 minutes or more has also been correlated with lower rates of depression and anxiety (Kandola & Stubbs, 2020).
Overexertion, on the other hand, can lead to injury. It is important for people who are new to exercise to begin slowly and avoid progressing too rapidly through their exercise plans. Regular exercise is preferable to intense sessions on an irregular basis. So-called “weekend warriors” are more likely to sustain injuries than individuals who exercise regularly throughout the week.
While moderate alcohol intake (defined as 1-4 drinks per week) has been associated with improved cardiovascular health (Krittanawong et al., 2022), excessive intake is one of the main causes of mortality in the United States (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2021).
Tobacco use, whether through smoking, vaping, or chewing, has no long-term health benefits and has substantial negative health effects. According to current research, cigarette smoking is the leading cause of preventable death in the United States (CDC, 2014). It is also a major contributor to other leading causes of death including heart disease, cancer, chronic lower respiratory disease, and stroke (CDC, 2014).
Cigarette smoke exposure not only affects the smoker but also those around them via secondhand smoke. Nicotine in cigarettes can leave a residue on clothing and surfaces and can expose those who come in contact with them to harm without exposure to the smoke itself. This is called third-hand smoke, and it is linked to higher rates of asthma, ear infections, pneumonia, and frequent illnesses in children of smokers (Ferrante et al., 2013).
While research on vaping and chewing tobacco is less extensive, both have deleterious effects on health. Research shows an association between vaping and chronic obstructive pulmonary disease (COPD) and asthma (Osei et al., 2020) while the use of smokeless tobacco, also known as “chew” or “dip,” has long been linked to cancers of the mouth, tongue, and throat (CDC, 2020).
Like tobacco use, the choice of whether to immunize yourself or your family against preventable illnesses has lasting societal effects. While there are tens of thousands of studies supporting the safety and efficacy of immunizations, some people choose not to immunize based on misunderstandings of science and safety concerns that have been magnified and manipulated for personal and financial gain. Lower rates of immunization have led to outbreaks of serious preventable diseases, such as measles, in the United States in the past decade (Phadke et al., 2016).
As you have read, personal decisions have lasting impacts both individually and societally. Personal choices around diet and exercise will affect our mortality and wellness for many years to come, as well as those who care for us when we can no longer do so. Decisions that affect exposure to others, whether to tobacco smoke or preventable illness, and decisions around consumption of alcohol and drugs that lead to drunk driving, fetal exposure to alcohol or drugs, and crime rates have a lasting effect on families and communities.
In the next section, we will discuss social determinants of health that are rooted in family and religion and how they can affect our physical and mental health. We will consider how individual decisions can affect family dynamics and vice versa, as well as how religious beliefs can affect our health.
Family and Religion
You may wonder how your family and religious beliefs affect your physical, mental, and emotional health. How do you define family? Families can be defined as family of origin, meaning the family in which you grew up, or family of choice, meaning a group of people that you choose to surround yourself with and with whom you have formed close bonds. The behavior modeled by parents, grandparents, siblings, and other role models in the family profoundly impact a person’s beliefs and behaviors surrounding their own health.
Religion can impact physical, mental, and emotional health by instilling values related to bodily autonomy, reproductive choices, sexuality, and death and dying. Many religions also have rules about diet, sexual activity, and respect for our own bodies and those of others. In these ways, our religion of upbringing or choice affects decisions we make about our health and that of our families.
Decisions made by parents around meal planning, cigarette smoke exposure, and support for their children’s socioemotional growth can have effects on the family’s health. Familial relationships, both in an individual household and with extended family can have a profound effect on mental and emotional health as well. For example, building healthy intergenerational relationships can positively affect both older and younger family members.
Also, the decision to distance oneself from an estranged or abusive family of origin necessitates a “chosen family” to provide familial support. A lack of outside support can lead to a person remaining in abusive situations or struggling to survive and thrive on their own.
Conversely, modeling and normalization of unhealthy behaviors, such as poor dietary choices, smoking, and drug use, may increase the likelihood of a person making the same decisions. Biological families also contribute genetic factors that predispose individuals to unhealthy outcomes, such as cancer, obesity, hereditary diseases, and addictions.
Finally, financial burdens or low socioeconomic status predispose families to other risk factors, such as limited access to healthcare, healthy food, clean water and air, as well as recreational spaces and other community resources.
Community, School, and Work
Our communities and the places where we spend most of our time are important factors in our health. Where we go to school or where we work affects us through environmental exposures, school or workplace culture, and support systems. Access to clean water, green spaces, recreational opportunities, physical safety, and low crime rates all play a role in the different facets of health.
Communities can provide positive and negative influences on an individual’s health. As mentioned in the previous section, access to clean water and clean air is not always guaranteed. Access to healthcare, jobs, and a strong school system, which may be a primary source of support for many families, also play a role in the different components of health.
As we saw during the COVID-19 pandemic in the United States, schools play an important role in the community beyond just providing education for children. Some families rely on schools for their children’s meals, and social support at school is an important component of children’s mental and emotional health. Teachers and school administrators play a key role in caring for children, acting as role models, observing health changes, and reporting suspected abuse. Communities formed around schools can provide much-needed support for entire families.
Many school districts rely on levies and taxes, particularly property taxes, to fund programs beyond those provided by state or federal funding. This leads to inequities in resources across districts, based on the value of homes within those districts. Districts that serve families in lower-income regions may lack many of the extracurricular activities and exposure to new technologies provided in more well-off school districts and suffer from lack of repairs and environmental hazards due to poor funding.
Workplace culture and environmental exposures affect all aspects of our health. Some individuals work in environments that put them at risk of occupational injuries, including repetitive motion injuries such as carpal tunnel syndrome or exposure to toxic materials or fumes. Others may work in supportive environments that accommodate their roles as parents or caregivers, providing benefits and amenities beyond those required by law.
In countries that lack universal healthcare, such as the United States, private insurance coverage is often linked to employment. However, some individuals have a work culture that discourages taking time off for illness, and many workers in the United States lack health insurance, sick leave benefits, or the financial resources to miss work if they are ill or need to care for a family member. In 2019, approximately 92% of the U.S. population had health insurance, leaving 26.1 million people uninsured. Among the insured, almost 56% obtained coverage through their jobs (Keisler-Starkey & Bunch, 2021).
Society and Culture
Societies around the world have been shaped by laws and regulations intended to support large groups of people living in close proximity. Different countries, and even regions within larger countries, such as cities, counties, and states in the United States, have distinct governmental laws and unofficial societal norms that affect access to healthcare and social support for residents. Culture can be defined as the institutions, collective beliefs, practices, and art of a specific social group. Within any society, various cultures can coexist, affecting an individual’s access to support, whether by choice or because of factors beyond their control. People can identify with multiple cultures, including ethnic backgrounds, sexual orientations, religious belief systems, countries of origin, or even regional or generational differences.
From governmental institutions providing public health interventions to the types of medical care systems in place (discussed further in Chapter 1), social mores and cultural values affect our healthcare decisions such as those around abortion, birth control, vaccinations, and euthanasia.
In some areas, societal and cultural norms are strongly informed by religious values. These norms include female reproductive rights (such as birth control, abortion, and sexual activity), preventive measures and medical interventions (such as stem cell research, immunizations, and blood transfusions), or issues of death and dying (such as Death with Dignity, suicide, and euthanasia). For example, while Jewish tradition supports palliative and end-of-life care in hospice, “the shortening of life through suicide, assisted suicide, or euthanasia is categorically forbidden” (Kinzbrunner, 2004).
In the following section, we will discuss various forms of public health and explore how public health utilizes three types of prevention (primary, secondary, and tertiary) to help the U.S. population maintain good health.
Attributions
- Figure 3.1: 13584554804 by Army Medicine is released under CC BY 2.0
- Figure 3.2: Measles Awareness Poster by City of Minneapolis Archives is released under CC BY 2.0
Factors that influence an individual's health beyond the pathogens, injuries and other physical causes that affect our physical, mental, and emotional health.
A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
A group of people sharing a common location, or one sharing common attitudes or interests. Community can be geographical or can be developed intentionally.
Enrollment or acceptance into a college’s degree program.
A group of people living together under the same set of laws or government.
The state of being dead, or the rate of deaths within a specific population or group over a particular period.
The institutions, collective beliefs and practices and art of a specific group of people.
Typical behavior or belief within a culture or society.
Beliefs about what is morally right or wrong.
Painless killing of a patient who is suffering from a severe terminal illness.