Chapter 3: Social Determinants of Health
Katie Baker
The social determinants of health include factors that affect health, that can not be controlled by individuals. The US Centers for Disease Control and Prevention (US CDC) created ”Healthy People 2030” to address societal-level determinants, such as access to education, clean water, healthcare, and healthy foods, that can be supported by Public Health initiatives.
”Healthy People 2030”
Healthy People 2030 divides social determinants of health into 5 categories: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. We will explore some of the healthy people 2030 goals with regard to each of these categories.
Economic Stability:
The goal is to help people earn stable incomes to help them address their healthcare needs. Related objectives include decreasing the following: 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 and the number of adults whose arthritis interferes with their work. In terms of employment, increasing employment rates and increasing the number of children who live with one parent working full-time as well as decreasing the number of teens and young adults who are not in school or working are some of the objectives (ATSDR 2023).
Education Access and Quality
The goal is to increase educational opportunities and help children and adolescents do well in school. Some of the objectives to meet the that goal include improving high school graduation and college matriculation rates, increasing the proportion of 4th and 8th graders with math and reading skills at or above the proficiency level, increasing the proportion of young children who participate in early childhood education programs and are developmentally ready for school, increasing intervention services for those who need it and increasing preventive care for mental health within schools. Specific to individuals with disabilities, objectives include increasing the proportion of those individuals in regular education programs. These goals are intended to minimize equity gaps that interfere with many students’ abilities to access higher education, well-paying jobs and services as they get older (ATSDR 2023).
Healthcare Access and Quality
The goal is to increase access to comprehensive high-quality healthcare services. Objectives in this field include reducing emergency room visit wait times and increasing the number of adults, adolescents, and children to take advantage of evidence-based preventive care. Included in preventive care is an increase in the proportion of patients who get screening for lung, breast, colorectal, and cervical cancer as well as those who have discussions with their providers about cancer prevention (ATSDR 2023).
Neighborhood and Built Environment
The goal is to create neighborhoods and environments that promote health and safety. This category includes everything from reducing adolescent crime to improving access to clean water and broadband internet. Other objectives focus on reducing exposures to lead and other environmental hazards as well as 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 and addressing a host of initiatives that have to do with asthma (ATSDR 2023).
Social and Community Context
With a goal of increasing community and neighborhood support, these objectives cover a very wide range of topics, from reducing anxiety and depression and reducing the number of children whose parents have been incarcerated to increasing voting participation. Specific objectives in the adolescent and child categories range from education preparation to preventive care and other topics (ATSDR 2023).
Healthy People 2030 Looking Forward
The goals for Healthy People 2030 are wide-ranging and touch on many different fields and disciplines. In order to meet these goals and objectives, many agencies at the local, state and federal levels must all be ready to interact in ways that benefit our most vulnerable members of society. If your career involves being a part of a Public Health Organization or even if you work for a larger medical group or hospital, you will likely be part of 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, the same underlying principles apply to health across the globe. While we explore the different social and environmental factors that affect health, keep in mind that the same core factors are involved in determining an individual’s health across the globe.
The Effect of Social Determinants on Our Health
Health Literacy
What is health? The World Health Organization defines health as not only lacking illness or injury but being in a state of “complete physical, mental and social well-being” (WHO, 2023). This might also be referred to as thriving. When someone is healthy, they are supported emotionally and physically by their personal decisions and their environment as well as being free from any infections, diseases or injuries caused by outside factors. Health includes mental health as well as physical.
Social determinants of health are factors that influence an individual’s health beyond the pathogens, injuries and other physical causes that affect our physical, mental, and emotional health. Health literacy includes knowing about healthy and unhealthy behaviors as well as understanding the explanations for illness and injury. For example, a patient who takes a full course of antibiotics in order to address an infection and prevent antibiotic resistance instead of stopping antibiotics as soon as they feel better shows an understanding of the treatment plan and the need to prevent resistance. This area in particular has been under increased focus lately through public health ads and patient education materials to improve health literacy around bacterial infections and resistance.
Personal decisions about our health, such as what foods and drinks we consume, how much exercise we perform and our choices around tobacco and drug use and immunizations can all be considered to have lasting impacts on our physical and mental health. Having a diet that is healthy, involves 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 as well as providing the energy and appropriate blood sugar levels to maintain your mood and energy levels, especially while in school and working. Choosing a diet that is rich in fruits and vegetables can have positive impacts on cardiovascular, gastrointestinal, neurological and mental health, among other benefits (Angelino et al., 2019). An increased intake of orange and yellow vegetables, for example, can help to provide the nutrients that are required for healthy vision. Choosing a diet that is heavy in preserved and smoked foods will have a negative impact on the health of our digestive system and cardiovascular system. For example, eating a lot of smoked meat such as bacon and grilled foods leads to the creation of chemicals that increase our likelihood of different types of cancers (National Cancer Institute, 2017). Poor blood sugar control from eating highly processed foods can lead to the development of type II diabetes. While tasty, consumption of foods that are linked to poor health come outcomes should be limited to reduce the risk.
The amount of exercise that we get, as well as the type, has been shown to have effects on our mental and reproductive health as well as the health of our musculoskeletal system and cardiovascular system. Different exercises will focus on endurance, flexibility, and cardiovascular health. An exercise routine that encourages stretching, weights or walking and quick bursts of high activity will address all three of these areas. Daily exercise is useful for improving 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 that people who are new to exercise begin slowly and avoid progressing too rapidly through their exercise plan. Regular exercise is preferable to intense sessions on an irregular basis. So-called “weekend warriors” are more likely to sustain injuries than individuals who maintain some form of exercise 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 (NIAAA, 2021).
Tobacco use, whether through smoking, vaping, or chewing tobacco, 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). Additionally, cigarette smoking also acts as a major contributor to other leading causes of death like heart disease, cancer, chronic lower respiratory disease and stroke (CDC 2014). Cigarette smoke exposure affects the smoker as well as surrounding individuals via secondhand smoke. Nicotine in cigarettes can leave a residue on clothing and surfaces and can even be a source of exposure to people who come in contact with them 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, 2013). While vaping and chewing tobacco have less research than cigarette use, they both have deleterious effects on health. Research on vaping shows an association between it and COPD and asthma (Osei et al., 2020), whereas 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 illness has lasting societal effects.While there are tens of thousands of studies supporting the safety and efficacy of immunizations, some families and individuals 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 has led to outbreaks of serious preventable diseases, such as measles, in the U.S in the past decade (Phadke et al., 2016).
As you have read, personal decisions have lasting impacts individually and societally. Personal choices around diet and exercise will affect our mortality and our wellness for many years to come and will impact those who care for us when we can no longer do so. Decisions that affect exposure to other individuals, whether to tobacco smoke or preventable illness, or 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 our next section, we will discuss determinants of health that are rooted in family and religion and how they can affect our physical and mental health. We will consider how personal decisions by individuals can affect family dynamics and vice versa as well as how religious beliefs can affect us.
Family and Religion
You may wonder how your family or your religious beliefs affect your physical and mental and emotional health. How do you define family? Families can be defined as your family of origin, meaning the family in which you grew up, or your family of choice, meaning a group of people that you choose to surround yourself with and with whom you have created close bonds. Modeling of behavior by parents, grandparents, siblings and other role models in the family can have a profound impact on an individual’s beliefs and behaviors surrounding their own health.
Religion can have an effect on physical, mental and emotional health through these values in which it can instill surrounding bodily autonomy, reproductive choices, sexuality and death and dying. In addition, various religions have rules about diet, sexual activity, and respect for our own bodies and those of others around us. In these ways, our religion of upbringing or of choice will have an effect on decisions we make about our health and that of our families.
Decisions made by parents around meal planning, cigarette smoke exposure, and support for socioemotional growth in their children can all 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 have a positive impact on both older and younger family members. Also, the decision to distance oneself from an estranged or abusive family of origin necessitates the presence of a “chosen family” to provide the support that is now missing. Lack of outside support can lead to individuals 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 an individual making the same decisions. Biological families also contribute many genetic factors that predispose individuals to unhealthy outcomes such as cancer, obesity, hereditary diseases and addictions.
Finally, financial burdens or low socioeconomic status predisposes families to other risk factors such as limited access to healthcare, healthy food, clean water and air and resources such as recreational spaces and other community resources discussed in the next section.
Community, School, and Work
Our communities and the places in which we spend most of our time are important factors in our health. Where we go to school or where we work will affect us through environmental exposures, school or workplace culture, and our support systems. Access to clean water, green spaces, and recreational opportunities as well as physical safety and lack of crime will 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 within the community 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 coronavirus pandemic in the United States, schools play an important role in the community beyond just providing education for children. Some families may rely upon the school for meals for their children. 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 and acting as role models in their lives, including observing health changes as well as observing and reporting on suspected abuse. Communities that are created surrounding a particular school can provide much-needed support for the entire family.
Many school districts rely upon levies and taxes, particularly property taxes, to fund programs beyond those provided by state or federal funding. This leads to inequities in the resources that a school district may have based on the value of homes within the district. In this way, districts that provide education for families in lower-income regions lack many of the extracurricular activities and exposure to new technologies that may be provided in more well-off school districts. These districts may also suffer from lack of repairs and environmental exposures due to poor funding.
Workplace culture and exposures can have a supportive or a chilling effect on all parts of our health. Some individuals work in environments that place them at risk of occupational injury including repetitive motion injuries such as carpal tunnel syndrome or exposure to toxic materials or fumes. Others may work in an environment that is supportive of their roles as parents or caregivers, providing benefits and amenities beyond those required by law.
Particular to countries that lack universal healthcare, such as the United States, is the practice of having private insurance coverage through the workplace. However, some individuals have a work culture that discourages taking time off for illness and many workers in the U.S. do not have health insurance or 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. Of those who are insured, almost 56% had insurance through their job (Keisler-Starkey & Bunch, 2021).
Society and Culture
Societies around the world have all been formed through laws and regulations intended to support large groups of people living in close proximity. Different countries, and even different regions within larger countries such as cities, counties and states in the U.S., have different official governmental laws and unofficial societal norms that affect access to healthcare and social support for people living in those areas. Culture includes the institutions, collective beliefs and practices and art of a specific group of people. Within any society, various cultures can exist that affect how people access these supports, whether by choice or through factors outside of individual control. Individuals can identify with more than one culture such as an ethnic background, sexual orientation, a religious belief system, a country of origin, or even regional or generational differences between groups.
From governmental institutions providing public health interventions and access, to the type of medical care systems we have (discussed more in Chapter 1), to social mores and cultural values around healthcare decisions such as abortion, birth control, vaccinations and euthanasia, society and culture affect our health in a wide variety of ways.
Societal and cultural norms in some areas are strongly informed by religious values. These can center around female reproductive rights, (such as birth control, abortion and sexual activity), around preventive measures and medical interventions, (such as stem cell research, immunizations and blood transfusions), or around death and dying, (such as Death with Dignity, suicide and euthanasia). For example, Jewish tradition supports palliative and end-of-life care in hospice, but “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 remain healthy.
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.