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by Ted Schettler
Social environmental determinants of health (SDOH) largely explain why a newborn girl has a life expectancy of more than 80 years if she is born in some countries but less than 45 years if she is born in others. Or why zip codes in the US accurately predict many measures of individual and community health, including life expectancy. Eco-social environments have greater influence on our health than access to good health care, although in the US we spend far more money on health care for sick people than on disease prevention in populations through eco-social interventions.
Social circumstances, environmental exposures, health behaviors, and health care are the predominant determinants of population health. In reality these categories are not separate but interact and can shape one another. For example, prenatal and early-life social stressors increase the risk of childhood asthma onset as a result of chronic exposure to traffic-related air pollution. And social circumstances can make exposure to traffic-related air pollution more likely. Reliable access to good health care may be challenging for families living in poverty, but it is essential for optimal asthma management. The primary prevention of asthma involves intervening further upstream across a range of social and environmental indicators.
The Centers for Disease Control and World Health Organization (WHO) define the SDOH as the conditions in which people are born, grow, live, work and age. These conditions are mostly shaped, they say, by the distribution of money, power, and other resources at global, national, and local levels. Social determinants of health are largely responsible for health inequities – the unfair and avoidable differences in health status within and between countries—sometimes called the health gap.
In their 2008 report, Closing the Gap , a WHO commission said:
“[Health inequities and the health gap] are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of people’s lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics. Together, the structural determinants and conditions of daily life constitute the social determinants of health and are responsible for a major part of health inequities between and within countries.”
The WHO commission made three overarching recommendations with the aim of achieving health equity:
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Improve daily living conditions; 2) Tackle inequitable distribution of power, money, and resources; and 3) Measure and understand the problem and assess the impact of action
Indicators of the social determinants of health:
Indicators of social factors that influence health have evolved and vary depending on the level of analysis, purpose, and where boundaries are set on sources of data. Here are several examples:
At the individual level, the National Academy of Sciences identifies five domains of social risk factors likely to be important to health outcomes of Medicare beneficiaries: 1. Socioeconomic position; 2. Race, ethnicity, and cultural context; 3. Gender; 4. Social relationships; and 5. Residential and community context.
The Area Deprivation Index is based on a combination of income, education, employment and housing quality evaluated at the census block group level throughout the US.
The National Equity Atlas considers a lengthy list of indicators that “track how communities are doing on key measures of inclusive prosperity. [It] defines an equitable community as one where all residents — regardless of their race, nativity, gender, or zip code — are fully able to participate in the community’s economic vitality, contribute to its readiness for the future, and connect to its assets and resources.”
The Opportunity Index uses indicators from the domains of economy, education, health, and community to give a broad picture of opportunity at the state and county level in the US.
Dignity Health (formerly Catholic Healthcare West) developed the Community Need Index to help health care organizations, not-for-profits, and policymakers identify and address barriers to health care access in their communities. The CNI aggregates five socioeconomic indicators long known to contribute to health disparities--income, culture/language, education, housing status, and insurance coverage--and applies them to every zip code in the United States.
County Health Rankings & Roadmaps measures health-related factors in communities around the US to drive change towards improving health. The program provides snapshots of community health as well as a community ranking system. Rankings are based on indicators of health outcomes—length and quality of life—and weighted scores of four health factors: health behaviors, clinical care, social and economic factors, and the physical environment.
A number of the indices and ranking systems give limited attention to physical environmental quality indicators even though many features of a community’s environment are determined by social policies and programs. That has begun to change as community groups repeatedly showed that adverse social and environmental conditions often co-occur and began demanding environmental justice.
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