Mar 22, 2024

Social Determinants of Health. Now what?

photo credit: (c) GETTY IMAGES/Thomas Barwick. Portrait of multigenerational family standing of front porch of home

I am fortunate enough to have the opportunity to share my thoughts about the importance of the Social Determinants of Health (SDoH) framework and advancing health equity. So, what is this and why does it merit discussion?

Most experts and organizations identify SDoH as the core conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. These external or contextual conditions exert influence over the resources, options, barriers and facilitators that individuals, groups and populations encounter across the life span. KFF (formerly Kaiser Family Foundation) provides an excellent description of some categories that comprise these contextual factors, which include economic stability, physical environment, education, food, community and social context, and healthcare. The World Health Organization specifically includes genetics and gender. Contextual factors are driven by systemic influences such as economic policies and systems, development agendas, social norms, social policies, racism, climate change, and political systems. Increasingly, war and civil unrest have been examined as important influences on health and quality of life worldwide (Penderson D, 2002; Wiist WH, et al, 2014).

Now that we’re on the same page regarding what SDoH is, I think a better way to understand what this looks like is through an individual life and how it impacts communities. I’ll use my life and the impact on the community with which I am most familiar.

photo credit: (c) GETTY IMAGES:Granger Wootz. Photo of family hugging at backyard barbecue

In 1951, I was born to a family with a young mother and father and ultimately nine children. My neighborhood, with one of the highest population densities in an urban city, included only Black residents. The community resources (stores, employment opportunities, public transportation) were limited.  A comprehensive health care center was not established until 1968 (which helped to replace the hospital emergency room outside the neighborhood as our primary source of healthcare). Racial discrimination was an accepted part of our daily experiences; some stores, recreation venues and communities were off limits to Black residents. Industrial, often polluting businesses were commonly placed within this community. So, many of the factors that are now established as SDoH influences were part of my and my family’s life and had significant impact on our opportunities, health, and wellbeing. One of my sisters died as a result. The context in which we lived directly influenced the late identification and severity of her chronic illness, the resulting disability, and subsequently her early death.

If you think ‘that was a long time ago,’ you’re right. It was. However, examining this same community more recently demonstrates that progress is slow. Data from 2017 show that there are still significant differences in income, morbidity and mortality between residents of my former, primarily Black community and the more affluent communities in the same city. Resources are significantly less and industry continues to be a concern related to its impact on environmental health. The first hospital within the community is only now being built. It will open soon. An excellent discussion of the impact of SDoH on my community (and two others) is presented in the 2008 PBS documentary series Unnatural Causes…. Is Inequality Making Us Sick?.

If we have this body of evidence available to us as health care providers, what are our opportunities for change (practice/service provision, advocacy, research, and education) and what should our obligations be to the populations we serve and our society at large?

A critical paradigm shift is needed. Healthcare provider education must include SDoH and the differences experienced by populations (historically and contemporaneously). This approach not only validates the importance of this framework to care delivery; involvement in learning such as this also serves as a lens to better understand the reality of inequity and the structures that perpetuate this inequity.

Health care provider organizations have long prioritized advocacy as part of their mission. However, much of that advocacy has been directed toward issues that address the perspectives of the profession (to better serve their identified population or to advance their profession). Fewer efforts are directed toward economic policies, social norms, and political systems that perpetuate negative influences on health, behavior, and wellbeing for the larger society.

“Eradication of racism and all forms of inequity is the test of mankind set forth by our creator. The choices we make are what free will is about. Challenging inequity is our goal to achieve. My sincere hope is that we are up to the challenge.”

– Vicki Hines-Martin

Nurses are the largest group of healthcare providers and they hold great potential for elevating and teaching SDoH and advocating for change to address those factors that result in disparate health outcomes. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (National Academies, 2021)explores how nurses can work to reduce health disparities and promote equity. This document and the evidence supporting the importance of the SDoH obligate nursing (and other professions) to be informed at all educational levels and tie their efforts to that knowledge.

It is past time to examine our theoretical underpinnings to determine how they do – or do not – consider external influences on individual or population behaviors and outcomes. Theory without context has limited utility for practice or research.

We need to examine our language. Does it absolve contextual influences and focus on the individual in unintended ways? If we call out and advocate for change in underlying causes, could we lessen the need for “building resilience” in affected individuals and communities? Are we teaching people to better bear a burden to the exclusion of putting our energies into relieving that burden? Understanding SDoH requires us to do both.

To make this paradigm shift, providers must be taught how to take risks, and be supported in doing so. We must expect those who teach to model behaviors that recognize SDoH and inequity. Nursing has been cautious in speaking out – to the systems to which we belong, to those who enact policies, and to political systems. Health is affected by all these. We cannot be silent and still lead. Join me in speaking out.

Vicki P. Hines-Martin is Professor Emerita at the University of Louisville School of Nursing and the recipient of the 2023 Equity-Minded Nurse Leadership Award.