Social Determinants of Health
The scriptures speak of health in terms of the tripartite being that God has created. It involves our mind, body, and soul. In essence we are spirits (souls) living in a body directed by the mind. 3 John 1:2 states, “Beloved, I pray that in all respects you may prosper and be in good health, just as your soul prospers.”
Without a healthy spirit, we cannot effectively handle the physical and mental challenges of life. Again, this concept is expressed in Proverbs 18:14 -“The spirit of a man will sustain his infirmities, but a wounded spirit, who can bear it?”
The scriptures seem to affirm, at least in part, the World Health Organization’s (WHO) definition of health: “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity,” and brings into account that there are other determinants of health beyond physical illnesses and impairments that affect the overall health of an individual. As Christians in health ministries, we need to be aware of those social determinants and the disparities that they produce.
In general, the determinants of health include our genetic make-up, our individual behaviors, and social issues that impact health. The social determinants are those issues that reside outside the individual. They are beyond our genetic predisposition or the individual choices that we make. The social determinants of health are defined as the economic & social conditions that influence health, the conditions in which people are born, grow, live, work, and age.
These determinants include factors in the social environment that contribute to or detract from health, and include one’s income, housing, education, access to services, physical environment, socioeconomic status/position, discrimination by social grouping, social or environmental stressors.1 In short, the major social determinants of health are affected by your social position, where you live, your race, and the stressors in your life.
Social position is directly correlated to your level of education and income. People with lower socioeconomic position are more likely to have worse access to healthcare. Social position influences whether a person is exposed to health risks or has resources to buffer health risks. Where a person lives can determine whether a person is surrounded by things that make it easy or difficult to maintain healthy behaviors.
Race matters in that racial discrimination contributes to factors affecting health in terms of uneven distribution of income, educational achievement, poverty, and access to health care. Racial discrimination also constitutes a chronic stressor that contributes to poor health independently of these factors.
Finally, stress is an important social determinant of health. Chronic stress is lethal, setting in motion physiologic processes that can exacerbate illnesses such as diabetes, hypertension, and cardiovascular disease. Researchers have observed that people with lower socioeconomic position have higher levels of chronic stress and have fewer resources to deal with stress.
Social determinants of health are largely responsible for health inequities – (the unfair and avoidable differences in health status) observed within and between countries. “Poorer people live shorter lives and are more often ill than the rich. This disparity has drawn attention to the remarkable sensitivity of health to the social environment.”2
Children Suffer the Most
These social determinants of health are often more evident in the lives of children and adolescents than in adults. Race and social class are the most notable markers and can be illustrated throughout childhood. Low income and children of color have worse health status than their more affluent and white counterparts. Lower socioeconomic status, linked with lower educational and income levels in adults, is a predictor for health. As a result, children in poor families are seven times more likely to be in poor or fair health than those in wealthier families and that children whose parents have not finished high school are over six times more likely to be in poor/fair health than those whose parents are college graduates. It is also noted that women not finishing high school are one and a half times more likely to have premature or low birth weight babies compared to those who complete college; babies born to college graduates are twice as likely to survive beyond their first birthday. Prenatal stressors (i.e. financial difficulties, violence, and racism), poor nutrition, and inadequate healthcare impact an infant’s health outcomes even before he is born.
Racial and ethnic health disparities in children have been observed for over 50 years. These disparitiesinclude increased childhood mortality rates (especially in infancy), decreased access to healthcare and quality of care, inadequate insurance, low interpersonal relationships with health providers which results in fewer physician visits and shorter duration of visits, poorer health status, limited health promotion, increased sequelae from chronic diseases (i.e. asthma, diabetes), special healthcare needs, and poorer outcomes from organ transplantations.
Specific childhood health inequities associated with social determinants include:
• Childhood Development
• Behavioral Health
• Oral Health
• Child Abuse and Neglect
Social determinants affect the development of children from birth throughout childhood and adolescence. Starting at birth, black infants are almost twice as likely to be born as low birth weight than white infants. This in turn increases the likelihood of poor health and learning difficulties later in life. It is believed that one of the major factors for this disparity is due to decreased access to prenatal health care for pregnant minority women.
When compared to their white counterparts, minority women are less likely to be insured which, limits their access to medical care. Exposure to toxins also affects the health outcomes for poor and minority children. Nicotine, alcohol, and drugs decrease a child’s IQ and increase learning disabilities, hyperactivity, and behavioral problems in the school-aged child. Exposure to lead also decreases IQ and learning abilities and increases attention deficits, hyperactivity, impulsiveness, aggression, failure to complete school, and delinquent behavior. Nutritional deficiencies lead to impaired IQ, memory, and hearing in children. Finally, socioeconomic stressors (i.e. neglect, physical abuse, family violence, etc) can lead to elevated corticosteroids in children, which affect progression of chronic illness and a child’s overall health status.
Childhood asthma is affected by social determinant. 12.7 percent of black children are reported as having asthma when compared with 7.8 percent of Latino and 8 percent of white children; black children are more than three and a half times as likely as white children to have had an ER visit for asthma in the past year and to be hospitalized for asthma; black children are six times as likely to die from asthma as white children; minority children have greater exposure to asthma triggers. They also have reduced access to healthcare and reduced compliance with medical interventions. Minority children are exposed to higher levels of psychosocial stressors that exacerbate asthma.
In the case of childhood obesity and Type 2 diabetes, one in four black children ages 6 to 17 is obese as compared to one in seven white children. Among black teenage girls ages 12 to 19, more than 40% are obese or at risk of becoming obese. In addition, black and Latino children are also more likely to be diagnosed with type 2 diabetes. The factors that contribute to these disparities include increased sedentary lifestyles of minority and poor children due to environmental restrictions (unsafe neighborhoods and limited play areas), increased TV viewing, poor food choices (increased number of convenience stores instead of markets and grocers), and family influences (selection of foods, serving amounts, food preparations, etc).
Disparities in behavioral or mental health disorders have also been noted in lower socioeconomic groups. In a study comparing children in Norway where child poverty is 5% and family income inequality is low with children in the USA where child poverty is 18% and family income inequality is high, it was found that Norway children were in better health and less anxious that American children. There was more bullying in the USA than in Norway.
Disparities in oral health, child abuse and neglect are also affected by these social determinants. In the case of oral health, it is noted that Blacks, Hispanics, American Indians and Alaskan Natives (AI/AN) have poorer oral health than other racial or ethnic groups: Latino children – 2.5 times more cavities than whites; black children have 1.5 times that of whites; and AI/AN – 5.8 times that of whites. All minority groups are less likely to have had a dental visit in the last year when compared to white counterparts.
Finally, it has been proven that child abuse and neglect increases with lower socioeconomic status, exposure to racism/discrimination, parental unemployment/homelessness, substance abuse, social isolation, and high general stress levels in families and caregivers.
Will Health Providers Treat the Source?
Given the affects of the social determinants of the health on health outcomes for children and the population as a whole, how do we address this important problem and what is the role of the health care provider in facilitating this solution? A concept that supports the basis for a solution is found in the phrase - “Why treat people without changing what makes them sick?”
The World Health Organization developed a Commission on Social Determinants of Health in 2005 to determine the scope of the problem globally and to provide advice on how to address it. The Commission’s final report (8/2008) contained three recommendations:
- Improve daily living conditions – the circumstances in which people are born, grow, live, work, and age.
- Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.
- Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.3
Healthcare providers should embrace an expanded role in enhancing the healthcare of their patients. This expanded role includes advancing patient education and empowerment, serving as an advocate for system changes and providing leadership in healthcare reform.
To advance patient empowerment, healthcare providers can facilitate increased patient involvement by making health education a higher priority in their practices. They can promote patient self management goals and incentivize healthy behaviors, especially in the areas of prenatal care, weight reduction, compliance with healthcare plans (i.e. asthma, diabetes), and in obtaining routine physical exams and screenings.
Physicians are in a unique position to advocate for our patients who suffer from disparities. As advocates for system changes, we should advocate for safer communities, affordable housing, increased access to healthy foods (like community gardens and farmer’s markets), and increased green spaces in high-risk communities. We should be petitioning policy makers to pass laws that improve the social determinants of the health of our patients. Universal health coverage, support for working families (i.e. tax credits, paid leave), expanded preschool services, improved quality in our schools, new mother support programs, economic development for underresourced neighborhoods, and clean up of toxic pollutants are examples of causes that physicians, and especially Christian health professionals, should champion.
Finally, healthcare professionals should be actively involved in developing and implementing health care reform. We should leverage our expertise and respect in the community to educate both our neighbors and lawmakers on the impact of social determinants on overall health. It is important for us to take leadership in framing and guiding the discussions for eliminating health disparities in our nation. Only then will the important issues of health promotion, social service delivery, mental health services, housing standards and educational achievement be addressed in the context of health and become a part of the reformation of health care in our country. We know what to do. The question is whether we have the will to do it.
For those of us who have committed ourselves to improve the health and welfare of those in our care and more importantly, for those of us who do this work as a response to God’s calling, it is imperative that we consider the needs of the whole person and make every effort to address those needs in the framework of every determinant of health.
1 www.cdc.gov/sdoh accessed on 11-9-07
2 Social Determinants of Health, The Solid Facts, World Health Organization. 2003.
Veda Johnson, MD, is the Director of the Urban Health Program and Assistant Professor of Pediatrics at Emory University School of Medicine. Dr. Johnson lives in Atlanta, Georgia with her husband Walter Johnson, Pastor of New Covenant Baptist Church, and their four children.