Social Determinants of Health

Beyond Healthcare in the U.S.

• Historically, the U.S. looked to healthcare systems as the main driver of health and health outcomes

• Over time, we've realized that achieving health equity requires looking broader – "outside the box"

• Despite significant spending, U.S. outcomes are among the lowest for developed countries, including significant inequities22

What is “Health Equity?”

• Everyone has a fair and just opportunity to be as healthy as possible.

Equality vs Equity

Health Equity

• Achieved by addressing the underlying issues that prevent people from being healthy.

• Benefits everyone

• A healthy nation improves

  • Economic growth

  • Healthier environment

  • National security

• Requires

  • Cross-sector collaborations

  • Policies and regulations

  • Community interventions

What determines our health?

• “The complex interactions between biological and social elements and their influence on health”
  (Raingruber, 2017, p. 98)

• Medical Factors

  • Biologic

    • Age

    • Gender

    • Infection

  • Genetic

    • Family

    • Origins

    • Race

    • Genetic predisposition

• Non-medical factors

  • Behaviors, lifestyle

  • Education

  • Employment

  • Reliable transportation

  • Public safety

  • Language and literacy

  • Culture

What are the Social Determinants of Health?

• The conditions and environment where people are born, live, learn, work, worship, and age.

Social Needs

• Individual-level nonmedical acute resource needs related to SDOH

  • Housing

  • Reliable transportation

  • Strong support system

• Person-centered

  • Varies from person-to-person

SDOH Factors

• The 5 factors (SDOH) affect:

  • Overall health and well-being

  • Quality of life outcomes

  • Health risks

• And are influenced by

  • Distribution of money, power, and resources

  • Policies at national, state, and local levels

• Identify and explain health inequalities

  • Unfair and avoidable differences in health status seen within and between populations

• Only promoting healthy choices won’t eliminate health disparities

• We need to take action to improve the conditions in people’s environments

Social Determinants of Health

• Education Access and Quality

• Health Care Access and Quality

• Neighborhood and Built Environment

• Social and Community Context

• Economic Stability

SDOH: Economic Stability

• Employment

  • Jobs, employment, workplace conditions

• Food insecurity

  • Limited or uncertain access to quality food

• Housing instability

  • Ability to remain housed

• Poverty

  • 2025 federal poverty levels

  • Individual: $15,650 annual income

  • Family of 4: $32,150

Examples of Economic Stability Health Outcomes

• Higher income associated with lower likelihood of disease and premature death

  • Lower income associated with higher rates of disease (including heart disease, stroke, diabetes, liver disease, and arthritis) and higher rates of preventable disease

• Poverty may increase the onset of mental illness, intensify the experience, or prevent people from accessing proper treatment

  • <$35,000 annual income: 6.4% report feelings of sadness, 3.8% feelings of worthlessness

  • $75,000-99,999 annual income: 1.3% report feelings of sadness, 0.6% feelings of worthlessness

• Health and socio-economic disadvantages accumulate over a lifetime and can persist across generations

SDOH: Education Access and Quality

• Early childhood development and education

• Enrollment in higher education

• High school graduation

• Language and literacy

Examples of Education Access and Quality Health Outcomes

• High school graduation

  • Students who graduate from high school on time are more likely to pursue postsecondary education or skills training

    • Earn higher wages, generally healthier than those who do not graduate on time

• Language and literacy

  • Limited literacy is a barrier to accessing health care services and understanding health information

SDOH: Health Care Access & Quality

• Access to services

  • Health insurance, costs, dept, quality

• Access to primary care

  • Early detection and treatment of disease

• Health literacy

  • Ability to use information to inform health-related decisions

Examples of Access to Health Care Outcomes

• Access to primary care prevents illness and death and is associated with positive health outcomes

• Factors: health insurance coverage, limited availability of health care providers -> leading to limited access to services

  • Those without health insurance less likely to receive preventative care, and care for major health conditions and chronic disease

  • Uninsured people often delay or forgo care because of its cost and are less likely to have a usual source of care which can lead to serious illness

  • In the U.S., racial and ethnic disparity in insurance coverage

SDOH: Neighborhood & Built Environment

• Access to foods that support healthy dietary patterns

  • Quality and quantity of foods

• Crime and violence

• Environmental conditions

  • Playgrounds, walking paths

  • Water and air quality, natural disasters

• Quality of housing

Examples of Neighborhood & Built Environment Health Outcomes

• Housing and Instability and Homelessness

  • People need stable housing to be healthy

• Food Insecurity

  • Food deserts

• Environment & climate change

  • Health hazards

    • More likely to exist in low-income communities

  • Natural disasters

    • Low-income residents have less capacity to move when risks become evident and during forced evacuation or displacement

SDOH: Social and Community Context

• Civic participation

  • Voting, volunteering, community activities

• Discrimination

  • Unfair or unjustified harm to individuals and groups

• Incarceration

• Social cohesion

  • Relationships, support networks

Rurality

• Geographic barriers to high-quality health care

• ~20% of Americans live in rural areas

  • 39.3% in North Dakota

  • 28.9% in Minnesota

• Injury and death:

  • Higher death rates across 5 leading causes of death in U.S.

  • Higher death rates in unintentional injuries

• Health care and insurance

  • Uninsured rural residents face greater difficulty in accessing care

    • Limited supply of rural health care workers who can provide low-cost or charitable health care

• Transportation and internet access

  • Increased travel time, costs, and time away from work to access care

  • More likely to travel long distances for care

  • May lack reliable transportation (like public transit options)

  • Telehealth: helping to mitigate transportation challenges

    • Requires broadband internet services (~33% of rural areas lack access to highspeed internet)

Vulnerability

• As a result of health inequities, some people are more vulnerable than others

  • More susceptible to effects of risk factors

  • More likely to develop health problems when exposed to risk factors

  • More likely to have poor health outcomes

Cumulative Effects

• The cumulative effects of multiple risks make it more difficult to be resilient in the face of stressors

  • Example: People who don't have access to grocery stores with healthy foods

• Less likely to have good nutrition —> Raises risk of health conditions like heart disease, diabetes, and obesity —> Lower life expectancy relative to people who do have access to healthy foods

 

Upstream Thinking

• All nurses have the opportunity to work upstream though advocacy for policy changes

• Most nurses in midstream and downstream

• Castrucci and Auerbach (2019)

  • Upstream – SDOH factors that affect communities in a broad, inequitable way

  • Midstream – social needs, individual needs that might affect a person’s health

  • Downstream – disease treatment and chronic disease management

• Nurses primarily work mid & downstream

  • Individual-level interventions

• To fully comprehend health on an individual level, must understand interrelationships across all levels

SDOH in North Dakota

Role of Nursing in SDOH

• Ask the right questions

• Understand the relationship between upstream and midstream on downstream care services

• Collaborate

• Advocate

Summary

• SDOH affect everyone

• Disproportionately affected

  • Higher burden of poor health among lower socioeconomic status, rural populations, communities of color (compared to high socioeconomic status, urban populations, and white)

  • Inequities are unnecessary, unjust, and avoidable

• Positive and negative aspects that support or challenge health status

• A pattern of social risk factors (negative SDOH) contributes to increased morbidity and mortality

• Improving population health = improving health for everyone