Understanding social determinants of health

Minnesota is widely regarded as one of the healthiest states in the nation. But this general description of our state’s good health masks alarming patterns across socioeconomic, racial and ethnic groups. Sizable disparities in health between the white population and populations of color and American Indians have been documented for overall health indicators, incidence of specific diseases and many risk factors.

Social determinants and health disparities

Pronounced disparities in health status mirror disparities on many broader social and economic indicators. For example, rates of child and adult poverty among populations of color and American Indians in Minnesota are three to four times that of whites, and whites receive almost twice as much income per capita. Similar disparities are evident in rates of unemployment, high school graduation, home ownership and housing.

Research from many disciplines now confirms what many have long suspected – social, economic and environmental factors have profound effects on health, quality of life, and life expectancy. Serious efforts to reduce health disparity must address these factors.

The importance of these findings is heightened by several trends, including:

• Increasing racial and ethnic diversity statewide
• Dramatic escalation of health care costs at a time of enormous national, state and local budget deficits
• Greater recognition that popular public health interventions focused on individual behavior change are limited. To reach their potential effectiveness, they need to be combined with an attention to a broad array of factors that shape individual choices, opportunities and risk exposures.

The Institute of Medicine stresses the importance of improving social, economic and environmental factors this way, “Interventions to improve access to medical care and reduce behavioral risk have only limited potential for success if the larger societal and economic context in which people live is not improved.”

Defining determinants of health

The social environment encompasses social and economic factors such as income, education, employment status and working conditions, social networks and community cohesion. The physical environment includes the natural environment (clean air, water and soil), the built environment (land use patterns, zoning and community design) and living conditions such as the availability of safe and affordable housing, transportation and nutritious foods.

Income and education are among the most potent determinants of health. Simply stated, the rich are healthier than the middle class, who are in turn healthier than the poor. At a community level, disease and death rates are higher in residential areas that have the greatest gap in income between the rich and poor.

“Upstream” orientation does not diminish the importance of delivering quality and timely health services or of addressing behavioral risks such as smoking and physical inactivity. Rather, this shift in focus has potential to lesson the burden on these critical services.

Investing upstream

Growing recognition of the importance of addressing social determinants of health is causing a reexamination of the current focus of public health in western Europe, Canada, Australia, New Zealand as well as the United States. Julie Gerberding, director of the Centers for Disease Control and Prevention (CDC), states, “One major task that CDC is intending to address is on making sure that we invest the same kind of intense resources into keeping people healthier or helping them return to a state of health and low vulnerability as we do to disease care and end of life care.”

Social and economic factors influence opportunities, exposures, decisions and behaviors that promote or threaten health. Effective “upstream” action to promote population health and eliminate health disparities will require knowledge of the factors that most clearly affect health, and use of interventions most likely to produce measurable change.

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