The Social Determinants of Health Explained: What Outreach Programs can do to help Achieve Health Equity

A large part of our health has to do with how our society is organized and where we fit in that organization.[i]  Imagine a patient (or client, or participant) you know.  Think of the things in this person’s life that contribute to her health.  Imagine the place where she lives, the food she eats.  Imagine her relationships with family and her relationship to the community around her. Is it healthy and supportive? Think about the type of work she does. If she does not work, why is that?  Based only on what she looks like, what do others think about this person? How does that impact her day-to-day experience? Where people live, the amount of money they make, and the type of work they do affects their health. These factors or “determinants” are often called the social determinants of health. This article discusses the social determinants of health including why those of us who work in community health outreach need to be thinking about them and what we can do to improve them. 

 

What are the Social Determinants of Health?

According to the World Health Organization, “the social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.”[ii]  Social determinants decide how long and how well we live.   Examples of social determinants include:

• Access to healthy foods
• Safe housing
• Supportive social networks
• Education level
• Exposure to violence

Our social, economic, and environmental settings shape our health outcomes. Social setting includes our social networks, friendships, relationships, and families.  Economic setting includes (un)employment, income, debt, and wealth.  Environmental setting includes level of violence and crime, access to healthy food, prevalence of alcohol and substance abuse, and exposure to toxins. These settings all shape our health even more than our individual behaviors and genes. In fact, individual behaviors are determined, in part, by our settings.  For example, many of our individual behaviors depend on our income, type of work, transportation access, and other social determinants of health.  A person may want to exercise regularly, but live in a neighborhood where there are no safe places to exercise.  In this case, this person’s individual behavior is shaped by the social, economic, and environmental setting.

Still, individual behavior explains only part of health status.  Social determinants have a large impact on the health of individuals and communities. But the social determinants of health—our social, economic, and environmental settings—are unequally distributed between various populations. This situation results in health inequity.  Health inequity refers to differences in health status (also called health disparities) that result from systemic, avoidable, and unjust policies and practices in a society.[iii]

 

What can health outreach programs do?

General examples of activities to address the social determinants of health include: improving access to healthy foods, working to change or enforce policies to promote equitable conditions, and development of healthy and affordable housing. Outreach programs alone cannot address all social determinants of health.  However, outreach programs must go beyond changing individual behaviors.  Outreach programs are poised to address social determinants of health for underserved populations because they are trusted within the community and understand the socioeconomic and cultural context in which people are living. Three ways that health outreach programs, specifically, can contribute to this effort are:

• helping patients overcome barriers to services
• promoting a sense of empowerment among underserved populations
• collaborating with different types of organizations and agencies to address a social determinant of health

Overcoming Barriers to Services
Many populations that community health organizations seek to serve live with conditions that negatively impact their health.  Further, these populations often lack resources to manage these conditions. Health outreach programs work to reduce barriers to services for these populations in order for them to easily access quality, patient-centered care.  Barriers to services vary depending on the population and community.  Common barriers to services for underserved populations include: cost of services, lack of transportation, and language barriers. It is vital for programs to conduct regular community needs assessments to always understand and properly respond to their priority populations’ specific barriers and needs. 

 
Promoting Empowerment
Having a sense of empowerment is an important protective factor for health. Characteristics of empowerment include:

• gaining a sense of community,
• perceived control (believing you can make change in your life),
• perceived control at community level (believing you can make change in your community),
• critical awareness of the world around you (realizing how you are connected to others and how larger societal structures impact you);
• taking action for change.

Outreach programs often achieve this by helping patients become equal partners in their care. Outreach plays a critical role in ensuring that patients realize that they can have an impact on their own health and know about and seek out services and resources available to them.

Outreach programs often also educate fellow staff and providers about the importance of empowerment, thus ensuring it is practiced throughout the care team to maximize the impact on patients. Other common strategies include designing programs to use popular education techniques and implementing peer-based programs such as promotor(a) programs or Community Health Workers programs.

Collaboration
Improving the social determinants of health requires coordinated strategies at many levels (individual, family, community, organizational, policy, etc.).  This type of community collaboration can be just as or even more impactful than simply addressing individual health behaviors.     

Medical-Legal Partnerships is one way community health organizations are addressing the social determinants of health.  A medical-legal partnership is when a health organization partners with legal-aid, pro-bono lawyers, or a law school to offer legal services in a health care setting.  These partnerships offer legal assistance related to many social determinants of health such as housing, working conditions, and domestic violence. Legal services can help patients address their unmet legal needs, which can often adversely affect their health.[iv]

 

Addressing the Social Determinants of Health and Achieving Health Equity

Health equity is an important concept for addressing the social determinants of health.  Based on the idea that everyone has the right to health, health equity is when everyone can “attain their full health potential” and no one is “disadvantaged from achieving this potential because of their social position or other socially determined circumstance.”[v]  The health equity approach requires the improvement of the social determinants of health so that all groups experience equal potential for health.  There is now a growing recognition of the social determinants of health and the need for health equity.  National attention has turned to addressing these important topics.  For example, two national frameworks that provide direction in this effort are Healthy People 2020 and the National Prevention Council Action Plan.

 
Healthy People 2020
Healthy People 2020 are national guidelines developed by the U.S. Department of Health and Human Services. Simply put, Healthy People 2020 sets a 10-year agenda for improving health in the U.S. One of the goals of Healthy People is to achieve health equity, eliminate disparities, and improve the health of all groups.[vi]  The Healthy People 2020 approach encourages social, organization, environmental, economic, and policy strategies to work with health services and individual behavior change efforts.

National Prevention Action Plan
The Affordable Care Act authorized the National Prevention Strategy, which identifies strategic directions and priorities for promoting good health in the U.S.  The National Prevention Action Plan builds on the National Prevention Strategy and identifies opportunities for improving the lives and health. It is an effort to transform our system of sick care into a system of wellness and prevention.  The National Prevention Action Plan includes strategies and priorities and provides a framework for how different types of organizations can work together to reach a common goal of increasing the number of Americans who are healthy at every stage of life.[vii]

 

Conclusion

The social determinants of health deeply impact the underserved populations served by community health organizations and outreach programs. Outreach programs are in a position to tap into national health equity strategies and help address the social determinants of health. Access to quality healthcare for underserved populations is an important piece of the puzzle.  We also need to improve the social determinants of health in order to improve the quality of life and health outcomes for underserved populations.  Outreach programs not only facilitate access to services, but can also play an important role in improving the social determinants of health for underserved populations.

 

Additional Resources

For additional information and tools regarding the Social Determinants of Health, check-out these resources: 

• California Newsreel’s Unnatural Causes…In Inequality Making Us Sick? [Video]
• Centers for Disease Control and Prevention’s webpage on the Social Determinants of Health
• Centers for Disease Control and Prevention’s Promoting Health Equity: A Resource to Help Communities Address Social Determinants of Health.  Includes:
  • Case Studies: Communities Working to Achieve Health Equity
  • Developing a Social Determinants of Health Inequities Initiative in Your Community
• National Association of County & City Health Officials’ Roots of Health Inequity: A Web-based Course for the Public Health Workforce
• National Association of County & City Health Officials’ Tackling Health Inequity through Public Health Practice: A Handbook for Actio