Social Determinants of Health: Addressing Access to Affordable and Nutritious Food for Underserved Populations

Eating nutritious food and maintaining a healthy diet are important parts of a person’s overall health and well-being. Evidence shows that poor nutrition and an unhealthy diet are leading risk factors for various chronic health conditions, including heart disease, hypertension, diabetes, and other diet-related diseases. The lack of access to affordable and nutritious food is a major public health problem, particularly for the poor and other underserved populations who often live in “food deserts” where the availability of fresh and healthy food is lacking or limited.[i]Further, the lack of access underscores how the social determinants of health impact underserved populations, which then results in health disparities. Food is a fundamental human need and influences health and quality of life. Access to affordable and nutritious food is a public health priority and requires broader, community-based interventions focused on addressing the social determinants of health and eliminating health disparities.

Health centers provide quality, comprehensive, and culturally competent primary health care to those who are medically underserved and most affected by health disparities.[ii] However, patients and families often come with a complex set of social and economic needs that goes beyond the scope of clinical care but have a major impact on their health. For many who are at risk or suffer from diet-related chronic conditions, a provider may prescribe changes in diet and nutrition to improve and manage their health. However, changing an individual’s health behavior can be extremely challenging if the environment in which they live does not support behavior change, such as living in a food desert or in an area where the cost of fresh and healthy food is highly prohibitive.

Given the commitment of health centers to being patient-centered and community-based, many are increasingly expanding on the whole person approach by doing more to address the social determinants of health of their patients, families, and communities to reduce health disparities.[iii] Further, many health centers rely on outreach to improve the quality of life for underserved populations by connecting with communities; identifying their social, economic, and clinical needs; reducing barriers to care; and facilitating access to health and social services. As outreach programs continue to serve as the “voice” of their patients and communities, health centers can leverage outreach programs to determine what role they can play in addressing the issue of food access for underserved populations.

Where people live, work, grow, and plays matters.

Increasing evidence shows that the conditions in which people live, work, grow, and play—referred to as the social determinants of health—influence their health and well-being more significantly than genetics and individual behaviors.[iv] Therefore, the sensitivity of a person’s health to their physical and social environment is primarily responsible for health disparities, which disproportionally affects low-income communities and racial and ethnic minorities.[v] For example, many low-income and underserved communities face many barriers to good health, including limited access to healthy food, lack of green and open spaces, dilapidated housing, underfunded schools and little economic opportunities.[vi] These community conditions are linked to higher rates of asthma, obesity, diabetes, heart disease and mortality, as compared to the general population.[vii] Recognition that efforts to promote health needs to go beyond the provision of health care is growing, which is evident in the shift of U.S. national health priorities. One of the four overarching goals of Healthy People 2020[viii] is to “create social and physical environments that promote good health for all”, and “the elimination of health disparities” is stated as one of the strategic directions for prevention under the U.S. Surgeon General’s National Prevention Strategy.

Places where people live and eat affect their health.[ix]

Nutritious food is important to the human body, because it provides needed nutrients for growth, development, and energy, as well as supporting disease prevention and maintaining good health. Evidence suggests that poor nutrition and an unhealthy diet are leading risk factors for various chronic health conditions, including heart disease, hypertension, diabetes, cancer, and other diet-related diseases. A healthy and balanced diet usually includes a combination of fresh fruits and vegetables with less processed foods and sugars. Yet studies show that low-income and underserved populations often have limited access to markets that sell healthy food, such as fresh fruits and vegetables.[x] Differences in food access across race, ethnicity, and socioeconomic status may contribute to or reinforce health disparities. Therefore, maintaining a healthy diet requires nutritious food to be affordable and accessible.

According to the US Department of Agriculture (USDA), more than 23 million people live in “food deserts” in the United States, meaning they are more than one mile away from a supermarket with fresh food. More than half of the population living in food deserts is low-income (13.5 million).[xi] Food deserts are described as urban neighborhoods and rural areas where access to fresh, healthy, and affordable food is limited or not easily available often due to the lack of healthy food outlets, such as full-service supermarkets and grocery stores, as well as limited transportation options and minimum investment in community development. The food outlets that do exist are usually fast food restaurants and convenience stores with very few healthy food options. Thus, the lack of access to nutritious food and the prevalence of unhealthy food options negatively impacts health and disproportionately affect low-income and other underserved populations due to the physical environments in which they live.

Outreach can support access to affordable and nutritious food.

As more attention is placed on the social determinants of health, health centers need to address both the medical and non-medical needs of underserved populations. Health centers, as trusted organizations in the community, can build upon its focus on access and eliminating health disparities by leveraging outreach programs to effectively connect with underserved populations to ensure that they are providing services that will address the needs of the whole person. Moreover, given its reach and unique perspective, outreach programs can effectively address the non-medical needs of their communities, such as food access, by building collaborations and partnerships, being advocates for their communities, and raising awareness within the health center and the community about the impact of the social determinants of health on underserved populations.

1. Collaboration: Addressing the social determinants of health is a complex and challenging health issue that cannot be tackled by health care alone but requires a comprehensive approach that focuses on collaboration across different sectors. Outreach programs know the community and have a good understanding of existing and potential community resources, such as social service agencies and organizations, churches, schools, businesses, advocacy groups, and community leaders. Awareness of these resources allows health center outreach programs to explore collaborations and partnerships. For example, to address the issue of food access, outreach programs could collaborate with food justice organizations or groups on various activities, such as pushing for healthier foods to be available at convenience stores or establishing community gardens. Outreach programs could also form partnerships with local farms and other producers to bring Farmers Markets to the community and perhaps even hold the market at the health center. They could also work to ensure that Farmers Markets accept public benefits for the purchase of fresh fruits and vegetables. One of outreach programs’ core strengths is cultural competency and cultural humility[xii], and they can help to ensure that any collaborations and community-based activities are designed to be culturally and linguistically appropriate, as well as relevant to the needs of the community.
2. Advocacy: Outreach programs promote health and access to health services for underserved populations, as well as to support individuals and communities in advocacy around their health. For example, outreach programs can engage communities into action around food access by linking them to and encouraging their participation in food justice organizations and advocacy groups. They can also provide technical support for those communities who may want to start their own advocacy around food access issues. Additionally, by working together with community members around food access, outreach programs are helping to build a new leaders and advocates within communities
3. Increasing Awareness: Outreach programs raise community awareness about the presence and needs of underserved populations. Health centers are on the forefront of providing much needed primary care services, and as a result, there is often less focus on addressing the non-medical needs of their patients and communities. Outreach programs can continue to raise awareness within the health center about the social and economic context of their patients and communities. Providers who identify food access as an issue for a patient can refer them to the outreach program for assistance and support. Also, the outreach program is in the community, and through its activities and advocacy, can continue to raise awareness and to garner support for underserved populations within the community.

Additional Resources

• Please see HOP’s article: The Social Determinants of Health Explained: What Outreach Programs can do to help Achieve Health Equity http://web.outreach-partners.org/resources/outreachconnection/161
• Institute of Alternative Futures. Community Health Centers Leveraging the Social Determinants of Health.http://www.altfutures.org/pubs/leveragingSDH/IAF-CHCsLeveragingSDH.pdf

This publication was made possible by grant number U30CS09743 from the Health Resources and Services Administration, Bureau of Primary Health Care. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA.