Social Determinants of Health: Applying Knowledge to Improve Health and Advance Health Equity – Part 1

Introduction

Social determinants of health (SDOH) can be defined as “the conditions in which people are born, grow, live, work and age. They include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care.” The Henry J. Kaiser Family Foundation.  Note the examples in each SDOH category. These examples are not “all-inclusive.”

As you read our blog, please bear in mind that numerous websites and volumes of information are available about SDOH. Our blog is a basic overview of a small portion of available data and information, derived from many sources. We recommend clicking on the links to the website references provided and encourage you to do additional research on your own.

Healthcare workers, including coders, are likely aware of the many services that their facility provides to their community. These services are may be coordinated by a department or departments called, for example, “Community Health,” “Population Health,” or “Community Outreach.”

What we may not be aware of is that these non-medical services exist to address the “social determinants of health” (SDOH) in the community. Much of the data and information collected on SDOH comes from, for example, community surveys and community forums and are not noticed by coders because they are not a component of an individual patient’s health record.

The Table below shows the types of non-medical services that hospitals and health systems provide, and the percentage of hospitals that do so. The pie-chart on the right side of the Table indicates a very high level of community partnerships between hospitals and communities.

We highly recommend a review of the American Hospital Association’s full power-point presentation (23 slides) “Addressing Social Determinants of Health,” in order to see the Table above in full context.  The PowerPoint presentation can be downloaded from this page.

Background

The World Health Organization and Social Determinants of Health (SDOH)

More than ten years ago, the World Health Organization (WHO) began using a tool called the Health Impact Assessment (HIA) as “a means of assessing the health impacts of policies, plans and projects in diverse economic sectors using quantitative, qualitative and participatory techniques.”

The purpose and goal of the HIA is to “help decision-makers make choices about alternatives and improvements to prevent disease/injury and to actively promote health…and well-being across sectors.”

The WHO’s underlying premise is that “Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact.”

These many factors have been categorized into groups called “social determinants of health (SDOH).”

Term defined: “Determinant” – a factor which decisively affects the nature or outcome of something.

The WHO’s Social Determinants of Health (SDOH)

• The social and economic environment, including “income and social status – higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.”

• The physical environment, including “safe water and clean air, healthy workplaces, safe houses, communities and roads all contribute to good health. Employment and working conditions – people in employment are healthier, particularly those who have more control over their working conditions,” and

• The person’s individual characteristics and behaviors, including “personal behavior and coping skills – balanced eating, keeping active, smoking, drinking, and how we deal with life’s stresses and challenges all affect health.”

Additional details and examples can be seen on the WHO website.

The United States and SDOH

In the United States, the Centers for Disease Control and Prevention website echoes much of the information from the WHO: “We know that poverty limits access to healthy foods and safe neighborhoods and that more education is a predictor of better health. We also know that differences in health are striking in communities with poor SDOH such as unstable housing, low income, unsafe neighborhoods, or substandard education. By applying what we know about SDOH, we can not only improve individual and population health but also advance health equity.” https://www.cdc.gov/socialdeterminants/index.htm

To put it another way, the goal of addressing SDOH is to “create social and physical environments that promote good health for all.” To help achieve this goal the CDC has initiated “Healthy People 2020.” https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health.

This goal is shared by other US health initiatives, including the National Partnership for Action to End Health Disparities, and the National Prevention and Health Promotion Strategy.

• The National Partnership for Action to End Health Disparities, under the US Department of Health and Human Services, has been in existence since 2011. At the time, it was noted that the Affordable Care Act (ACA) would “increase both access to and the affordability of care for underserved populations.” https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2011.0673
• The National Prevention and Health Promotion Strategy, also developed in 2011, is also under the US Department of Health and Human Services and is intended to “…move us from a system of sick care to one based on wellness and prevention. It builds upon the state-of-the-art clinical services we have in this country and the remarkable progress that has been made toward understanding how to improve the health of individuals, families, and communities through prevention,” and notes that “This strategy is a critical component of the Affordable Care Act, and it provides an opportunity for us to become a more healthy and fit nation.” https://www.hhs.gov/sites/default/files/disease-prevention-wellness-report.pdf

Five Key Areas of SDOH

“Healthy People 2020” identified these five key areas of SDOH:

• Economic Stability
• Education
• Social and Community Context
• Health and Health Care
• Neighborhood and Built Environment

Each of these five key areas, or categories are further defined below. Note that the examples in each category varies somewhat from the information in the Kaiser Foundation Table, above.

• Economic Stability

• • • Employment
    • Food Insecurity
    • Housing Instability
    • Poverty

• Education

• • • Early Childhood Education and Development
    • Enrollment in Higher Education
    • High School Graduation
    • Language and Literacy

• Social and Community Context

• • • Civic Participation
    • Discrimination
    • Incarceration
    • Social Cohesion

• Health and Health Care

• • • Access to Health Care
    • Access to Primary Care
    • Health Literacy

• Neighborhood and Built Environment

• • • Access to Foods that Support Healthy Eating Patterns
    • Crime and Violence
    • Environmental Conditions
    • Quality of Housing

In Social Determinants of Health: Applying Knowledge to Improve Health and Advance Health Equity – Part 2 we will take a closer look at the SDOH Z- codes and issues concerning them.