Countervailing forces

During my first month as an intern, our team admitted a middle-aged man with acute onset heart failure. He had been untethered to regular medical care, and several neglected conditions had finally caught up with him. We did what inpatient medical teams do best and, by the end of the week, he was in a much better-balanced state of health and ready to be discharged home. 

But as his nurse was instructing him about his new medications, he flew into a rage. He said he couldn’t afford the medications and would go home just to get sick all over again. While our team had been diligent in addressing his acute cardiac needs and devised an effective treatment plan, we failed to explore other dimensions that had contributed to his illness and long-term outcome. While he had a home and family, clearly economic factors were a significant driver of his recent health event. Care management to the rescue! 

All these years later, I remember this incident with compassion and believe his outburst was likely a painful expression of frustration and embarrassment. I’ve tried to let this event remind me of the deeper social context into which medical care is delivered. 

The innovative ground-breaking therapies that IR offers advance the possibilities and standards of healthcare. Our efforts can lengthen and improve the quality of life for our patients. However, there are powerful countervailing forces outside of our medical practices that reduce or even block the impact of our work.  

Social determinants of health 

Social determinants of health (SDOH) are the economic, social and environmental factors that influence health outcomes, oftentimes before patients are even sick. The lifestyles and conditions in which people grow, live and work directly impact their health and longevity.  

These factors are often invisible to care providers but are powerful drivers of individual well-being and broader population health care disparities. Surprisingly, research estimates that direct clinical care affects just 20% of county-level differences in health outcomes, while SDOH affect up to 50%.  

The socioeconomic factors of poverty, employment and education are the chief drivers of these differences.¹ Variation in the SDOH among populations contributes to healthcare disparities. For instance, in communities with less access to stores with high-quality food, residents are likely to have poorer nutrition that in turn affects rates of diabetes, hypertension, heart disease and renal disease. This in turn negatively impacts life expectancy. Counseling patients on dietary choices may not be enough if their neighborhood infrastructure and personal economic status don’t provide easy access to high-quality food choices.   

By understanding the five principal social determinants of health, we can gain a deeper understanding of how they shape individual patient and population health and keep them in mind as we pursue treatment plans for patients.  

1. Economic Stability 

Employment 

The ability to have a regular and reliable source of income directly allows individuals to purchase access to food, housing and healthcare. Benefits of employment such as health insurance, paid sick leave, parental leave and participation in a retirement plan fortifies the health of the employee and their family. Further, safe workplaces promote employees’ physical and mental health.  

Conversely, research has demonstrated negative health consequences related to unemployment such as depression, anxiety, poor self-image and physical pain.^2,3,4 Illnesses associated with stress such as hypertension, stroke and cardiac disease are also found at higher rates in people who are unemployed. Even perceived job insecurity has been shown to negatively impact physical and mental health.⁵ 

Food insecurity 

Food insecurity refers to the household condition of scarce or uncertain access to adequate food. This condition may be transient or long-term in its nature. In 2020, it was determined that 13.8 million American households (10.5%) had been food insecure during the previous year.⁶ This condition negatively impacts the quality, variety and desirability of food and in its most severe forms leads to disrupted eating patterns and reduced caloric intake. The risk for household food insecurity is associated with employment, income, race, ethnicity and overall health.⁷ 

Understandably, households with unemployed adults leave children exposed to higher rates of food insecurity.⁸ Those affected with chronic medical problems often have less disposable money due to unemployment and increased health-related expenses, in turn exposing them to an increased risk of food insecurity.⁹ The prevalence of insecurity is significantly higher in Black households (21.7%) and Hispanic households (17.2%) compared to the national average (10.5%).⁶ Higher rates of unemployment and neighborhood design—such as lack of proximity to full-service grocery stores and robust transportation infrastructure—are the most likely contributing factors. 

Housing instability 

Households whose costs exceed 30% of income are considered cost burdened and those whose costs exceed 50% of income are considered severely cost burdened. Accordingly, such households have less disposable income to spend on food and healthcare. This reality affected more than 37 million American households in 2019 and is twice as common in Black and Hispanic households than in white households.^10,11 Those on the lowest rungs on the socioeconomic ladder often live in housing that is substandard, exposing them to health and safety risks. The most severe form of housing instability is homelessness, affecting over a half-million Americans.¹² Studies have shown those affected have significantly higher rates of chronic disease such as diabetes, hypertension, asthma, depression and substance use disorder than the overall population. Mortality rates are 3.5 times higher among the non-elderly unhoused population than those who have reliable housing.¹³ 

2. Education access and quality 

The quality and level of educational attainment are key SDOH in that they influence most of the others, primarily by affecting income. Educational achievement directly contributes to job attainment and that in turn affects income, housing, healthcare access and transportation. Further, a higher level of education is linked to higher health literacy and greater proficiency in navigating the healthcare system.¹⁴ Attainment of higher levels of education is directly associated with longer life expectancy.¹⁵ Children who have access to high-quality early education with healthcare and nutritional supports have better health than those who do not have access to such programs.  

It's not difficult to appreciate the concept that racial disparities in education amplify racial healthcare disparities.¹⁶ A 2021 report from UnitedHealthcare American’s Health Rankings Health Disparities showed that educational attainment was a leading SDOH contributing to racial health disparities, with those without a high school degree faring the worst in health outcomes.   

3. Healthcare access and quality 

For healthcare to be impactful, it needs to be affordable, easily accessible and high quality. Access to insurance increases the likelihood that patients will seek out preventative and routine care. Proximity to local healthcare centers and telehealth services improves access for many. Reliable mass transit is imperative for urban dwellers. Mobile health units may be a supplement for rural communities and places where transportation is unreliable.    

4. Neighborhood and built environment 

Where we live has a direct impact upon our health and sense of well-being. Our living environment interacts with our individual choices and biology to affect our personal outcomes.   

Many of us have heard news stories regarding lead contamination of drinking water supplies and neighborhoods with inexplicably high levels of cancer. Environmental conditions such as air and water quality, noise level, and proximity to hazardous wastes directly impact health. Communities that are more walkable and those with recreational resources are associated with higher levels of physical activity and better health outcomes. Neighborhoods where the housing is in subpar condition and the closest accessible food is via fast food establishments and liquor stores are associated with poorer health outcomes. Communities with higher rates of crime and violence understandably have measurably lower life expectancies.¹⁷  

The legacy of redlining—the historic practice of racially-based housing discrimination which led to segregated communities—has ensured a multigenerational impact on population health in many American cities. Statistically significant associations have been measured between greater incidents of redlining and chronic medical conditions of current-day inhabitants such as asthma, diabetes, hypertension, diabetes, chronic kidney disease and stroke. Such neighborhoods have greater rates of racial minorities and poverty and lower life expectancy.^18,19 

5. Community and social context 

The relationships an individual has with their family, friends and communities have an important impact on their personal health. Social and civic connections can be powerful in influencing some health and safety dangers.  

For example, adolescents are less likely to engage in high-risk behaviors if they have a close adult to confide in.²⁰ There is a positive linkage between parents who read out loud with their children at least 4 days a week and improved childhood language and literacy skills as well as better health.²¹   

The impact of racism, structural and individual, and incarceration are also potent contributors to the well-being of individuals and families. Children with a parent who has served time in prison are more likely to live in poverty and homelessness.²² High school students identifying as LGBTQ report being bullied at twice the rate of their heterosexual counterparts. This leads to increased rates of depression, anxiety and high school dropout rates. 

Conclusion 

The SDOH represent factors that impact health outcomes outside of the direct care we provide. These forces are vast, variable, powerful and systemic in their nature, influencing the conditions into which individuals are born, live, work and age. The five factors of the SDOH discussed have a deep impact on an individual’s overall health, sense of well-being and quality of life. 

As deeply integrated medical specialists, we’ve stepped out of the comfort zone of our labs and expanded the reach of our care by opening clinics. Yet, for IR to maximize its value, we must go even further.  

Tackling the effects of the SDOH is a unique challenge. It requires a different skillset than what we may be hardwired for. Awareness is the first step, and once we have a better understanding of all the factors impacting health, we can be better prepared as clinicians and provide better care. 

References 

1. Whitman A, De Lew N, Chappel A, Aysola V, Zukerman R, Sommers BD. Addressing social determinants of health: Examples of successful evidence-based strategies and current federal efforts. ASPE Office of Health Policy. 2022. aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/SDOH-Evidence-Review.pdf. 
2. Dooley D, Fielding J, Levi L. Health and unemployment. Annual Review of Public Health. 1996:17;449–465. 
3. Avendano M, Berkman LF. Labor markets, employment policies, and health. Social Epidemiology. 2014:182–233. 
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5. Nella D, Panagopoulou E, Galanis N, Montgomery A, Benos A. Consequences of Job Insecurity on the Psychological and Physical Health of Greek Civil Servants. Biomed Res Int. 2015. doi: 10.1155/2015/673623.  
6. U.S. Department of Agriculture, Economic Research Service. Key statistics and graphics, food security status of U.S. households. Retrieved March 10, 2022. ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/key-statistics-graphics.aspx.  
7. Nord M. Characteristics of low-income households with very low food security: An analysis of the USDA GPRA food security indicator. USDA-ERS Economic Information Bulletin. 2007(25). 
8. Nord M. Food insecurity in households with children: Prevalence, severity, and household characteristics. USDA-ERS Economic Information Bulletin. 2009(56). 
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10. Joint Center for Housing Studies. The state of the nation’s housing 2014. Harvard University. 2014. chs.harvard.edu/sites/default/files/sonhr14-color-full_0.pdf. 
11. Joint Center for Housing Studies. The state of the nation’s housing 2020. Harvard University. 2020. jchs.harvard.edu/sites/default/files/reports/files/Harvard_JCHS_The_State_of_the_Nations_Housing_2020_Report_Revised_120720.pdf.  
12. The 2022 Annual Homelessness Assessment Report (AHAR) to Congress. huduser.gov/portal/sites/default/files/pdf/2022-AHAR-Part-1.pdf. 
13. Meyer BD, Wyse W, Logani I. The mortality of the U.S. homeless population. Becker Friedman Institute, University of Chicago. March 2023. bfi.uchicago.edu/wp-content/uploads/2023/03/BFI_WP_2023-41.pdf. 
14. Jansen T, Rademakers J, Waverijn G, et al. The role of health literacy in explaining the association between educational attainment and the use of out-of-hours primary care services in chronically ill people: a survey study. BMC Health Serv Res. 2018(19). Doi: 10.1186/s12913-018-3197-4. 
15. Case A, Deaton A. Life expectancy in adulthood is falling for those without a BA degree, but as educational gaps have widened, racial gaps have narrowed. PNAS. 2021:118(11). pnas.org/doi/10.1073/pnas.2024777118. 
16. Heath S. Educational attainment emerges as SDOH predicting health disparities. Patient care access news. 2021. patientengagementhit.com/news/educational-attainment-emerges-as-sdoh-predicting-health-disparities. 
17. High T. Social determinants of health: Thoughts on neighborhood and built environment. Focus for Health Foundation. 2017.focusforhealth.org/sdoh_neighborhood.  
18. Cutter SL, Boruff BJ, Shirley W L. Social vulnerability to environmental hazards. Soc. Sci. Q. 2003:84(2);242–261. 
19. Dreier P, Mollenkopf JH, and Swanstrom T. Place matters: Metropolitics for the twenty-first century. 2001. 
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