Social Determinants of Health

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Achieving Health Equity by Addressing the Social Determinants of Health

The conditions in which we are born, live, learn, work, play, worship, and age – known as social determinants of health (SDoH)1 – have a profound impact on health. They influence the opportunities available to us to practice healthy behaviors, enhancing or limiting our ability to live healthy lives.

Differences in SDoH contribute to the stark and persistent chronic disease disparities in the United States among racial, ethnic, and socioeconomic groups,2 systematically limiting opportunities for members of some groups to be healthy.3 While public health crises and economic uncertainty may focus attention on disparities, health inequities have persisted across generations because of structural policies and practices that have systematically limited health access and opportunities.4,5

Interventions targeting SDoH have tremendous potential to narrow disparities across many chronic diseases by removing systemic and unfair barriers to practicing healthy behaviors.6 By addressing SDoH, we make progress toward health equity, a state in which every person has the opportunity to attain their highest level of health.7

Our Framework

Addressing SDoH to achieve health equity requires multisectoral and multilevel collaboration. Given our organizational expertise, capabilities, and congressional mandates, NCCDPHP is uniquely positioned to drive progress by addressing the following five determinants:

BUILT ENVIRONMENT

Built environment is human-made surroundings that influence overall community health and individual behaviors that drive health.

COMMUNITY-CLINICAL LINKAGES

Community-clinical linkages are connections made among health care systems and services, public health agencies, and community-based organizations to improve population health.

FOOD INSECURITY

Food insecurity is an economic and social condition characterized by limited or uncertain access to adequate and nutritious food.

SOCIAL CONNECTEDNESS

Social connectedness is the degree to which individuals or groups of individuals have and perceive a desired number, quality, and diversity of relationships that create a sense of belonging and being cared for, valued, and supported.

TOBACCO-FREE POLICY

Tobacco-free policies are population-based preventive measures to reduce tobacco use and tobacco-related morbidity and mortality.

By using this framework, we intend to achieve equity, which requires acknowledging and addressing unfair, avoidable, and solvable differences in opportunities for health that systematically disadvantage people.

Our Role

NCCDPHP is uniquely positioned to:

focus
focus

Focus on primarily upstream, evidence-based interventions that can be expanded in many communities to advance health equity.

identify
identify

Identify gaps in the evidence base, inform research priorities, and accelerate translation and implementation science to minimize health disparities.

foster
foster

Work with partners from different sectors, such as education, housing, health care, community development, or transportation, to expand proven interventions that address SDoH.

conduct
conduct

Conduct high-quality surveillance and use datasets to identify disparities and equitably target funding, guidance, and technical assistance.

Examples of Our Work

At NCCDPHP, our work is deeply rooted in addressing social determinants of health to reduce barriers and promote health and wellness for all. Some examples of our work and successes are:

Racial and Ethnic Approaches to Community Health (REACH)

The REACH program is one of the only CDC programs that focuses on reducing high rates of chronic diseases for specific racial and ethnic groups in urban, rural, and tribal communities. For over 20 years, the REACH program has funded communities to work with racial and ethnic minorities to reduce tobacco use, improve access to healthy foods, change the built environment to promote physical activity, and connect people to clinical care.

  • From 2014 to 2018, in DeKalb County, Georgia, access to healthy food increased for about 242,000 African American residents. As a result, county officials reported a 34% increase in the consumption of fruits and vegetables among customers of farmers’ markets participating in the program.

Healthy Tribes

CDC’s Healthy Tribes partners with American Indian and Alaska Native communities to strengthen cultural connections to improve health, promote wellness, and prevent disease. Healthy Tribes supports three cooperative agreements with 77 awards to tribes and tribal organizations that work synergistically to build public health infrastructure, strengthen chronic disease prevention, and promote wellness with a focus on indigenous culture and cultural connectedness.

  • With support from the Healthy Tribes Good Health and Wellness in Indian Country program, the Winnebago Tribe of Nebraska (Ho-Chunk) conducted a food insecurity survey in 2016 revealing that a third of tribal members lacked access to healthy foods. Historically, the Ho-Chunk People were a “planting people” of corn, beans, and squash – the Three Sisters. In conjunction with the US Department of Agriculture, the Little Priest Community College Extension program, Healthy Tribes Tribal Practices for Wellness in Indian Country program, and other partners, the tribe is now working to increase access to traditional foods and food sovereignty. This effort has increased the number of tribal members growing their own food and expanded access to fresh, healthy, locally grown food for purchase on the reservation. In 2020, 80 family gardens were established, and farmers’ market produce has been distributed weekly to families across the reservation.

Well-Integrated Screening and Education for Women (WISEWOMAN)

WISEWOMAN screens low-income women aged 40 to 64 for heart disease risk factors and refers them to community resources that can help them control their blood pressure, eat a healthier diet, be more physically active, and quit smoking.

  • From 2014 to 2018, the Utah WISEWOMAN program provided 17,435 heart disease and stroke risk factor screenings to 10,537 women. It also provided 41,405 healthy behavior support services. A total of 674 women who were previously undiagnosed learned that they had high blood pressure and were referred for treatment.

National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

The NBCCEDP helps low-income women with little or no health insurance gain access to timely breast and cervical cancer screening, diagnostic, and treatment services.

  • The Illinois Breast and Cervical Cancer Program (IBCCP) and the state of Illinois offer breast and cervical cancer screening and diagnostic tests to uninsured or underinsured women in the state. In 2017, IBCCP started the Community Navigation Pilot (the Pilot) to to link the community to these services. The Pilot funds seven IBCCP lead agencies to hire and sustain community navigators, implement evidence-based interventions for funded services, partner with local community agencies to help with social media outreach, and increase awareness and enrollment of non-Hispanic Black and Hispanic women. From 2018 to 2019, caseload totals increased 341% for Hispanic women, 95% for non-Hispanic Black women, and 35% for non-Hispanic White women.

National Tobacco Control Program (NTCP)

The NTCP encourages coordinated national efforts to reduce tobacco-related diseases and deaths by eliminating exposure to secondhand smoke, promoting quitting among adults and youth, preventing initiation among youth and young adults, and identifying and eliminating tobacco-related disparities.

  • The National Alliance for Hispanic Health’s Nuestras Voces (Our Voices) National Network, a CDC-funded initiative, helps Hispanic communities to decrease tobacco use and secondhand smoke exposure, increase cancer prevention strategies, and improve disease management. Nuestras Voces used the Alliance’s Su Familia helpline to provide tailored answers to health concerns, connect callers to local services, and help them navigate the health care system. During 2014–2018, the helpline served 2,739 Hispanic callers nationally with tobacco or cancer-related issues by referring them to the Spanish-language quitline, Déjelo Ya, and to local health care services. During 2014–2016, Su Familia helped another 3,138 Hispanic callers with tobacco cessation counseling services and cancer information and referrals.

National Diabetes Prevention Program

Scaling the National Diabetes Prevention Program (National DPP) in Underserved Areas expands access to the National DPP lifestyle change program to increase enrollment of men, Medicare beneficiaries, African Americans, Asian Americans, Hispanics, American Indians, Alaska Natives, Pacific Islanders, and people with visual impairments or physical disabilities.

  • Using a faith-based approach, The Balm in Gilead established the Southeast Diabetes Faith Initiative (SDFI), a partnership of historically black church denominations in five states in the Southeastern U.S., to expand access and utilization of the National Diabetes Prevention Program (National DPP). The goal of this multi-faceted initiative is to create a sustainable infrastructure within faith-based institutions to effectively deliver the National DPP lifestyle change program to underserved communities in Alabama, Georgia, North Carolina, South Carolina and Virginia. As of 2020, SDFI has enrolled over 1,100 participants, of which more than 60% were African American, in the National DPP.

Community Pilots

The purpose of this project is to identify coalitions with multi-sector partners that have successfully implemented programs and policies in their communities to address chronic disease prevention in one of five areas of NCCDPHP’s targeted determinants: built environment, community-clinical links, food insecurity, social connectedness, or  tobacco-free policy. Evaluation-focused technical assistance will be provided to up to 50 communities to understand progress to date and document outcomes and lessons learned. The Association of State and Territorial Health Officials (ASTHOexternal icon) and National Association of County and City Health Officials (NACCHOexternal icon) are being considered as partners to coordinate the technical assistance.

Tools and Resources

COVID – Underlying Medical Conditions by County
This dashboard presents county-level, model-based estimates of the prevalence for any of five underlying medical conditions that increase the risk for severe COVID-19 illness, including chronic kidney disease, chronic obstructive pulmonary disease, heart disease, diagnosed diabetes, and obesity. The data reflected are based on an analysis of 2018 Behavioral Risk Factor Surveillance System (BRFSS) data and US Census population data for adults in 3,142 counties.

Glossary of Key Terms

Health Equity: Health equity is when every person has the opportunity to attain their “full health potential” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.”8

Health Disparity: Health disparity is a type of difference in health that is closely linked with social or economic disadvantage. Health disparities negatively affect groups of people who have systematically experienced greater social or economic obstacles to health. These obstacles stem from characteristics historically linked to discrimination or exclusion based on characteristics such as race or ethnicity, socioeconomic status, disability, sexual orientation, and many other factors.9

Institutional, Institutionalized, or Structural Racism: “Processes of racism that are embedded in laws (local, state, and federal), policies, and practices of society and its institutions that provide advantages to racial groups deemed as superior, while differentially oppressing, disadvantaging, or otherwise neglecting racial groups viewed as inferior.”10 Institutionalized racism is defined as “differential access to the goods, services, and opportunities of society by race. Institutionalized racism is normative, sometimes legalized, and often manifests as inherited disadvantage. It is structural, having been codified in our institutions of custom, practice, and law, so there need not be an identifiable perpetrator.”11

Social Determinants of Health (SDoH): Social Determinants of Health (SDoH) are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.12

References
  1. Social Determinants of Health. Healthy People 2020 website. Updated June 1, 2020. Accessed June 2, 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-healthexternal icon
  2. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annu Rev Public Health. 2011;32:381‐398. doi:10.1146/annurev-publhealth-031210-101218
  3. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129 Suppl 2(Suppl 2):19‐31. doi:10.1177/00333549141291S206
  4. McGovern L. The relative contribution of multiple determinants to health. Health Affairs. August 21, 2014
  5. Thornton RL, Glover CM, Cené CW, Glik DC, Henderson JA, Williams DR. Evaluating Strategies for Reducing Health Disparities By Addressing The Social Determinants Of Health. Health Aff (Millwood). 2016;35(8):1416‐1423. doi:10.1377/hlthaff.2015.1357
  6. Thornton RL, Glover CM, Cené CW, Glik DC, Henderson JA, Williams DR. Evaluating Strategies for Reducing Health Disparities By Addressing The Social Determinants Of Health. Health Aff (Millwood). 2016;35(8):1416‐1423. doi:10.1377/hlthaff.2015.1357
  7. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254‐258. doi:10.1136/jech.57.4.254
  8. Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57(4):254‐258.
  9. Disparities. Healthy People 2020 website. Updated June 1, 2020. Accessed June 2, 2020
  10. Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:105-125.
  11. Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212‐1215.
  12. Social Determinants of Health. Healthy People 2020 website. Updated June 1, 2020. Accessed June 2, 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-healthexternal icon
Page last reviewed: September 21, 2020