Social determinants of health (SDoH) are the conditions under which people are born, grow, live, work, and age, and include factors such as socioeconomic status, education, employment, social support networks, and neighborhood characteristics.1 These have a greater impact on population health than factors like biology, behavior, and health care.2,3 SDoH, especially poverty, structural racism, and discrimination, are the primary drivers of health inequities.4-6 Reducing health inequities is important because they are pervasive; unfair and unjust; individuals affected have little control over the contributing circumstances; affect everyone; and can be avoided with existing policy solutions.7
The purpose of this position paper is to outline prevalent health inequities; describe how social factors impact health; discuss the role family physicians can play in addressing SDoH and reducing health inequities; and state the American Academy of Family Physicians (AAFP) stance on relevant policy interventions.
Social Determinants of Health: The conditions under which people are born, grow, live, work, and age.1
Structural Determinants of Health Inequities: The social, economic, and political mechanisms which generate social class inequalities in society.8
Health Equity: “Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”9
Health Disparities: “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 such as race or ethnicity, religion, socioeconomic status, gender, mental health, sexual orientation, or geographic location. Other characteristics include cognitive, sensory, or physical disability.”10
Health Inequities: “A difference or disparity in health outcomes that is systematic, avoidable, and unjust.”10
The most prevalent and severe health inequities occur where there is poverty, systematic racism, and discrimination.6 Some of the most common and well-researched health inequities are experienced between groups based on socioeconomic status, race and ethnicity, sexual orientation and gender expression, as well as geographic location.11,12 Information is provided in the following sections to help characterize these health inequities. However, this is not intended to be comprehensive or cover all health inequities.
Socioeconomic status refers to the social and economic factors that influence the position individuals hold in society. This includes factors like occupation, class, education, income, and wealth.11,12 Individuals with higher socioeconomic status consistently experience better health outcomes than those with lower socioeconomic status, and this occurs across a social gradient.11 It is not just the very poor who are affected. Research has shown that:
Race and ethnicity are associated with many indicators of health status, even after considering socioeconomic status, behavior, and other characteristics. Systematic, persistent, and long-felt discrimination is thought to be the main contributor.11 Research has shown that:
Lesbian, gay, bisexual, and transgender (LGBT) people also experience higher levels of discrimination, stigma, stress, and worse outcomes for a variety of health status indicators. Research has shown that:
The physical features of an area can impact people’s health. Physical features like air and water quality and climate, as well as housing, parks, and other recreation areas all play a part in physical activity and life expectancy.11 Research has shown that:
Health equity scholars use a metaphor of a “stream” of causation to illustrate how social factors impact health. The “downstream” factors include issues that medicine and public health typically deal with—morbidity and mortality, access to health care, behavioral risk factors, and living conditions. The questions that arise from this illustration are why are so many people sick and why are there such great differences among groups? The answer lies in the “upstream” factors, which include governance, culture, and societal values. These, as well as economic, social, and public policies, are the factors that lead to long-held social inequities (Figure 4).8,27 To understand how social factors impact health, it is important to understand how risk factors are shaped upstream, and how differences in living conditions and exposures are physically embodied by individuals.
Figure 4: Public Health Framework for Reducing Health Inequities
Used with permission from the Bay Area Regional Health Inequities Initiative (BARHII)
The structural determinants of health inequities are the social, economic, and political mechanisms which generate social class inequalities in society.8 These are macro-level factors that impact large numbers of people. Examples of structural determinants of health include the degree that government subsidizes health care or education; decisions about pollution, including minimum standards or where toxic substances are stored or released; and decisions about the built environment, which can benefit or harm communities. These all contribute to social class inequalities. Jim Crow laws and redlining are more specific examples. These laws and corporate policies legislated segregation, restricted access to good housing from black Americans, and reduced their ability to influence governmental decisions or live in a healthy neighborhood. This had a substantial negative impact on the health of black Americans. Data showed that life expectancy and infant mortality improved for black Americans after these policies were eliminated.24,28
Social factors also influence health by providing or constraining opportunities for people to access resources that promote better health. Individuals with low socioeconomic status are less likely to be able to acquire health care, nutritious foods, good educational opportunities, safe housing, or safe spaces for exercise.29 Negative health behaviors, like tobacco, alcohol, or explicit drug use are often pervasive in disadvantaged communities. These types of behaviors are then socially patterned in children, who have not fully developed their ability to make rational decisions.30 These factors are shaped by more upstream factors.
The upstream and downstream factors shape the conditions under which people live. Differences in living conditions and opportunities to make healthy decisions result in differentials in exposures and chronic stress. Embodiment is “a concept referring to how we literally incorporate, biologically, the material and social world in which we live...”31Social factors are embodied as individuals are exposed to repeated and chronic stress.32 The autonomic nervous system, the hypothalamic-pituitary-adrenal axis, and the cardiovascular, metabolic, and immune systems protect the body by responding to internal and external stress. Over time, chronic stress can increase the allostatic load, or the “wear and tear” that accumulates on the body over time. This “wear and tear” has health damaging effects.32,33Historically-disadvantaged groups have been found to experience greater allostatic load, more “wear and tear” than more advantaged groups.34 Embodiment and allostatic load are thought to explain why social factors are linked with almost every measure of health status throughout time.31,33
The AAFP urges its members to become more informed about the impact SDoH have on health and health inequities, and to identify tangible next steps they can take to address their patients’ SDoH and reduce health inequities within their scope. The AAFP also urges hospitals and health care systems to consider the SDoH in their strategic plans and to provide their staff, including family physicians, with opportunities to engage with and advocate on behalf of their community to advance health equity. In addition, the AAFP urges health insurers and payors to provide appropriate payment to support health care practices to identify, monitor, assess, and address SDoH.35Finally, since health inequities arise outside of the health care sector, the AAFP urges funders, including the federal government, to provide sufficient funding to address the SDoH and reduce health inequities. In addition to other interventions, this includes robust financial support for the nation’s public health infrastructure to support their efforts to facilitate cross-sector community collaboration, strategic planning for health, Health in All Policies, and the core public health functions.36
Family physicians can play an important role in addressing both the upstream and downstream SDoH. They provide high-quality health care for underserved populations more so than other medical specialties.37 Family physicians can also work with their practice teams and community members to address SDoH in any of the following ways:
The AAFP has created resources to assist family physicians and their health care teams at The EveryONE Project Toolkit.
The AAFP supports the following types of public policies for their ability to address SDoH and reduce health inequities.
Social determinants of health have a substantial impact on the health of many Americans and are a key driver of health inequities. Family physicians have an important role in addressing both upstream and downstream SDoH and reducing health inequities by providing high-quality health care for the underserved and advocating to raise the prominence of health inequities among the public and policymakers. The AAFP urges its members to work with their practice teams and community members to address SDoH and urges government, health care systems, and public health organizations to develop policies and practices that address SDoH to help reduce health inequities.
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