Social determinants of health

By Lynn N. Asher, RN, MHA, CHC

Lynn N. Asher (lynn@lnaconsult.com) is Principal at L.N. Asher in Dallas, TX.

The concepts behind social determinants of health (SDOH) have been with us for many years. The Commission on Social Determinants of Health was established by the World Health Organization in 2005 to consider social conditions that affect a society’s poor health and health inequalities. The commission’s initial work has been further developed over the years, resulting in several formats, including the current one used by the Office of Disease Prevention and Health Promotion (ODPHP) under the U.S. Department of Health & Human Services. The department establishes public health objectives every 10 years, with the current plan covering the 2020–2030 period.^[1] The department’s objectives include SDOH, leading health indicators, and overall health and well-being measures.

SDOH basics

ODPHP defines SDOH as “conditions in the environments where 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.”^[2] It groups the determinants into five domains that play a role in improving a community’s health outcomes (Table 1). Each domain has specific goals and objectives established by ODPHP. Even though they are separate areas, they are interconnected, and improvements in one area can have a positive impact on other domains.

Table 1: The five SDOH domains that affect a community's health outcome improvement.
Domain	Economic stability	Education access and quality	Healthcare access and quality	Neighborhood and built environment	Social and community context
Goal	Create steady incomes that allow people to meet their healthcare needs.	Increase educational opportunities and help children and adolescents do well in school.	Increase access to comprehensive, high-quality healthcare services.	Create neighborhoods and environments that promote health and safety.	Increase social and community support.
Objectives	Increase employment Affordable housing Reduce food insecurity and hunger	Increase proficiency in math and reading Provide preventive mental healthcare services in school Participation in high-quality early education	Improve health literacy Increase healthcare insurance coverage Access to medical services when needed	Reduce violent crime Improve air and water quality Transportation systems to promote walking and biking	Reduce bullying Improve availability of someone to discuss concerns with Reduce incarceration rates for parents and guardians

Economic stability can result in improved nutrition and affordable housing. This in turn can promote better performance in school for children, address mental health concerns related to homelessness, and decrease food insecurity for adults and families. Some healthcare organizations are faced with challenges related to treating individuals without adequate housing. This can range from the individual who is homeless to someone who lacks a consistent address to provide care. Addressing concerns in this domain can have far-reaching improvements in many of the other domains.

Improvements in a community’s physical environment and social support affect both health outcomes and the use of healthcare services. Respiratory illnesses, such as asthma and other pulmonary diseases, can be difficult to manage in communities with poor air quality, resulting in increased readmissions and additional clinic visits.^[3] Suicide is one of the leading causes of death in the United States, with rates being higher in rural counties than in metropolitan areas.^[4] Actions to reduce bullying in schools, improving a community’s social support network, and expanding access to mental health services can reduce the number of suicides.

ODPHP is not the only federal entity that has a role in this area. Other agencies such as the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality participate in research related to SDOH. The Centers for Medicare & Medicaid Services (CMS) is also taking action in this area.