5 Underrecognized Social Determinants of Health

In recent years, the term social determinants of health has gained prominence in the population health lexicon. Discussion of social determinants of health can be found on almost every medical conference’s agenda and on the priority lists of a growing number of health systems, insurers, employers, and nonprofits.

Social determinants of health are defined by the World Health Organization as “the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”¹ That definition calls to mind some of the most obvious social determinants and those whose links to health outcomes are fairly straightforward, such as income, education, and nutrition. But what are some social determinants that aren’t always top of mind? Here are 5 underrecognized social determinants, how they impact health outcomes, and what can be done to address them.

Discussions of social determinants of health might focus on the obvious—like income or education—while overlooking some other social determinants that impact health in complex ways. | Image Credit: © TarikVision - stock.adobe.com

Safe housing

A person’s housing situation can impact their health in a myriad of ways. Homelessness is a risk factor known to be associated with worse physical and mental health and higher mortality, but even those with a stable housing environment may face health risks if the quality or safety of that home isn’t optimal.² For instance, conditions like leaking water, poor ventilation, and mold or pest infestation are linked with poor health outcomes, especially those related to asthma.²

Successful efforts to improve housing safety can involve the people directly affected. One such initiative brought community health workers and families together to weatherize and repair their Philadelphia homes, leading to huge improvements in asthma symptoms, medication use, and missed school days, as well as a 90% decrease in emergency department and hospital visits.³

Job opportunities

Multiple aspects of employment can affect a person’s health, such as via workplace safety, job-related injuries, and workplace conflict or stress.⁴ However, an underappreciated aspect of the work/health relationship is the risk of underemployment, or situations where the schedule, social status, and income of a job don’t match the employee’s education, abilities, and skills. For example, this could look like a person working part time or seasonally despite being willing and able to work full time. This scenario is particularly concerning given the employment-based health insurance system in the US.

Federal and state initiatives to provide financial assistance after job loss have been shown to alleviate the poor health outcomes associated with unemployment, but not as much research has analyzed the relationship between underemployment and health outcomes.⁵ Such research is needed to support any potential policy efforts to address underemployment.

Broadband internet access

With the increased reliance on video telemedicine visits during and since the COVID-19 pandemic, broadband internet access is emerging as a driver of health outcomes and disparities.⁶ One in 4 Americans lacks the internet or device access needed to engage in video visits, so they’re unable to reap the benefits of telehealth and other important functions with health implications, like participating in virtual education, interviewing for jobs, applying for benefits, or accessing health care information. Even more concerning is that reduced internet access has the potential to exacerbate existing disparities because it most affects those who are already vulnerable, such as older people, members of racial/ethnic minority groups, rural residents, and those with lower education or income.

Starting in December 2021, the Bipartisan Infrastructure law funded the Affordable Connectivity Program, which offered eligible households a discount on their monthly internet bill and a one-time discount on the purchase of a device.⁷ However, the program was not reupped by Congress and the funding ran out in June 2024, meaning more than 23 million households can no longer receive these discounts.

Social connections

Amid growing recognition of the importance of social connectivity, the US Surgeon General has declared loneliness a profound public health threat on the level of smoking and obesity.⁷ In our increasingly divided and digital society, 50% of US adults experience loneliness, which has consequences for mental and physical health, including increased risks of depression, anxiety, and even heart disease, stroke, and dementia. Conversely, positive social support can encourage healthier behaviors and even contribute to physiological benefits like lower atherosclerosis levels.⁸

Health systems and insurers are beginning to recognize the role of social connection and launch initiatives to encourage it in their patients. For instance, SCAN Health Plan’s Togetherness Program includes peer callers who check in on plan members just to chat and support them.⁹ The plan says that these peer-to-peer interventions have “helped members become more physically active, address mobility issues, and seek treatment for a variety of mental health issues.”

Exposure to violence

Crime and violence can impact individuals’ physical and mental health whether experienced directly or indirectly; for example, the ripple effects of gun violence in a neighborhood can decrease the amount of physical activity in local parks as well as lead to higher levels of depression or suicidal ideation.¹⁰ Exposure to violence in childhood is particularly impactful on the risk of lifelong health outcomes, and reducing violence can also begin in childhood, as the US Community Preventive Services Task Force has recommended the implementation of school-based programs that emphasize problem-solving and teamwork.

Hospitals also have a role to play via screening and case management for victims of violence. Some studies have found hospital-based violence intervention programs to be successful and cost-effective in reducing recidivism,¹¹ but more research is needed on interventions that can address crime and violence across settings.

References

1. Social determinants of health. World Health Organization. Accessed September 4, 2024. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

2. Taylor LA. Housing and health: an overview of the literature. Health Affairs. June 7, 2018. Accessed September 4, 2024. https://www.healthaffairs.org/content/briefs/housing-and-health-overview-literature

3. Bryant-Stephens TC, Strane D, Robinson EK, Bhambhani S, Kenyon CC. Housing and asthma disparities. J Allergy Clin Immunol. 2021;148(5):1121-1129. doi:10.1016/j.jaci.2021.09.023

4. Employment. Healthy People 2030. Accessed September 4, 2024. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/employment

5. Golden L, Kim J. The rise and fall of underemployment: implications for workers’ health. Health Affairs. July 13, 2023. Accessed September 4, 2024. https://www.healthaffairs.org/content/briefs/rise-and-fall-underemployment-implications-workers-health

6. Affordable Connectivity Program (ACP) fact sheet. Federal Communications Commission. June 3, 2024. Accessed September 4, 2024. https://www.fcc.gov/sites/default/files/ACP-Fact-Sheet-Post-ACP-Ending.pdf

7. What we’re reading: Congress wants to lower health costs; HIV drug patent trial; loneliness is a public health threat. AJMC^®. May 2, 2023. Accessed September 4, 2024. https://www.ajmc.com/view/what-we-re-reading-congress-wants-to-lower-health-costs-hiv-drug-patent-trial-loneliness-is-a-public-health-threat

8. Social cohesion. Healthy People 2030. Accessed September 4, 2024. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/social-cohesion

9. As older adults reel from COVID isolation, SCAN Health Plan launches one-of-a-kind Togetherness Program. News release. SCAN Health Plan. May 19, 2021. Accessed September 4, 2024. https://www.businesswire.com/news/home/20210519005476/en/As-Older-Adults-Reel-From-COVID-Isolation-SCAN-Health-Plan-Launches-One-of-a-Kind-Togetherness-Program

10. Crime and violence. Healthy People 2030. Accessed September 4, 2024. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/crime-and-violence

11. Juillard C, Cooperman L, Allen I, et al. A decade of hospital-based violence intervention: Benefits and shortcomings. J Trauma Acute Care Surg. 2016;81(6):1156-1161. doi:10.1097/TA.0000000000001261