Marilyn Metzler on "Social Determinants of Health"

There isn’t really an agreed upon definition for Social determinants of health but Sherman James, who is at the Univ. of Michigan, defines social determinants of health as life enhancing resources such as safe housing, social and economic conditions, employment and other resources that are necessary for health.

I think this is a good place to begin because it names some of the non-biological, non-behavioral factors that effect health and very importantly it mentions that how these resources are distributed across populations determines health outcomes. For example, higher asthma rates are associated with poor housing conditions. People among certain minority groups primarily inhabit public housing in inner city areas where pest control is not great, dampness is a factor and other environmental pollutants, and consequently there are higher rates of asthma among inner city populations that live in poor housing conditions.

Just about every study that we have conducted in health research shows worst health outcomes for people who are poor or less well off than others in the population. The relationship between social determinants of health and health disparities is important if we’re serious about our goal of eliminating health disparities which we mentioned explicitly as one of two goals in Healthy People 2010 and in fact Healthy People 2010 mentions that its important for states and the nation and other agencies to work together across disciplines to address housing conditions, neighborhood conditions, employment opportunities, justice, all the factors that effect peoples’ everyday lives and their health.

… if we really want to maximize the impact of our other public health interventions it’s important to address the underlying causes, the social and environmental and economic factors that are affecting health. For example, messages for people with diabetes include the importance of eating fresh fruits and vegetables. We know that nutrition is an important factor in preventing diabetes and in treating diabetes for people who already have this disease. However, if we’re sending this message to people who live in communities where there aren’t grocery stores, where people have access to affordable fresh fruits and vegetables then our messages are less likely to be able, people are less likely to be able to hear our messages.

I definitely think that you can include addressing social determinants of health across the planning process for a social marketing project. Certainly can include it in the explanatory process when you’re trying to link health outcomes with causes and developing your model. When you’re looking at theories you could look at gender power theory, Bronthen Brenner’s model, or the Evan’s and Stoddard model out of Canada. When putting together your partnership you would think of the usual suspects that we all put together when we develop partnership but also perhaps thinking of other partners that would address the social factors that affect health whether you might be talking to grocery store owners or you might be including public housing advocates in your message.

When you do your SWAT analysis you would probably want to include under weaknesses that addressing social factors will take longer than simply addressing behavioral or message oriented interventions.

There’s certainly a whole body of literature on the effects of racism on health. Pre-term infant delivery is now associated with perceived and real discrimination.

There’s a whole body of literature on how stress gets under the skin and when it gets under the skin how it affects health by interrupting immune process, hormone process and actually impacts health very directly.

When addressing social determinants of health at the community level it’s very important to include community partners throughout the entire process, from beginning to end. Community members have a wealth of knowledge about what are the issues affecting health in their communities and wealth of knowledge about how to address those issues and so combining local knowledge and resources with public health knowledge and resources increases the likelihood that we will design and implement interventions that are more effective.

Those of us in public health spend much of our energies and resources trying to get certain groups to change their behavior in order to improve their health. It’s really important that we remember that many people do not have access to the resources and the opportunities that support good health. Working for the conditions in which health can happen is really well within the role of public health and in fact the Institute of Medicine says that is our role; to create the conditions in which people can be healthy.

We need to educate funders and others as to the long lead times that it does take to improve health. These health disparities did not happen over night.

What we’re talking about here is thinking beyond messages and strategies for individuals and really thinking about opportunities and strategies for whole groups. That we’re talking about neighborhoods, or we’re talking about African Americans who live below the poverty line, or we’re talking about groups that don’t have access to health care. We’re thinking of a population-based approach to public health interventions as a means of improving health not just individual based messages.

It’s important to think across these silos that we create in public health. There’re groups of us that are working on diabetes and groups of us that are working on cardiovascular disease and yet many of the root causes are similar along disease lines and so working with each other to address social determinants of health is important. But we really don’t have much of a precedent for that in public health so that’s our task, to take that on.