Social Determinants of Health
Social determinants of health are conditions in which patients are born, grow, live and work, and include socioeconomic status, education, environmental factors, employment, access to health care, transportation and housing.1 Disparities in social factors can create inequities in health and quality of life, making them key drivers in health and health outcomes.1 Contemporary research on health care suggests that social factors, which lie well outside of the health care system, are at the root of many health inequalities.2 Thus, modern health care solutions have begun to shift focus from medicine and diagnostic solutions toward broader social and environmental determinants of health.
A major influence on health is access to health care, often determined by proximity to health centers and transportation. Poor, elderly and chronically ill patients may rely on nonemergency medical transportation (NEMT) to access care.3 Recent initiatives have used NEMT in hopes of transporting patients to appointments, and several studies have evaluated the efficacy of NEMT. For example, a recent intervention by CareMore, a health plan and care delivery system for Medicare and Medicaid patients, showed that using Lyft for NEMT resulted in patient satisfaction and was economically advantageous.4 Additionally, a rural NEMT program in West Virginia reached patients who needed transportation assistance and led to patient satisfaction.5 However, NEMT interventions are not perfect solutions to the barriers to health care. For one, rural patients appear to benefit less than urban patients from NEMT, given that rides are longer and more expensive.4,6 Additionally, NEMT programs may not be financially sustainable, given costs such as salary and mileage expenses and reliance on Medicaid reimbursement.5 As these data show, transportation efforts may improve patients’ satisfaction, but may not be financially practical.
Another social determinant of health is housing, which consists of internal housing conditions, area characteristics and housing tenure (i.e., financial arrangements).7 Recently, Kaiser Permanente, a widespread health maintenance organization (HMO), invested $200 million in projects that aim to prevent displacement or homelessness of lower- and middle-income families and make affordable homes healthier and more environmentally sound.8 This effort represents the company’s acknowledgement that unstable housing status can worsen chronic health problems.8 Indeed, one study in the United Kingdom found that rehousing, refurbishment and energy optimization improved participants’ health.9 Also, according to a synthesis by Gibson et al., many housing interventions successfully improved area characteristics, as well as warmth and energy efficiency.7 Nevertheless, the health impacts of these interventions remain unclear, and no interventions for housing tenure were found.7 Also, small study populations and the inability to control several confounding factors make it difficult to draw conclusions about housing interventions in general.9 Thus, while housing may contribute to health, better quality research is needed to improve housing interventions and clarify their effects on health.
Aside from transportation and housing, race and racial relations also impact health, often through access to economic, social and physical resources essential to health.10 Using Detroit as a case study, Schulz et al. discussed the higher risks of morbidity and mortality for people of color in the United States, and the possible influence of urban planning and policies on these disparities.10 Also, a review by Williams and Mohammed showed that discrimination, such as racism, can cause declines in health among its targets.11 In response to race’s effect on health, the Centers for Disease Control and Prevention (CDC) developed Racial and Ethnic Approaches to Community Health programs that promote health equity among those with chronic illnesses.12 Another study by Jackson and Garcia suggested that increasing the diversity and cultural competency of the health care workforce could improve the health of patients from racial and ethnic minority groups.13 However, health interventions targeting race are few and far between, and future research should explore such interventions and further examine racial disparities in health.14
Overall, social determinants of health such as transportation, housing and race have clear impacts on health. However, research on the ways that social factors affect health is limited and small-scale.9 Additionally, interventions intending to improve access to transportation and housing conditions and reduce racial discrimination are few and their results are mixed.4,6,15 Going forward, researchers should further explore the ways in which social factors affect health, as well as interventions that adequately—and cost-effectively—target social inequities in health.
1. Artiga S, Hinton E. Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity. Kaiser Family Foundation; May 10, 2018.
2. Marmot M. Social determinants of health inequalities. The Lancet. 2005;365(9464):1099–1104.
3. Powers BW, Rinefort S, Jain SH. Nonemergency Medical Transportation: Delivering Care in the Era of Lyft and Uber. JAMA. 2016;316(9):921–922.
4. Joszt L. CareMore Finds Success Using Lyft to Transport Medicare Beneficiaries to Appointments. The American Journal of Managed Care. September 14, 2018.
5. Bellamy GR, Stone K, Richardson SK, Goldsteen RL. Getting From Here to There: Evaluating West Virginia’s Rural Nonemergency Medical Transportation Program. The Journal of Rural Health. 2003;19(S5):397–406.
6. Smith M, Prohaska T, MacLeod K, et al. Non-emergency medical transportation needs of middle-aged and older adults: A rural-urban comparison in Delaware, USA. International Journal of Environmental Research and Public Health. 2017;14(2):174.
7. Gibson M, Petticrew M, Bambra C, Sowden AJ, Wright KE, Whitehead M. Housing and health inequalities: A synthesis of systematic reviews of interventions aimed at different pathways linking housing and health. Health & Place. 2011;17(1):175–184.
8. Rosenberg J. Kaiser Permanente Investing $200 Million to Address Housing Instability, Improve Health. The American Journal of Managed Care. May 24, 2018.
9. Thomson H, Petticrew M, Morrison D. Health effects of housing improvement: Systematic review of intervention studies. BMJ. 2001;323(7306):187–190.
10. Schulz AJ, Williams DR, Israel BA, Lempert LB. Racial and Spatial Relations as Fundamental Determinants of Health in Detroit. The Milbank Quarterly. 2002;80(4):677–707.
11. Williams DR, Mohammed SA. Discrimination and racial disparities in health: Evidence and needed research. Journal of Behavioral Medicine. 2009;32(1):20–47.
12. Buckner-Brown J, Tucker P, Rivera M, et al. Racial and Ethnic Approaches to Community Health: Reducing Health Disparities by Addressing Social Determinants of Health. Family & Community Health. 2011;34:S12–S22.
13. Jackson CS, Gracia JN. Addressing Health and Health-Care Disparities: The Role of a Diverse Workforce and the Social Determinants of Health. Public Health Reports. 2014;129(1_suppl2):57–61.
14. Williams DR. Race and health: Basic questions, emerging directions. Annals of Epidemiology. 1997;7(5):322–333.
15. Marmot M, Friel S, Bell R, Houweling TAJ, Taylor S. Closing the gap in a generation: Health equity through action on the social determinants of health. The Lancet. 2008;372(9650):1661–1669.