As the landscape of healthcare and public health continues to change and develop, the term “social determinants of health,” or SDOH, has become commonplace. It is assumed that professionals in those fields will already have a full understanding of what SDOH means and why it matters. However, while the term’s meaning has expanded and evolved with new insights and research, articles and seminars that use the term rarely pause to update their audience with the newest information on all it encompasses.
During Mental Health America’s 2023 Conference, a session by speakers JaNeen Cross, DSW, MSW LICSW, LCSW-C, and Shavonne Simmons, LMSW, reexamined SDOH in its most updated context from a social work perspective. SDOH is such an important concept for everyone to understand, including people who are not medical professionals, that this article’s aim is to offer an explanation that can make it more easily understandable for anyone.
As defined by Healthy People 2030, “SDOH are the 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.” In other words, SDOH encompasses everything which a person cannot reasonably be said to have direct control over, but which impacts their health nevertheless. The term expands to include more factors as research offers new insight into aspects of life which affect health and as attitudes change about which aspects of life for which people should or should not be held personally accountable, meaning it changes almost constantly.
For example, a belief which was once the dominant social narrative in America held that the “American Dream” of working hard to find success and build a nice life for oneself and one’s family, especially on a single wage, was not only equally accessible to anyone, but also the expectation placed on everyone. This narrative, of course, completely ignored everything ranging from facts of life that may not be obvious to middle-class white people, such as systemic racism and access to education, to even plainly observable imbalances such as generational wealth versus inherited debt or disability or language barriers and so forth.
According to this narrative, then, a person should be held directly responsible for the job they hold, meaning that if someone has a job that pays poorly or has negative effects on mental health or has no flexibility to allow for time caring for family, that becomes their fault. Over time, the dominant social narrative of America changed to a more realistic assessment of the factors outside of a person’s control which influence what job they have. Under the old way of thinking, a person’s job would not qualify as SDOH because it would not be thought of as a “condition of their environment,” but rather a consequence of their own efforts and nothing more.
Only once the dominant social narrative changes to acknowledge the experiences of people outside of those who have controlled that narrative for centuries does research actually happen about those experiences and their effects. After all, if everyone with the power to do research thinks that a person’s career is nothing more than a consequence of how hard they work and how much ambition they have to achieve better for themselves and their family, then no research is likely to happen about the effects of career on health. Social norms are constantly evolving, and the corresponding research takes time to catch up, so the meaning of SDOH will always be something which requires constant learning to understand fully.
As Cross and Simmons explained, SDOH encompasses a wide variety of complex subjects which can be broken down into five domains: economic stability, education access and quality, health care access and quality, neighborhood or built environments, and social or community context.
However, none of these domains exist in isolation. Social and community contexts such as race correlate with economic stability. The poverty rate in the U.S. is 11.6%, approximately 40 million people, and breaks down disproportionately to the ratio of racial groups in the U.S. Education access and quality is also connected to economic stability, and to social and community contexts, as statistics about education, poverty, and race also show disproportionate correlations compared to the demographics of the U.S. Health disparities grow with socioeconomic inequalities.
In other words, poor quality of life often means poor health outcomes. A broad swath of research Cross and Simmons shared demonstrated each of these points, from data about poverty rates compared to racial groups and education levels to the association of education levels with health outcomes and longevity. One of the more recent developments in health professionals’ understanding of SDOH is the inclusion of mental health as a component of physical health and a consequence of SDOH, such as the increased rates of suicidality in low-income schools compared to middle-income schools, the influence of neighborhood poverty on suicide, and the disproportionate amount of young Black men dealing with suicidal ideation.
Ultimately, as Cross said, “Achieving health equity really depends on understanding cultural perceptions as it relates to health. Yes, providing insurance is important, yes, providing education is important, but really understanding how different cultures perceive health systems and the stigma that’s not just related to health care but cultural stigma, as well, really understanding that.” Only through understanding that we are never “done” learning about SDOH, that it must always be a process of continuing education, will we ever have an accurate perspective of everything that comprises SDOH and its importance.
To learn more about SDOH, read more from Healthy People 2030.