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Social Determinants of Health

Last updated April 2019

 

This social determinants of health glossary was produced by the Team Best Practices - Social Determinants Working Group of the Ohio Cardiovascular Collaborative (Cardi-OH). The working group consists of co-directors Adam Perzynski, PhD 1 , 2 and Joseph Sudano Jr. PhD 1 , 2 members, Aaron Clark, DO3 , Colleen Fitzgibbons, MPH3 , Dan Hargraves, MSW4 , Nicholas Horen, MD 5 , Lisa Raiz, PhD 3 , Saundra Regan, PhD 4 , Kristen Rundell, MD3 , Shipra Singh, MD5 and John Daryl Thornton, MD1 ,2 and contributor Kristen Berg, PhD1

1. Case Western Reserve University 2. The MetroHealth System 3. The Ohio State University
4. University of Cincinnati 5. University of Toledo

 

Introduction to the Cardi-OH SDOH Glossary

In recent years the need to address social determinants of health (SDOH) has been clearly recognized by health care payers, patients, health professionals and provider organizations. For example, in Ohio a needs assessment conducted by Cardi-OH in 2019 found that that a majority of care providers surveyed were either extremely interested or very interested learning more about social determinants of health. In addition, 89% stated that it was extremely or very important to screen for social determinants of health in clinical care. However, only 14% were confident in their practice site’s ability to address social determinants. As a starting point for facilitating growth and learning, experts from CARDI-OH’s Team Best Practices convened to create the set of SDOH concepts and definitions in this glossary. The glossary serves as a shared communication resource for efforts to disentangle concepts, plan initiatives, have discussions and take action to meet the social needs of patients. The glossary is not intended to be a comprehensive list of all possible social determinants, but rather a summary of key concepts, factors and social needs that have some relationship with etiology, prevention, outcomes and/or management of cardiovascular disease.

 

Conditions in the environments in which 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.

Reference: (Healthy People 2020, 2018)

View our Executive Summary for more information.

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. The World Health Organization further describes addiction as a social determinant of health, "Drug use is both a response to social breakdown and an important factor in worsening the resulting inequalities in health." Alcohol and substance use are associated with lower socioeconomic status. This is in part a result of substances and alcohol used as a coping mechanism and becomes cyclical and intensified when addiction and dependence becomes the source of diminished opportunities and lesser quality of life. (WHO 2003)

References:

American Society of Addiction Medicine. (2011). Definition of Addiction. Available: https://www.asam.org/resources/definition-of-addiction

World Health Organization, SDH: The Solid Facts; Second Edition, 2003

Most educators today consider literacy to include more than just the ability to read.  They often consider literacy to also include writing, basic mathematical calculations and speech and speech comprehension skills, with reading and writing collectively called “print literacy”, math skills “numeracy”, and speech and speech comprehension “oral literacy.” Further differentiations among these terms also exist such as basic print literacy, literacy for different types of text and functional literacy. These terms have implications for our definition of “health literacy” that follows.

References:

Baker, D.W., Williams, M.V., Parker, R.M., Gazmararian, J.A., Nurss, J. (1999). Development of a brief test to measure functional health literacy. Patient Educ Couns, 38(1):33-42.

Davis, T., Long, S., Jackson, R., Mayeaux, E., George, R., Murphy, P., & Crouch, M. (1993). Rapid Estimate of Adult Literacy in Medicine: A shortened screening instrument. Family Medicine, 25, 391–395.

Lee, S.Y., Bender, D.E., Ruiz, R.E., & Cho, Y.I. (2006). Development of an easy-to-use Spanish Health Literacy test. Health Serv Res, 41(4 Pt 1):1392-412.

Parker, R., Baker, D., Williams, M., & Nurss, J. (1995). The test of functional health literacy in adults: A new instrument for measuring patients’ health literacy. Journal of General Internal Medicine, 10, 537–541.

Ratzan SC, Parker RM. 2000.  Introduction. In: National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, Editors. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services

 

Culture is the blended patterns of human behavior that include "language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups." Cultural competence is "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations." "Competence" in the term cultural competence implies that an individual or organization has the capacity to function effectively "within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities."

References:

U.S. Department of Health and Human Services, What is Cultural Competency? Office of Minority Health (HHS).

Cultural humility is a process oriented approach or stance toward persons of different cultures and backgrounds. Cultural humility is characterized by an open-ended commitment to understand the varied cultural perspectives of others. The practice of cultural humility also includes the aspiration of being a partner and/or advocate for persons with diverse racial, ethnic and cultural backgrounds.

References:

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Undeserved, 9, 117-125.

The blended patterns of human behavior that include "language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups."

References:

U.S. Department of Health and Human Services, What is Cultural Competency?, Office of Minority Health (HHS).

 

The Americans with Disabilities Act (ADA) became law in 1990. The ADA is a civil rights law that prohibits discrimination against individuals with disabilities in all areas of public life, including jobs, schools, transportation, and all public and private places that are open to the general public. In the context of the ADA, “disability” is a legal term rather than a medical one. The ADA defines a person with a disability as a person who has a physical or mental impairment that substantially limits one or more major life activity. This includes people who have a record of such impairment, even if they do not currently have a disability. The ADA also makes it unlawful to discriminate against a person based on that person’s association with a person with a disability.

The definition of disability under Social Security is different from ADA. Social Security pays only for total disability, not for partial disability or for short-term disability. Disability under Social Security refers to:

  • You cannot do work that you did before
  • Social security administration decides that you cannot adjust to other work because of your medical condition(s)
  • Your disability has lasted or is expected to last for at least one year or to result in death.

The Social Security Administration (SSA) maintains a "Listing of Medical Impairments” that automatically qualifies a person for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), provided certain conditions are met.

References:

The health benefits of education accrue at the individual level (e.g., skill development and access to resources); the community level (e.g., the health-related characteristics of the environments in which people live); and the larger social/ cultural context (e.g., social policies, residential segregation, and unequal access to educational resources). All of these upstream factors may contribute to health outcomes, while factors such as ability to navigate the health care system, educational disparities in personal health behaviors, and exposure to chronic stress act as more proximate factors. It is also important to consider the impact of health on educational attainment and the conditions that occur throughout the life course that can impact both health and education"

References:

https://www.ahrq.gov/professionals/education/curriculum-tools/population-health/zimmerman.html

Employment status consists of three categories: employed, unemployed, and inactive. The employed group included only those who reported being in paid work including self-employment, and either full or part time. The unemployed group consists of those who were not in paid work but were looking for work or intending to look for a job but were prevented by temporary sickness or injury or who were waiting to take up a job. The inactive were those who were neither in work nor looking for work but who were permanently unable to work or who had already taken retirement (Bartley & Owen, 1996).

References:

Bartley, M., & Owen, C. (1996). Relation between socioeconomic status, employment, and health during economic change, 1973-93. Bmj, 313(7055), 445-449.

The traditional family structure in the United States is considered a family support system involving two married individuals providing care and stability for their biological offspring. However, this two-parent, nuclear family has become less prevalent, and alternative family forms have become more common (Edwards, 1987). The family is created at birth and establishes ties across generations. Those generations, the extended family of aunts, uncles, grandparents, and cousins, can hold significant emotional and economic roles for the nuclear family. Over time, the traditional structure has had to adapt to very influential changes, including divorce and the introduction of single-parent families, teenage pregnancy and unwed mothers, and same-sex marriage, and increased interest in adoption. Social movements such as the feminist movement and the stay-at-home dad have contributed to the creation of alternative family forms, generating new versions of the American family.

References:

Edwards, H.N. (1987). Changing family structure and youthful well-being. Journal of Family Issues 8, 355–372

Interpersonal violence has been defined as “the intentional use of physical force or power against another person that can result in injury, death, psychological harm, maldevelopment, or deprivation” (Suglia et al). Intimate partner violence includes physical, sexual, psychological or stalking violence by a current or former intimate partner that is actual or threatened (Thompson et al., 2006). Measurement of intimate partner violence can include: physical victimization, sexual victimization, psychological/emotional victimization and stalking victimization (Thompson et al.). Intimate partner violence has been associated with negative physical and psychological health outcomes (Thompson et al.). Family violence can be represented in different ways. There is recognition that the effects of violence vary by the lifecourse stage in which it is experienced (Suglia et al.). Child abuse and neglect are acts of commission or omission and may be perpetrated by a parent or caregiver resulting in “harm, potential harm or the threat of harm to a child” (CDC, nd). The association between childhood violence exposure and the development of cardiovascular risk factors has been documented consistently (Suglia et al.). Elder abuse also may be an act of commission or omission by a caregiver or trusted other (CDC, 2016). Types of elder abuse include: physical, sexual, emotional or psychological, neglect and financial (CDC). An association between elder abuse and negative health outcomes has been reported which includes evidence suggesting that it may be associated with cardiovascular related mortality (Dong and Simon, 2015).

References:

Suglia, S.F., Sapra, K.J. & Koenen, K.C. (2015). Violence and cardiovascular health. Am J Prev Med, 48(2), 205-212.

 

Thompson, M.P., Basile, K.C., Hertz, M.F. & Sitterle, D. (2006). Measuring intimate partner violence victimization and perpetration: A compendium of assessment tools. Atlanta (GA). Centers for Disease Control and Prevention. National Center for Injury Prevention Control.

 

Centers for Disease Control (nd). Child abuse and neglect: Definitions. Retrieved from

              https://www.cdc.gov/violenceprevention/childabuseandneglect/definitions.html

 

Centers for Disease Control (2016). Understanding elder abuse. Retrieved from

            https://www.cdc.gov/violenceprevention/pdf/em-factsheet-a.pdf

 

Dong, X. & Simon, M. (2015). Association between elder abuse and metabolic syndromes: Findings from The Chicago Health and Aging Project. Gerontology, 61), 389-398.

Food deserts are defined as parts of the country vapid of fresh fruit, vegetables, and other healthful whole foods, usually found in impoverished areas. This is largely due to a lack of grocery stores, farmers’ markets, and healthy food providers. This has become a big problem because food deserts are often short on whole food providers, especially fresh fruits and vegetables, but are heavy on local quickie marts that provide a wealth of processed, sugary, and fat laden foods that are known contributors to our nation’s obesity epidemic.

References:

http://www.countyhealthrankings.org/rankings/data/OH            

https://familydoctor.org/neighborhood-navigator/                         

http://americannutritionassociation.org/newsletter/usda-defines-food-deserts

Food insecurity is the household-level economic and social condition of limited or uncertain access to adequate food.  In its Healthy People 2020 initiative, the Department of Health and Human Services, Office of Disease Prevention and Health Promotion set a goal of reducing household food insecurity from a baseline of 14.6 in 2008 to a target of 6 percent by the year 2020.

References:

http://www.countyhealthrankings.org/rankings/data/OH            

https://familydoctor.org/neighborhood-navigator/                         

http://americannutritionassociation.org/newsletter/usda-defines-food-deserts

Gender is a construct of biological, psychosocial, and cultural factors generally used to classify individuals as male or female. Transgender is an inclusive term to describe people who have gender identities, expressions, or behaviors not traditionally associated with their birth sex (Mayer, et al., 2008).

References:

Mayer, Kenneth & Bradford, Judith & Makadon, Harvey & Stall, Ron & Goldhammer, Hilary & Landers, Stewart. (2008). Sexual and Gender Minority Health: What We Know and What Needs to Be Done. American journal of public health. 98. 989-95. 10.2105/AJPH.2007.127811.

Access to health services is a fundamental part of whether people can be healthy.  Access can influence physical and mental health, and a person’s overall quality of life. Care access can be further subdivided into insurance coverage, availability of health services and timeliness of care. Access can be overlapping with other social determinants. For example, transportation constraints can influence timeliness and language differences can influence availability. Having consistent access to a usual source of primary care services has been found to be critically important for health across a wide range of diseases, health conditions and personal characteristics (IOM; Starfield).

References:

Access and Disparities in Access to Health Care [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; May 2016. Available from: http://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/access.html

Institute of Medicine. Primary care: America's health in a new era. Donaldson MS, Yordy KD, Lohr KN, editors. Washington, DC: National Academies Press; 1996.

Starfield B, Shi L, Machinko J. Contribution of primary care to health systems and health. The Milbank Quarterly. 2005;83(3):457-502

Distinct from the more general concept of health disparity, health care disparities are differences that exist between groups in the access, process, quality and coverage of health care and health services.

References:

U.S. Department of Health and Human Services. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020 [Internet]. Section IV: Advisory Committee findings and recommendations [cited 2010 January 6]. Available from: http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf

Whitehead M. The concepts and principles of equity and health. Int J Health Serv. 1992;22:429–45.

Also known as “health inequalities” in most other countries, a simple definition comes from Margaret Whitehead (1992) in the United Kingdom and reads “health differences that are avoidable, unnecessary and unjust”.  A more detailed and nuanced definition comes from US Department of Health and Human Services (2010) via the Healthy People 2020 and 2030 Initiative.  It reads: “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”

Please note that health disparities are not the same as health differences. For example, there are health differences between old and young people, but these are not necessarily “disparities”.  Similarly, there maybe differences between sport participants (knee, elbow, shoulder problems) and those not participating, and these are not “disparities”.  Disparities again arise from differences affecting disadvantaged groups and the differences are typically recognized as unjust.

            Finally, recognize that “health disparities” are a distinct concept from “healthcare disparities”.  The latter have to do specifically with disparities that arise as a result of individuals’ interactions with the health care system, although many of the same forces that drive health disparities are also operational in creating health care disparities.

References:

U.S. Department of Health and Human Services. The Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I report: Recommendations for the framework and format of Healthy People 2020 [Internet]. Section IV: Advisory Committee findings and recommendations [cited 2010 January 6]. Available from:http://www.healthypeople.gov/sites/default/files/PhaseI_0.pdf

Whitehead M. The concepts and principles of equity and health. Int J Health Serv. 1992;22:429–45.

Having affordable health insurance enables individuals to receive care in the United States health care system. Persons who lack health insurance coverage get diagnosed at later disease stages, often receive lower quality medical care, have difficulty paying for health services and prescriptions, and may forego needed care. Lack of insurance can further lead to a higher rate of adverse health events and premature death from causes like cardiovascular disease. Persons without insurance coverage are far less likely to receive the benefits of services that can prevent costly and debilitating health problems. Even temporary lack of coverage can be detrimental.

 

References:

Hadley J. Insurance coverage, medical care use, and short-term health changes following an unintentional injury or the onset of a chronic condition. JAMA. 2007;297(10):1073-84.

Institute of Medicine. Insuring America's health: Principles and recommendations. Acad Emerg Med. 2004;11(4):418-22.

Sudano Jr, J. J., & Baker, D. W. (2003). Intermittent lack of health insurance coverage and use of preventive services. American Journal of Public Health, 93(1), 130-137.

Baker, D. W., Sudano, J. J., Albert, J. M., Borawski, E. A., & Dor, A. (2001). Lack of health insurance and decline in overall health in late middle age. New England Journal of Medicine, 345(15), 1106-1112.

A definition of health literacy includes all of the elements mentioned above in our definition of basic literacy. An operational definition of health literacy developed for the National Library of Medicine and used by the Healthy People 2010-2030 Initiatives is instructive and should suffice for the purposes of this glossary: “The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions (Ratzan and Parker, 2000).”

Here follows just some of the skills related to health literacy that are needed for health, healthcare, and health system interactions from the National Institute of Medicine: 1) Promote and protect health and prevent disease; 2) Understand, interpret, and analyze health information; 3) Apply health information over a variety of life events and situations; 4) Navigate the health care system (insurance forms, enrollment, rights and responsibilities, etc.); 5) Actively participate in encounters with healthcare providers and workers; 6) Understand and give consent; 7) Understand and advocate for rights.

Finally, here are a few of the measures used in health literacy research:

1) Rapid Estimate of Adult Literacy in Medicine (REALM; Davis et al., 1993); 2) the Test of Functional Health Literacy in Adults (TOFHLA; Parker et al., 1995); 3) the Short Test of Functional Health Literacy in Adults (S-TOFHLA; Baker et al., 1999); 4) and the Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50; Lee et al., 2006).

References:

Baker, D.W., Williams, M.V., Parker, R.M., Gazmararian, J.A., Nurss, J. (1999). Development of a brief test to measure functional health literacy. Patient Educ Couns, 38(1):33-42.

Davis, T., Long, S., Jackson, R., Mayeaux, E., George, R., Murphy, P., & Crouch, M. (1993). Rapid Estimate of Adult Literacy in Medicine: A shortened screening instrument. Family Medicine, 25, 391–395.

Lee, S.Y., Bender, D.E., Ruiz, R.E., & Cho, Y.I. (2006). Development of an easy-to-use Spanish Health Literacy test. Health Serv Res, 41(4 Pt 1):1392-412.

Parker, R., Baker, D., Williams, M., & Nurss, J. (1995). The test of functional health literacy in adults: A new instrument for measuring patients’ health literacy. Journal of General Internal Medicine, 10, 537–541.

Ratzan SC, Parker RM. 2000.  Introduction. In: National Library of Medicine Current Bibliographies in Medicine: Health Literacy. Selden CR, Zorn M, Ratzan SC, Parker RM, Editors. NLM Pub. No. CBM 2000-1. Bethesda, MD: National Institutes of Health, U.S. Department of Health and Human Services.

Housing has a powerful influence on a person’s health in two connected areas: affordability and quality. Affordability refers to whether a person has access to a place to live that they are able to afford. Low availability of affordability housing creates a cascade of a challenges that ultimately influence health. Housing quality can refer to the conditions of a person’s home and the neighborhood or area in which that home resides. Indoor issues include lead, air quality, mold, asbestos and general safety concerns like poor lighting and unsafe stairways. The layout and design of buildings can have important health consequences for older adults and persons with disabilities. Poor quality housing has been associated with higher rates of injury, chronic disease, poor nutrition and mental illness (Krieger).

References:

Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002;92(5):758-68.

Office of the Surgeon General. The Surgeon General's Call to Action to Promote Healthy Homes. Rockville (MD): Office of the Surgeon General; 2009.

Jacobs DE, Wilson J, Dixon SL, Smith J, Evens A. The relationship of housing and population health: a 30-year retrospective analysis. Environ Health Perspect. 2009;117(4):597-604. doi: 10.1289/ehp.0800086

Lloyd E. The role of cold in ischaemic heart disease: a review. Public Health. 1991;105:205-215.

Useful and beneficial health information technologies are continuing to grow rapidly. Patient portals and electronic health records are in nearly every doctors’ office in the United States. Patients can message clinicians, schedule appointments, review lab results, refill prescriptions, and monitor health changes. Recent research has clearly demonstrated a digital divide in access to these new technologies. Community and individual gaps exist in the availability of internet access, internet enabled devices and the digital skills required to take advantage of new health information technologies. Many individuals who lack digital skills or connectivity are systematically excluded from the benefits of these new advances. Research has demonstrated important health promoting benefits of patient portals, and that these benefits are systematically unavailable to persons on the wrong side of the digital divide (Sarkar et al; Perzynski et al).

References:

Perzynski AT, Roach MJ, Shick S, Callahan B, Gunzler D, Cebul R, Kaelber DC, Huml A, Thornton JD, Einstadter D. Patient portals and broadband internet inequality. Journal of the American Medical Informatics Association. 2017 Sep 1;24(5):927-32.

Sarkar U, Lyles CR, Parker MM, Allen J, Nguyen R, Moffet HH, Schillinger D, Karter AJ. Use of the refill function through an online patient portal is associated with improved adherence to statins in an integrated health system. Medical care. 2014 Mar;52(3):194.

Intersectionality is a theoretical framework that posits that multiple social categories (e.g., race, ethnicity, gender, sexual orientation, socioeconomic status) intersect at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (e.g., racism, sexism, heterosexism).

References:

Bowleg L. The Problem With the Phrase Women and Minorities: Intersectionality—an Important Theoretical Framework for Public Health. American Journal of Public Health. 2012;102(7):1267-1273. doi:10.2105/AJPH.2012.300750.

First, a few simple definitions from various dictionaries around the globe. From the Oxford Living Dictionary: “The method of human communication, either spoken or written, consisting of the use of words in a structured and conventional way,” and “A system of communication used by a particular country or community.”  From the Collins English Dictionary: “human speech and the ability to communicate by this means; a system of vocal sounds and combinations of such sounds to which meaning is attributed, used for the expression or communication of thoughts and feelings and the written representation of such a system.”

Now, let us wax philosophically and address how language might be related to SDOH.  Here are a few quotations that introduce this topic. From E. M. Cioran, Anathemas and Admirations: “One does not inhabit a country; one inhabits a language. That is our country, our fatherland, and no other” And similarly From Heidegger, “Language is the house of being.” Both of these quotes and what they tell us about language suggest two essential elements of the communication process and what language means regarding health. Language is more than just words or a system of words, it literally is a mechanism of cultural transmission. To the extent that individuals have learned and speak different languages, their “worlds” are different and this has significant implications for issues such as cultural competence in health care. Health care providers and the health care system should be aware of this critical component of language as related to social determinants of health.  It is within language that people live their lives and true communication, understanding, transmission of meaning, and issues of decision making between folks who speak different languages is not as simple as translation or interpretation…a “world of culture” lies between different language speakers.  Language is also implicated in other terms such as health literacy. Awareness of this issue is the starting point for addressing SDOH related to language.

References:

Research suggests that LGBT individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights. Discrimination against LGBT persons has been associated with high rates of psychiatric disorders, (McLaughlin, et al., 2010) substance abuse (Ibanez, et al., 2005) and suicide (Remafedi, et al., 1998). Experiences of violence and victimization are frequent for LGBT individuals, and have long-lasting effects on the individual and the community (Roberts AL, et al., 2010). Personal, family, and social acceptance of sexual orientation and gender identity affects the mental health and personal safety of LGBT individuals (USDHHS).

References:

McLaughlin KA, Hatzenbuehler ML, Keyes KM. Responses to discrimination and psychiatric disorders among black, Hispanic, female, and lesbian, gay, and bisexual individuals. Am J Public Health. 2010;100(8):1477-84.

Mental health is critical to individuals’ global health and well-being across every stage of human development. The World Health Organization (WHO) defines mental health as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” Importantly, the Centers for Disease Control specifies the functional importance of a person’s mental health, highlighting that mental health determines how individuals “handle stress, relate to others, and make healthy choices.”

Of note, some scholars highlight concern for the potential misunderstanding of the common definitional component of positive functioning (i.e., “well-being”), underscoring that part of living a full human life entails dynamic states of sadness, anger, unhappiness, or being unwell. As such, Galderisi et al (2015) re-define mental health as a “dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with universal values of society”, specifying that examples of “universal values” include “respect and care for oneself and other living beings; recognition of connectedness between people; respect for the environment; respect for one's own and others' freedom.” Galderisi et al (2015) identify the following components of mental health that cause variation in an individual’s state of internal equilibrium: “Basic cognitive and social skills; ability to recognize, express and modulate one's own emotions, as well as empathize with others; flexibility and ability to cope with adverse life events and function in social roles; and harmonious relationship between body and mind.”

References:

Galderisi S, Heinz A, Kastrup M, Beezhold J, Sartorius N. Toward a new definition of mental health. World Psychiatry. 2015;14(2):231-233.

Mental Health: A State of Well-Being [Internet]. World Health Organization. Available from: https://www.who.int/features/factfiles/mental_health/en/

Mental Health [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; January, 2018. Available from: https://www.cdc.gov/mentalhealth/index.htm

Neighborhood deprivation and area deprivation are closely related concepts that summarize the extent of vulnerability or disadvantage in a neighborhood or geographic area. Multiple indices have been created that describe a neighborhood's or areas potential for health risk. Such indices typically included multiple measures such as education, poverty, family structure and material resources.

References:

Singh, G. K. (2003). Area deprivation and widening inequalities in US mortality, 1969–1998. American journal of public health, 93(7), 1137-1143.

Occupational prestige is based on a collective perception of the value or social standing inherent to a particular professional activity. Thus occupational prestige is synonymous with the recognition and respect that society accords a person because of their occupation as a reward for their services to the community (Ganzeboom, De Graaf, Treiman & de Leeuw, 1992).

References:

Ganzeboom, H.B.G., P.M. De Graaf, D.J. Treiman & J. de Leeuw, 1992: A Standard International Socio-Economic Index of Occupational Status. In: Social Science Research 21, pp. 1-56.

Occupational status is one component of socioeconomic status (SES), summarizing the power, income and educational requirements associated with various positions in the occupational structure (Burgard, Stewart & Schwartz, 2003). It reflects the outcome of educational attainment, provides information about the skills and credentials required to obtain a job, and the associated monetary and other rewards. Finally, occupational status is also a promising measure of social position that can provide information about job characteristics, such as environmental and working conditions, decision-making latitude, and psychological demands of the job.

References:

Burgard, S, Stewart, J. & Schwartz, J. (2003). MacArthur research network on socioeconomic status and health: Occupation status. Retrieved from https://macses.ucsf.edu/research/socialenviron/occupation.php

Absolute poverty was defined as: a condition characterized by severe deprivation of basic human needs, including food, safe drinking water, sanitation facilities, health, shelter, education and information. It depends not only on income but also on access to services.  Census Bureau uses a set of money income thresholds that vary by family size and composition to determine who is in poverty. If a family's total income is less than the family's threshold, then that family and every individual in it is considered in poverty. The official poverty thresholds do not vary geographically, but they are updated for inflation using the Consumer Price Index (CPI-U). The official poverty definition uses money income before taxes and does not include capital gains or noncash benefits (such as public housing, Medicaid, and food stamps).

References:

https://www.census.gov/topics/income-poverty/poverty/guidance/poverty-measures.html

Crime and violence is one of the SDOH identified by Healthy People 2020 and falls within the Neighborhood and Built Environment area. Neighborhood disadvantage has been found to be associated with a number of health conditions, including hypertension (Cockerham, Hamby & Oates, 2016). Fear, crime and personal safety have been identified as components within neighborhood disadvantage (Cockerham et al). The MESA Neighborhood Study has reported an association between select dimensions of neighborhood environments, including public safety and violence, and the progression of subclinical cardiovascular disease to cardiovascular disease (Diez Roux, A.V. et al., 2016).

References:

Cockerham, W.C., Hamby, B.W. & Oates, G.R. (2016). The social determinants of chronic disease. Am J Prev Med, 52(1S1), S5-S12.

Diez Roux, A.V., Mujahid, M.S., Hirsch, J.A., Moore, K,K & Moore, L.V. (2016). The impact of neighborhoods on cardiovascular risk: The MESA Neighborhood Study. Glob Heart, 11(3), 353-363.

Racism is a system of beliefs and practices that serves to reinforce the power and well-being of whites at the expense of people of color. Discrimination is the practice of exclusion or differing treatment based on one or more of an individual's specific characteristics, including race. In specific regards to health, racism and discrimination may impact, among other things: (1) educational attainment, thus influencing wages/income, quality of life, and access to care; (2) levels of stress. Experiences of racism has been linked with biomarkers of stress, and also associated with areas of the brain consistent with social exclusion; (3) coping mechanisms including alcohol and substance use disorder, as a result of discrimination, social exclusion, and overall diminished quality of life.

References:

Gee, G. Leveraging the Social Determinants of Health to Build a Culture of Health: Racism as a Social Determinant of Health, 2016

Recreation refers to activities of leisure (i.e., done during discretionary time) for purposes of pleasure or enjoyment. Leisure and recreation management scholar George Torkildsen offers the following definition:

“In its purest sense, recreation is re-creation—an inner consuming experience that leads to revival of the senses and the spirit. In this sense recreation renews, restores and recharges the batteries” (pp 13–14).

Following Torkildsen’s conceptual definition, research broadly suggests that recreation is key to individuals’ physical, mental, and social health (see Maller, Townsend, Pryor, Brown, & St Leger, 2006). Healthy People 2020 discusses that both social and physical factors about the places in which groups of people live that combine to designate access to recreation space as a SDOH. For example, Healthy People 2020 identifies “neighborhood and built environment” as one of five key areas of SDOH. Within this domain, the presence of natural spaces such as trees, grass, and other green space, as well as built environment features such as sidewalks, bike lanes, or physical infrastructure for neighborhood recreation centers are examples of physical determinants that affect individuals’ and families’ recreation opportunities and thus their health. Social determinants, such as community violence or disorder, can determine whether or not such resources are safe to access and thus true opportunities for families and individuals to take advantage of. Disparate access to recreation resources and opportunities, then, can be a source of health inequity.

References:

Maller C, Townsend M, Pryor A, Brown P, St Leger L. Healthy nature healthy people: Contact with nature as an upstream health promotion intervention for populations. Health Promot Int, 2006;21(1):45-54.

Office of Disease Prevention and Health Promotion. Determinants of Health [Internet]. Available from: https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health

Torkildsen G. Leisure and recreation management. 4th ed. New York, NY: Routledge; 2012.

Safety broadly refers to an individual’s or entity’s condition of being protected from danger, harm, or risk. Safety may be transmitted through various social determinants of health such as substandard housing (e.g., inadequate heat or the presence of lead may create unsafe residential environments for children or pregnant women), neighborhood disorder (e.g., the presence of firearm violence, criminal activity, exposed garbage or litter, unsafe outdoor play spaces may pose risk to residents), or under-resourced communities or municipalities (e.g., damaged and unsafe infrastructure, over-taxed or under-resourced law enforcement may pose danger to residents’ physical or mental health). 

References:

National League of Cities. Advancing a Culture of Health in Cities: Understanding the Factors the Influence Health Where We Live, Learn, Work & Play [Internet]. Available from: http://www.healthycommunitieshealthyfuture.org/learn-the-facts/social-determinants-of-health/

Office of Disease Prevention and Health Promotion. Determinants of Health [Internet]. Available from: https://www.healthypeople.gov/2020/about/foundation-health-measures/Determinants-of-Health

Segregation is: the separation or isolation of a race, class, or ethnic group by enforced or voluntary residence in a restricted area, by barriers to social intercourse, by separate educational facilities, or by other discriminatory means. In regards to SDOH, segregation (or social exclusion) impacts health through diminished quality of life and a life of social and economic poverty. This can result in limited or no access to housing, education, reliable transportation, services and networks, among other factors associated with higher quality of life. This increases stress and over time can exacerbate physical health problems such as cardiovascular disease. As with other SDOH that are rooted in social exclusion, segregation can result in increased substance and alcohol use as a coping mechanism, as well as higher rates of divorce, illnesses and disability.

References:

World Health Organization, SDH:The Solid Facts; Second Edition, 2003

Sexual and Gender Minority is an umbrella term that encompasses lesbian, gay, bisexual, and transgender populations as well as those whose sexual orientation, gender identity and expressions, or reproductive development varies from traditional, societal, cultural, or physiological norms. This includes individuals with disorders or differences of sex development (DSD), sometimes known as intersex (National Institutes of Health).

References:

National Institutes of Health, Sexual and Gender Minority Research Office (SGMRO). https://dpcpsi.nih.gov/sgmro

Sexual orientation incorporates three core ideas. First, sexual orientation is about intimate human relationships—sexual, romantic, or both. These relationships can be actualized through behavior or can remain simply an object of desire. Second, the focus of sexual orientation is the biological sex of a person's actual or potential relationship partners—that is, people of the same sex as the individual, people of the other sex, or people of either sex. Third, sexual orientation is about enduring patterns of experience and behavior. A single instance of sexual desire or a single sexual act generally is not regarded as defining an individual's sexual orientation (Institute of Health, 2011).

References:

National Institutes of Health, Sexual and Gender Minority Research Office (SGMRO). https://dpcpsi.nih.gov/sgmro

Social class is a social category referring to social groups forged by interdependent economic and legal relationships, premised upon people’s structural location within the economy—as employers, employees, self-employed, and unemployed, and as owners, or not, of capital, land, or other forms of economic investments; possession of educational credentials and skill assets also contribute to social class position (Kreiger, et al., 1997).

References:

Krieger N, Williams D R, Moss N E. Measuring social class in US public health research: concepts, methodologies, and guidelines. Annu Rev Public Health 199718341–378.

Both the World Health Organization and Healthy People 2020 recognize social support as a social determinant of health (Holt-Lunstad, Sbarra and Robles, 2017). Research has examined the relationship between social support and management of stressful life events, illness and treatment adherence (Heitzmann and Kaplan, 1988) and its association with health has been documented (Holt-Lunstad et al.). Social support has been defined as “The social resources that persons perceive to be available or that are actually provided to them in the context of both formal support groups and informal helping relationships” and can include “…emotional, instrumental, informational, companionate and esteem support” (Gottlieb and Bergen, 2010). Both tangible and intangible dimensions of social support exist (Heitzmann and Kaplan). “Social connection” (Holt-Lundstad et al.) and “social capital” (Cockerham, Hamby & Oates, 2016) represent additional constructs to examine interpersonal relationships and their association with health. Diverse methods can be employed to measure social support and selection of a measurement strategy should be deliberate. It also is critical to recognize that social support must be examined with respect for cultural diversity (Gottlieb and Bergen). The social relationships that comprise social support may have a direct effect on health or an indirect effect by buffering against stressors that may impact health (Bell, Thorpe Jr. & LaVeist, 2010).

References:

Holt-Lunstad, J., Sbarra, D.A. & Robles, T.F. (2017). Advancing social connection as a public health priority in the United States. American Psychologist, 72(6), 517-530.

 

Heitzmann, C.A. & Kaplan, R.M. (1988). Assessment of methods for measuring social support. Health  Psychology, 7(1), 75-109.

 

Gottlieb, B.H. & Bergen, A.E. (2010). Social support concepts and measures. Journal of Psychosomatic Research, 69, 511-520.

 

Cockerham, W.C., Hamby, B.W. & Oates, G.R. (2016). The social determinants of chronic disease. Am J  Prev Med, 52(1S1), S5-S12.

 

Bell, C.N., Thorpe Jr., R.J. & LaVeist, T.A. (2010). Race/ethnicity and hypertension: The role of social support. Am J Hypertens, 23(5), 534-540.

Socioeconomic position refers to the social and economic factors that influence what positions individuals or groups hold within the structure of a society. Socioeconomic position is an aggregated concept that includes both resource-based and prestige-based measures, as linked to both childhood and adult social class position. Resource-based measures refer to material and social resources and assets, including income, wealth, educational credentials; terms used to describe inadequate resources include “poverty” and “deprivation.” Prestige-based measures refer to individual’s rank or status in a social hierarchy, typically evaluated with reference to people’s access to and consumption of goods, services, and knowledge, as linked to their occupational prestige, income, and education level (Kreiger, et al., 1997).

References:

Krieger N, Williams D R, Moss N E. Measuring social class in US public health research: concepts, methodologies, and guidelines. Annu Rev Public Health 199718341–378.

Socioeconomic status is "a composite measure that typically incorporates economic status, measured by income; social status, measured by education; and work status, measured by occupation" (Adler, et al., 1994; Dutton & Levine, 1989). Although these dimensions of SES are interrelated, it has been proposed that each reflects somewhat different individual and societal forces associated with health and disease. For example, income reflects spending power, housing, diet, and medical care; occupation measures prestige, responsibility, physical activity, and work exposures; and education indicates skills requisite for acquiring positive social, psychological, and economic resources (Winkleby, et al., 1992). 

References:

Winkleby, M. A., Jatulis, D. E., Frank, E., & Fortmann, S. P. (1992). Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. American journal of public health, 82(6), 816-820.

Adler, N. E., Boyce, T., Chesney, M. A., Cohen, S., Folkman, S., Kahn, R. L., & Syme, S. L. (1994). Socioeconomic status and health: the challenge of the gradient. American psychologist, 49(1), 15.

Dutton, D. B., & Levine, S. (1989). Overview, methodological critique, and reformulation. In J. P. Bunker, D. S. Gomby, & B. H. Kehrer (Eds.), Pathways to health (pp. 29-69). Menlo Park, CA: The Henry J. Kaiser Family Foundation.

Healthy People 2020 highlights transportation options as a social determinant of health. In this sense, transportation refers to the systems and vehicles by which people and families may transport themselves from one location to another. This also includes infrastructure amenable to travel to daily commitments (e.g., work) or appointments (e.g., medical care) such as accessible public transportation like bus or rail routes. Transportation-related issues also include lack of access to such resources:

“Transportation issues include lack of vehicle access, inadequate infrastructure, long distances and lengthy times to reach needed services, transportation costs and adverse policies that affect travel. Transportation challenges affect rural and urban communities.

“Because transportation touches many aspects of a person’s life, adequate and reliable transportation services are fundamental to healthy communities. Transportation issues can affect a person’s access to health care services. These issues may result in missed or delayed health care appointments, increased health expenditures and overall poorer health outcomes. Transportation also can be a vehicle for wellness. Developing affordable and appropriate transportation options, walkable communities, bike lanes, bike-share programs and other healthy transit options can help boost health. This guide outlines transportation issues and the impact on health and health care access.”

References:

http://www.hpoe.org/resources/ahahret-guides/3078

According to the U.S. Department of Veterans Affairs and Cornell University’s Legal Information Institute, a veteran is “a person who 1) served in the active military, naval or air service, and 2) was discharged or released under conditions other than dishonorable”.

References:

Legal Information Institute, Cornell University. 38 U.S. Code § 101 – Definitions [Internet]. Available from: https://www.law.cornell.edu/uscode/text/38/101

The Ohio Cardiovascular Health Collaborative is funded by the Ohio Department of Medicaid and administered by the Ohio Colleges of Medicine Government Resource Center. The views expressed in this document are solely those of the authors and do not represent the views of the state of Ohio or federal Medicaid programs.

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