Advancing health equity: Contemporary perspectives on social and structural determinants of health

Social determinants of health (SDoH) have finally received more attention from the various players in health information, regulatory and payer industries worldwide. This year’s “World Report on Social Determinants of Health Equity” published by the World Health Organization informs us that where we are born, grow, live, work and age, and our access to power, money and resources influence our health outcomes more than genetic influences or healthcare. This is indeed a powerful statement. 

From determinants to drivers: Rethinking health equity

So, what then is the latest with SDoH? Let’s step back to when this all started — SDoH were originally defined back in 2005. There has been a recent shift, starting in the United States, to call these factors social drivers of health to more accurately reflect that health outcomes related to socioeconomic factors aren’t predetermined. As this idea starts to gain ground and the terms begin to be used interchangeably, we are now introducing the concept of structural determinants of health.

Structural factors such as social, economic and political mechanisms surely impact the health of communities. Governing processes, economic and social policies and institutional practices that affect pay, housing, working conditions, education, access to resources, etc., can vary for different populations within a country and also contribute to inequities.

Historical and systemic racism have also contributed to health inequity. Certain populations, such as low-income communities and communities of color, are disproportionately impacted. Consider the vast differences in crime, disease, suicide and incarceration rates for indigenous populations as compared to non-indigenous people in the same geographic area. Access to care is a huge issue in many areas — rurality and transportation issues contribute to this problem, as do other factors like economic stability and health literacy.

The importance of social work

From general access to care to the different players in the care setting, it can sometimes be difficult for patients to navigate the system. While the nurses and doctors address a patient’s clinical concerns, socioeconomic factors were historically only addressed by a social worker. Now there is a vast array of resource workers with different titles – we have community health workers, patient advocates, care navigators, and more — all at different levels of clinical training. Where does this leave the value of the social worker? 

It's important to recognize that many of these job roles are held by individuals with social work degrees either at the BSW or MSW levels and certain positions may require licensing depending on whether the tasks are clinical in nature. In settings where social workers and community health workers differ, it is essential that the professions work together to address the patient's comprehensive needs. 

From the very beginning, the social work profession has been grounded in the community identifying and addressing factors that were social determinants of health. Social work pioneer Jane Addams, who was the first woman to win the Nobel Peace Prize, understood the need to meet people where they live and work in their own communities. What was known as "settlement houses" were essentially community centers that provided social, economic, educational, health, and other services. But they were also instrumental in facilitating political reform and influencing legislation to help those in need so in essence, they addressed those structural determinants of health too.

Of course, health inequities require the community to come together with the patient to address the issues jointly. Community-based organizations (CBOs) like food banks, shelters, etc., play a vital role in shifting the needle. Of late, and more than ever, they are in crisis mode. Pinched food banks, elevated need, and federal cuts mean there’s very little resiliency in the system. A recent example: The U.S. Department of Agriculture cut $500 million from the Emergency Food Assistance Program which buys food from domestic producers and sends it to pantries nationwide. The program has supplied more than 20 percent of the distributions by Feeding America, a nonprofit that serves a network of over 200 food banks and 60,000 meal programs.

The path forward: Data, documentation and community support

Until we can understand how big the problem is, we cannot trend the issues nor design ways to alleviate the inequities. While there is no clear path to a nationwide or global solution, we can take small steps to move us forward. 

First, we need to get the patient’s holistic story in the clinical documentation. This will require our health care systems to shift our focus away from diagnosis to assessing functioning and the environment (essentially, the contextual situation of the patient). Next, we codify the data so we can measure, analyze and report on the issues. Fortunately, there is a classification and coding system called the ICF, International Classification of Functioning, Disability and Health, that will enable us to do so. Lastly, we can plan for and align resources, which can later show the population shift and its needs. Social workers, community health workers, and others will continue to play an instrumental role in connecting patients to resources in their communities. 

Michelle Badore, manager of international clinical development at Solventum. 

Dr. Patricia Welch Saleeby, Ph.D., professor and program director of social work at Bradley University.