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- Social determinants of health are conditions in places where you live, work, learn, and play that can affect a number of health outcomes—including your risk of chronic conditions like diabetes, heart disease, and obesity.
- Generational trauma, or generational challenges passed down within families, can set the stage for adverse childhood events that can make you even more vulnerable to disproportionate health outcomes caused by social determinants of health.
- Addressing the health disparities caused by social determinants of health will require big-picture policy movements, as well as more localized, creative solutions.
For too long, chronic conditions like diabetes and obesity have been framed as outcomes that result only from individual behavior, whether it’s lack of exercise, poor nutrition, inconsistent check-ups at the doctor, or all of the above. But, in reality, social determinants of health—from socioeconomic status to healthcare access—play a much larger role in impacting not just who’s more likely to be diagnosed with these chronic conditions, but also who’s more likely to be successful in managing their condition and achieving positive health outcomes. So, what exactly are social determinants of health, and how do they influence chronic condition risk?
What Are Social Determinants of Health?
According to the Centers for Disease Control and Prevention (CDC), social determinants of health are circumstances in the places where people live, learn, work, and play that affect a wide range of health and quality-of-life risks and outcomes. Think: economic stability, neighborhood safety, housing security, language and literacy skills, domestic violence, air/water quality, as well as access to quality education, healthcare services, nutritious food, safe transportation, and opportunities for physical activity. They’re conditions that are determined by something larger than yourself as an individual.
So, depending on which ones affect you and your life, social determinants of health can contribute to a number of health disparities and inequities. For instance, if your doctor tells you that you need to exercise more, but you live in a snowy climate, can’t afford a gym membership, and your house is too small and cluttered to make space for home workouts, what are you supposed to do? Or, if you live with diabetes, and seeing your endocrinologist requires you to take three different forms of public transportation, resulting in hours-long treks back and forth, and paid time off from work isn’t an option for you, how are you going to stay consistent with those appointments?
In other words, social determinants of health give context to the barriers that you may face when managing your health—barriers that can make all the difference in terms of your health outcomes, whether you’re striving for lower blood sugar or a change in your approach to weight management.
“You can’t take somebody’s context out of their health outcomes,” says Alexandra Coria, MD, a pediatric hospitalist at Maimonides Children’s Hospital and executive director of Maimonides Medical Center Global Health Institute. “It’s impossible to unmarry the two.”
Social Determinants of Health, Generational Trauma, and Chronic Condition Risk
When talking about social determinants of health, it’s crucial to consider not just the present-day circumstances that might influence your health outcomes, but those of your past as well, and how those may have influenced where you stand today.
“There’s this concept of generational trauma, which refers to a history of disenfranchisement and lack of access to resources that afflicts a lot of people who, oftentimes, are descended either from enslaved or ex-colonized people,” explains Dr. Coria. “If someone is descended from one of those populations, and they carry with them the generational build-up of what that history means—for example, lack of economic opportunities, or exposure to systemic racism—their family is now more likely to live in an area with social determinants that can negatively affect their health, such as poor air quality or lack of access to fresh, nutritious food.”
All of these factors then build up to create more toxic stress and disenfranchisement, setting the stage for what are called adverse childhood events (ACEs), continues Dr. Coria. “ACEs are specific childhood events that result from generational trauma,” she explains. “Examples might include child abuse, exposure to parents who are dealing with unmanaged mental illness, domestic violence, or even societal violence in the individual’s community.”
ACEs can further put people at risk for poor health outcomes because, when you’re dealing with stress, all of your body systems are affected, notes Dr. Coria.
For instance, “chronic stress that comes from living in an unsafe environment can cause elevated blood sugar levels,” says One Drop coach, Melinda Washington, a registered dietitian/nutritionist (RDN) and certified diabetes care and education specialist.
Moreover, adds Dr. Coria, “we know that people who are under high stress in their own lives are more likely to develop chronic conditions,” including not just diabetes, but also cancer, heart disease, stroke, and even depression.
While we don’t completely understand why these associations exist, notes Dr. Coria, we know that ACEs are correlated with poor health outcomes in adulthood.
All of that trauma—from one’s own childhood, all the way back to the trauma that happened in generations past—can essentially put some people in a position that’s “behind from the start” in terms of health equity, says Dr. Coria, leaving them at a disadvantage health-wise for the rest of their lives.
The Added Toll of the COVID-19 Pandemic
As the director of complex care management and social determinants of health at MetroPlus Health Plan, a health insurance agency based in New York City, Andrea Zaldivar, Ed.D., MS, ANP-BC, says she’s not only seen the COVID-19 pandemic make existing social determinants of health more extreme (food and housing insecurity, for example), but it has also extended these determinants to new populations.
“As a result of texting campaigns with our members throughout the pandemic, we were made aware that individuals who were historically food-insecure and relied on meals delivered through senior centers and food pantries were now struggling even more because of the COVID-related closures of these locations,” shares Zaldivar. “Additionally, we became aware of members who had never experienced food insecurity nor housing issues, who were now exposed to both because of loss of employment due to the pandemic.”
Even for those who have managed to maintain employment throughout the pandemic, COVID has still taken quite the toll, adds Dr. Coria. “There’s a multitude of factors that have gone into that,” she explains. “One factor is that people who make less money tend to live in closer proximity to one another and tend to work in professions where quarantining and isolation aren’t as easy, putting them at a higher risk of contracting COVID. They also already have a greater burden of chronic conditions, which increases their risk of dying from COVID-related complications.”
However, notes Dr. Coria, it’s worth clarifying that generational trauma (and its links to chronic condition risk and, in turn, COVID-19 complications) “transcends” income and wealth.
“It doesn’t necessarily matter whether people make exactly the same amount of money or even live in the same apartment building,” she explains. “If one person is descended from a formerly enslaved population, for example—and they carry the generational trauma that comes with that—and another person is not, you still may see a difference in their health outcomes,” including how they’re affected by COVID-19.
Addressing Social Determinants of Health and the Disparities They Cause
Considering that social determinants of health are largely outside of the scope of individual influence, what will it take to eliminate the health disparities caused by these determinants?
First, says Dr. Coria, it’s important to distinguish between health equity and health equality. “We don’t want to offer everybody the same package of interventions across the board,” she explains. While health equality would mean giving everyone the same resources, health equity means giving people individualized care that accounts for the unique social determinants that may have put them at a disadvantage with their self-care for most of their lives.
“When you have a community or a family that needs extra help to reach a certain health outcome, you have to provide that extra help,” continues Dr. Coria. “You have to target those services at those individuals, specifically.”
So, where does that extra help come from? Oftentimes, says Dr. Coria, it’s up to federal and state policymakers to have safety nets in place for vulnerable populations, to make certain services, resources, and interventions available to those who need them most, and to ensure that drug pricing isn’t a barrier for people who need medications.
“But it’s not always a matter of policy,” she adds. “For example, smaller, more local interventions, like sliding-scale memberships to gyms, can be helpful for those who otherwise have trouble accessing physical activity opportunities.”
The healthcare community can also play an active role in addressing these disparities early on. For example, the ACEs Aware Initiative in California is a first-in-the-nation effort to train providers to screen people for ACEs, track health outcomes that may be related to these ACEs, and help improve those outcomes as much as possible.
“The California Surgeon General, Dr. Nadine Burke Harris, also recently led a national campaign to address ACEs,” adds Washington. Using public service announcements and social media partnerships, the campaign brought much-needed attention to both the prevalence and long-term effects of ACEs.
According to One Drop coach, Lisa Graham, a CDCES and registered nurse (RN), this type of education is “key,” not just in raising awareness about ACEs and social determinants of health but also in helping those who may be impacted by these disparities learn how they can impact their own lives through small lifestyle changes.
“In some communities, there may be a place that you can go to for health-related information and resources, such as a church, community center, library, public health department, or even small, non-profit organizations in your area,” she explains. “Look for organizations that have boots on the ground, with community leaders who have built relationships and trust with the residents of your community.”
Bottom line: Health equity interventions don’t have to be complicated, says Dr. Coria. “A lot of the work simply involves talking to people about what they need and looking beyond their chronic condition,” she explains. For instance, if you have to measure your blood sugar on your own to manage diabetes, do you understand how to use a blood glucose meter? Do you know what the “mg/dl” unit of measurement means for your blood sugar levels? “Support groups, focus groups, and populated-based research techniques can give us some insight into these questions, including what a community prioritizes and what its barriers are,” says Dr. Coria.
Throughout the month of February, One Drop is focused on raising awareness about the importance of culturally competent healthcare and increasing equity in health technology (a.k.a. “TechQuity”). Be sure to follow our Instagram, Facebook, LinkedIn, and Twitter accounts for more content that will highlight the TechQuity movement and demonstrate how One Drop contributes to the advancement of health equity through our product development and commitment to conducting equitable outcomes research.
This article has been clinically reviewed by Jamillah Hoy-Rosas, MPH, RDN, CDCES, and VP of clinical operations and program design at One Drop, and Dr. Harpreet Nagra, PhD, VP of behavior science and advanced technologies at One Drop.