social elements of disability

1. Social Determinants of Health:
The Basics
Gwendolyn A. Daniels, DNP, RN IPH Healthy Start Director

2. Overview of Training Modules
1. Terminology
2. Data and Context
3. Field Examples

3. Background
• WHO Commission on SDOH
www.who.int/social_determinants/thecommission/en/index.html
• Unnatural Causes documentary
www.unnaturalcauses.org/
• NACCHO Health Equity and Social Justice Committee
www.naccho.org/topics/justice/mission.cfm
• RWJ Commission on SDOH
www.rwjf.org/pr/product.jsp?id=41008
• CDC Expert Panel on SDOH
www.healthyohioprogram.org/ASSETS/AF886060E94E4823A9338F7E68139947/hepanel.pdf
• IOM Committee in SDOH
www.iom.edu/Activities/SelectPops/HealthDisparities.aspx
• IOM Local Government Actions to Prevent Childhood Obesity
Report
www.iom.edu/Reports/2009/ChildhoodObesityPreventionLocalGovernments.aspx
• Healthy People 2020 Report
www.healthypeople.gov/hp2020/advisory/PhaseI/PhaseI.pdf
• PolicyLink
http://www.policylink.org/site/c.lkIXLbMNJrE/b.6728307/k.58F8/Why_Place___Race_Matter.htm#

4. ADD Picture of Tree

5. Terminology: Learning a
Common Language
 Community
 Health disparities
 Health inequities
 Health equity
 Social determinants
of health (SDOH)
Photo provided by the CDC REACH program

6. Social Determinants of Health
Life-enhancing resources, such as food
supply, housing, economic and social
relationships, transportation, education
and health care, whose distribution across
populations effectively determines length
and quality of life.
Reference: James S. (2002)

7. Community
 A group of people with a shared identity,
including: living in a particular geographic
area, having some level of social
interaction, sharing a sense of belonging
or having common political or social
responsibilities
 REACH communities focus on race,
ethnicity, and culture.
References: Eng, Parker (1994), Fellin (1995), Hunter (1975), Israel, et al (1994), MacQueen, et al (2001), McKnight (1992)

8. Health Equity
 The opportunity for everyone to attain his
or her full health potential
 No one is disadvantaged from achieving
this potential because of his or her social
position or other socially determined
circumstance.
 Distinct from health equality
Reference: Whitehead M. et al

9. Health Inequities
 Systematic and unjust distribution of social,
economic, and environmental conditions needed
for health
 Unequal access to quality education, healthcare,
housing, transportation, other resources (e.g., grocery
stores, car seats)
 Unequal employment opportunities and pay/income
 Discrimination based upon social status/other factors
Reference: Whitehead M. et al

10. Health Disparities
 Differences in the incidence and
prevalence of health conditions and health
status between groups, based on:
Race/ethnicity
Socioeconomic status
Sexual orientation
Gender
Disability status
Geographic location
Combination of these

11. Comparison of Definitions
Health Disparities Health Inequities
Differences in the incidence and
prevalence of health conditions and
health status between groups based
on:
•Race/ethnicity
•Socioeconomic status
•Sexual orientation
•Gender
•Disability status
•Geographic location
•Combination of these
Systematic and unjust distribution of
social, economic, and environmental
conditions needed for health.
•Unequal access to quality education,
healthcare, housing, transportation,
other resources (e.g., grocery stores,
car seats)
•Unequal employment opportunities
and pay/income
•Discrimination based upon social
status/other factors

12. Comparison of Definitions
Health Disparities Health Inequities Health Equity SDOH
Differences in the
incidence and
prevalence of health
conditions and
health status
between groups
based on:
•Race/ethnicity
•Socioeconomic status
•Sexual orientation
•Gender
•Disability status
•Geographic location
•Combination of these
Systematic and
unjust distribution of
social, economic,
and environmental
conditions needed
for health.
•Unequal access to
quality education,
healthcare, housing,
transportation, other
resources (e.g., grocery
stores, car seats)
•Unequal employment
opportunities and
pay/income
•Discrimination based
upon social status/other
factors
The opportunity for
everyone to attain
his or her full health
potential.
No one is
disadvantaged from
achieving this potential
because of his or her
social position or other
socially determined
circumstance.
•Equal access to
quality education,
healthcare, housing,
transportation, other
resources
•Equitable pay/income
•Equal opportunity for
employment
•Absence of
discrimination based
upon social status/other
factors
Life-enhancing
resources whose
distribution across
populations
effectively
determines length
and quality of life.
•Food supply
•Housing
•Economic
relationships
•Social relationships
•Transportation
•Education
•Health Care

13. Discussion: Community
 Who does your community include? Who does it
not include?
 What are the geographic boundaries?
 What are the cultural and psychosocial
experiences of people in the community (e.g.,
traditions, social networks, history,
representation in the local government)?
 Does your community have multiple
communities within it? How would you describe
these communities? What are the relationships
between these communities?

14. Discussion: Health Inequities
 What social, economic, or environmental
conditions affect your whole community (e.g., air
pollution, high concentration of fast food
restaurants, inadequate public transportation
system)?
 What conditions differentially affect subgroups in
your community?
 Why are these conditions experienced
differentially for subgroups in your community?

15. Discussion: Health Disparities
 What health concerns are experienced by
people in your community (e.g., obesity, asthma,
diabetes, heart disease)?
 What behaviors are more or less common
among people in your community (e.g., food and
beverage consumption, physical activity,
tobacco or substance use, violence)?
 Do these health concerns or behaviors vary by
subgroup? What are the differences?

16. Data and Context
Photo provided by the CDC REACH program

17. Social Determinants of Health
 Access to health care
 Access to resources
 Education
 Employment
 Environment
 Income/Poverty
 Insurance Coverage
 Housing
 Racism/Discrimination
 Segregation
 Transportation

18. Share of Population that is a Racial/Ethnic Minority by State
2005-2006

19. Equity
Environment
Health
Intersection of Health, Place & Equity
Access to
Healthy
Food
Schools/
Child care
Health
facilities
Community
Safety/
Violence
Transportation
Traffic patterns
Work
environments
Housing
Parks/Open
Space/
Playgrounds
Reference: PolicyLink

20. Place Matters
Parks
Sidewalks
Grocery Stores
Financial Institutions
Better Performing
Schools
Good Public
Transportation
Fast Food Restaurants
Liquor Stores
Unsafe/Limited Parks
Poor Performing Schools
Increased Pollution and
Toxic Waste Sites
Limited Public
Transportation
Communities of
Opportunity
Low- Income Communities
Good Health
Status
Poor Health
Status
contributes to
health disparities:
Obesity
Diabetes
Asthma
Infant mortality
Reference: PolicyLink

21. Across America, Differences in How Long and How Well We Live

22. Within States, Large Gaps in Life Expectancy
22
.

23. Examples of Health Inequities
Education Infants born to African American mothers with
only a high school education were 2.2 times
more likely to die in the first year of life
compared to their White counterparts.
Income Low socioeconomic status is associated with an
increased risk for many diseases, including
CVH, arthritis, diabetes, chronic respiratory
diseases, cervical cancer and frequent mental
distress.1
Access to resources Lower income and racial/ethnic minority
communities are less likely to have access to
grocery stores with a wide variety of fruits and
vegetables.2,3
References: 1Pleis, Lethbridge-Cejku (2006), 2Morland, et al (2002), 3Baker, et al (2006)

27. Place Matters
Reference: Robert Wood Johnson Foundation (2008)
http://www.commissiononhealth.org/PDF/adaed392-81b0-4c3f-8015-
0bc10dfed2fd/whereyoulivematters_philadelphia.pdf
http://www.commissiononhealth.org/PDF/7d8e7a6c-1989-4257-885b-
25782cf7ec4a/RWJ045_Denver_5x7_3b.pdf

28. Distribution of U.S. Population by Race/Ethnicity
2000 and 2050
NOTES: Data do not include residents of Puerto Rico, Guam, the U.S. Virgin Islands, or the Northern Marina Islands. “Other” category includes
American Indian/Alaska Native, Native Hawaiian or Other Pacific Islander, and individuals reporting “Two or more races.” African-American, Asian,
and Other categories jointly double-count 1% (2000) and 2% (2050) of the population that is of these races and Hispanic; thus, totals may not
add to 100%.
SOURCE: Kaiser Family Foundation, based on http://www.census.gov/population/www/projections/popproj.html, U.S. Census Bureau, 2004, US
Interim Projections by Age, Sex, Race, and Hispanic Origin.
Total = 282.1 million
Total = 419.9 million
8.0%
12.7%
14.6%
12.6%
24.4%
69.4%
50.1%
2.5% 5.3%
3.8%
2000 2050
White, Non-Hispanic
Hispanic
African American
Asian
Other

29. Cancer Screening Rates by Race/Ethnicity*
2003
18.3%
67.8%
58.2%
22.3%
82.6%
70.0%
15.4%
74.6%
65.1%
22.7%
80.2%
70.4% White, Non-
Hispanic
Hispanic
African-
American, Non-
Hispanic
Asian
NOTES: * Data for American Indians/Alaska Natives and Native Hawaiians/Pacific Islanders do not meet the criteria for statistical reliability, data
quality or confidentiality. Age-adjusted percentages of women 40 and older who reported a mammography within the past 2 years, women 18 and
older who reported a pap test within the past 3 years, and adults 50 and older (male and female) who reported a fecal occult blood test within the
past 2 years.
SOURCE: Kaiser Family Foundation, based on the National Healthcare Disparities Report, 2005, available at:
http://www.ahrq.gov/qual/nhdr05/index.html, using data from the Centers for Disease Control and Prevention, National Center for Health
Statistics, National Health Interview Survey.
Breast Cancer
(Mammography)
Cervical
Cancer
(Pap Test)
Colon and
Rectum Cancer
(Fecal Occult
Blood Test)

30. Examples of Health Disparities
Diabetes As of 2007, Native Americans and Alaska Natives
(17%), African Americans (12%), and
Hispanics/Latinos (10%) were all significantly more
likely to have been diagnosed with diabetes
compared to their White counterparts (7%).1
Heart Disease In 2000, rates of death from diseases of the heart
were 29 percent higher among African American
adults than among white adults, and death rates from
stroke were 40 percent higher.2
Infant Mortality In 2002, Sudden Infant Death Syndrome (SIDS)
deaths among American Indian and Alaska Natives
was 2.3 times the rate for non-Hispanic white
mothers.3
References: 1CDC (2008), 2NCHS (2002), 3NICHD (2007)

31. Health Insurance Status, by Race/Ethnicity: Children
2007
36% 43%
68%
31%
58%
43%
45%
19% 34%
8%
21%
13% 12%
19%
73%
20%
NSD
8%
White
44.7 million
African
American
11.6 million
Hispanic
16.5 million
Asian/
Pacific
Islander
3.3 million
American
Indian/
Alaska Native
0.5 million
NOTES: “NSD” = Not sufficient data; “Other Public” includes Medicare and military-related coverage. All racial groups non-Hispanic.
* = Estimate has a large 95% confidence interval of +/- 5.0 - 7.9 percentage points.
SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured analysis of the March 2008 Current Population Survey.
http://facts.kff.org/chartbook.aspx?cb=55
Total Child
Population
2007
Two or
More Races
2.1 million
Private (Employer and Individual) Medicaid and Other Public Uninsured
*
*

32. Infant Mortality Rates for Mothers Age 20+
by Race/Ethnicity and Education, 2001-2003
4.6
5.3
5.2
3.9
5.6
5.0
4.2
6.5
9.2
7.0
9.2
10.7
11.5
13.4
15.1 African American,
Non-Hispanic
American
Indian/Alaska Native
White, Non-Hispanic
Asian/Pacific
Islander
Hispanic
SOURCE: Kaiser Family Foundation, based on Health, United States, 2006, Table 20, using data from the National Center for Health
Statistics, National Vital Statistics System, National Linked Birth/Infant Death Data.
www.kaiseredu.org/tutorials/.../REHealthcare_download.ppt
Less
than
High
School
High
School
College
+
Infant deaths per 1,000 live births:

33. Diseases and Behaviors
Tobacco
Use
Poor
Nutrition
Physical
Activity
Physician
Visits
Arthritis/Lupus
Asthma
Breast Cancer
Colorectal Cancer
COPD (Lung Disease)
Diabetes
Heart Disease and Stroke
Hepatitis B
Immunizations (for adults)
Infant Health Problems
Injury from falls
Lung Cancer
Oral Health
Pneumonia and Influenza

34. SDOH and Health

35. SDOH and Health

36. Figure 5: Pathways
from social
determinants to
health

37. Figure 4:
Social
Determinants
of Health

38. Field Examples
 http://www.youtube.com/
watch?v=mOxMiugtjiU

http://www.youtube.com/
watch?v=diMVgcb8Qzk
 http://www.youtube.com/
watch?v=k8fuzh4d544&f
eature=related
Photo provided by the CDC REACH program

39. Types of Initiatives
 Eliminating racial and ethnic disparities in breast and
cervical cancer by promoting screening, education,
prevention, treatment, and access to care for black
women and women of African descent
 Addressing disparities in diabetes education and quality
of care by building community capacity, identifying people
at high risk for diabetes, offering training and education,
supporting health promotion activities, and creating
diabetes self-care centers.
 Improving community health by addressing social factors
that have been linked to high infant death rates. These
include violence, substance abuse, crime, poor nutrition,
food insecurity, and lack of community unity and
leadership.

40. Discussion:
Social Determinants of Health
 How are resources (e.g., food, housing, local
businesses, transportation, health care
services) distributed within your community?
 How does this compare to surrounding
communities?
 What are the relationships among social
determinants, cultural and psychological?

41. Six Ways to Talk about Social Determinants of
Health
 Health starts – long before illness – in our homes,
schools, and jobs.
 All Americans should have the opportunity to make the
choices that allow them to live a long, healthy life,
regardless of their income, education or ethnic
background.
 Your neighborhood or job shouldn’t be hazardous to your
health.
 Your opportunity for health starts long before you need
medical care.
 The opportunity for health begins in our families,
neighborhoods, schools, and jobs.
Robert Wood Johnson Foundation

42. References
 Baker E, Schootman M, Barnidge E, Kelly C. The role of race and poverty in access to foods that
enable individuals to adhere to dietary guidelines. Preventing Chronic Disease 2006;3(3):1–11.
 Braveman P. Health disparities and health equity: concepts and measurement. Annual Review of
Public Health 2006;27:167–194.
 CDC. National Diabetes Fact Sheet; 2007; http://apps.nccd.cdc.gov/DDTSTRS/FactSheet.aspx
 Eng E, Parker E. Measuring community competence in the Mississippi Delta: the interface
between program evaluation and empowerment. Health Education Quarterly 1994;21(2):199–220.
 Fellin P. Understanding American Communities. In: Rothman J, Erlich JL, Tropman JE, editors.
Strategies of Community Organization. 5th edition. Itasca, IL: Peacock; 1995.
 Hunter A. The loss of community: an empirical test through replication. American Sociology
Review 1975;40(5):537–552.
 Israel BA, Checkoway B, Schulz A, Zimmerman M. Health education and community
empowerment: conceptualizing and measuring perceptions of individual, organizational, and
community control. Health Education Quarterly 1994;21(2):149–170.
 James S. Social determinants of health: implications for intervening on racial and ethnic health
disparities. Paper presented at: Minority Health Conference, 2002; University of North Carolina.

43. References
 MacQueen K, McLellan E, Metzger D, Kegeles S, Strauss R, Scotti R, et al. What is community?
An evidence-based definition for participatory public health. American Journal of Public Health
2001;91(12):1929–1938.
 McKnight JL. Redefining community. Social Policy 1992;23(2):56–62.
 Morland et. al. (2002)
 NIH. National Institute of Child Health and Human Development, SIDS; 2007;
http://www.nichd.nih.gov/health/topics/Sudden_Infant_Death_Syndrome.cfm
 Pleis JR, Lethbridge-Çejku M. Summary health statistics for U.S. adults: national health interview
survey, 2005. National Center for Health Statistics. Vital Health Statistics 2006;10(232). Available
at http://www.cdc.gov/nchs/nhis.htm.
 Whitehead M, Dahlgren G. Levelling Up (Part 1): A Discussion Paper on Concepts and Principles
for Tackling Social Inequities in Health. World Health Organization. Available at
http://www.euro.who.int/document/e89383.pdf.