Structural and Social Determinants of Health

00:01 Hello. Today we're going to talk about the structural and social determinants of health.

00:07 Let's start with a story.

00:09 I will share a little bit about my own experiences in San Francisco and connect them to the social determinants of health.

00:17 This is a map of San Francisco where I live.

00:21 It is seven miles by seven miles.

00:27 And here on the east side of the city is the Bayview-hunters Point neighborhood.

00:33 The life expectancy is 77 years.

00:38 On the west side of the city, in the Outer Sunset neighborhood, the life expectancy is eight years longer, 85 years now.

00:47 seven miles away, there is a significant discrepancy in the life expectancy.

00:54 You may not be surprised if I tell you that the Bayview-hunters point neighborhood here is more polluted, has higher rates of asthma and higher rates of ER visits per capita.

01:09 Why would this be? Why seven miles away? Would you have completely different health outcomes in the same city? We'll come back to this in a few minutes.

01:20 In medical school and the way that I was taught medicine, we traditionally focus on this box here on the right, the risk behaviors, the individual contributions of my patients to their health outcomes. What are their behaviors, what are their genetics and the disease processes that are contributing to the health that we see in our patients? What we've learned over time and the evolution of medical training is that we need to understand much more than the patient who is sitting in front of us and understand the social determinants and the other factors that have contributed to their health care, their health outcome that we are seeing today.

02:05 This includes their living conditions, the institutional inequities, and the social status and the social conditions from which they come.

02:13 These are the social determinants.

02:17 And to formally define them, the social determinants of health are the conditions in which people live, work, play and age that influence health outcomes. And separating the structural determinants from the social determinants.

02:31 The structural determinants are the policies, histories, and values that drive the social determinants of health and the health inequities. For the purposes of our conversation, we will often combine the social and the structural determinants, but it's important to understand that the structures are underlying the social determinants of health that we see.

02:54 The social determinants of health include such things as educational access, the quality of your education, healthcare access, and quality. For example, what kind of insurance do you have? And especially in the United States, your insurance access often determines your health and health care access.

03:12 The neighborhood and the built environment.

03:15 Do you have playgrounds and open environments in which you can be outside in the fresh air and play, and be in a safe space? Do you have grocery stores that are close to your home, or do you predominantly have fast food restaurants which will influence your nutritional access? The social and the community context in which you live and the economic stability of the communities? The social determinants are not just theory.

03:42 There's quite a bit of data supporting the social determinants and their impact on health and health inequities.

03:49 This is a diagram from the famous Whitehall study conducted by Geoffrey Rose and Michael Marmot in the 1960s, and 70s.

03:58 It's a study of over 18,000 British civil servants and their health outcomes over time.

04:06 If you see here on this diagram, the admin class is the highest class at that time in society. And as you go up here on this list, the other class is the lowest socio social class in Britain at that time.

04:21 Just from the stratification of these lines, you can see that as the years go by, the mortality of the admin class is lower than the mortality of the other class.

04:32 And correspondingly, as you go down in social class, you go up in mortality.

04:38 We might think about specifically for coronary artery disease, the individual behaviors and the individual risk factors that contribute to coronary artery disease. So when you look at this diagram on the right, you can see that cholesterol levels, smoking levels and blood pressure does contribute to the risk of coronary heart disease.

05:00 Yet as you move down in social class, there is a significant component of unexplained reasons for an increased mortality and an increased risk of coronary heart disease in these populations.

05:17 This is where the social determinants come into play, and can explain some of this difference that we see in health and explain the disparities that we see in the health outcomes.

05:30 The psychosocial and behavioral stressors that may not be immediately apparent with individual risk behaviors and genetics are what's contributing to this difference in health that we see. There are other ways that this plays out and can be seen in current data. So these are models from the centers for Disease Control.

05:49 And the picture on the left is a map of the United States and shows the percentage of the population living in poverty in 2015.

06:00 The darker areas correspond to higher levels of poverty.

06:04 Now, if you look at heart disease rates, which is the diagram on the right, the darker areas corresponding to higher rates of heart disease, you can visually see that it maps upon the rates of poverty in our country.

06:19 This again shows the impact of the social determinants and the social structures in place that influence health.

06:28 It is much larger than the individual patient whom we might usually attribute their status, their health status to, but in fact there are larger social structures at play. This holds true for other disease states as well.

06:44 Diabetes is traditionally thought to be individually mediated, mediated by behaviors, by eating patterns, by medication adherence.

06:53 And we can see here that, again, the diabetes prevalence in the United States correlates to the levels of poverty and that there are larger structures influencing the health outcomes of our patients.