Improving Health Outcomes Starts With Addressing the Social Determinants of Health

What are the Social Determinants of Health?

The social determinants of health are non-medical factors that influence health outcomes. These factors vary greatly from individual to individual, and can impact on a person’s overall health and life expectancy.

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Multiple factors are considered to be social determinants of health, and these include:

• Education
• Income and job security
• Neighborhood and physical environment
• Food security
• Community and social support networks
• Access to healthcare

How Important are Social Determinants of Health?

Addressing social determinants of health is crucial to improve health and reduce longstanding disparities in healthcare. It seems logical to view the healthcare system as a key driver of health outcomes and although healthcare is essential to good health, it is a relatively weak health determinant. More research is needed to determine the relative impact each factor contributes to health, but studies show that socioeconomic factors can shape individuals’ health and lifestyle behaviors – and we know behavior is key in addressing chronic disease in particular.

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The USA spent $4.3 trillion on healthcare in 2021, and by 2030 the health spending share of GDP is projected to reach 19.6%, higher than in any other country at $6.8 trillion. However, the vast proportion of spending on healthcare is not matched by corresponding positive health outcomes. The USA spends more on healthcare than any other high-income country, but has the least to show for it, in terms of population health. Over 60% of Americans have a chronic disease, the current leading cause of death in the USA.

Put into context, this is not altogether surprising. The actual make-up of good health, namely healthy behaviors, genetics, environmental factors and access to healthcare, are not given proportionate investment in the US healthcare system, with an overwhelming majority of 88% of spending being plunged directly into medical services (Fig. 1).

The Covid-19 pandemic has served to only widen the socioeconomic and racial disparities in healthcare access, highlighting the urgent need to look beyond healthcare systems to reduce the inequity in health outcomes in the USA and across the world.

Achieving Health Equity

Education

Empirical data from the Organization for Economic Cooperation and Development (OECD) between 1995-2015 showed that adults with lower educational attainment had worse health and reduced lifespans compared to their more well-educated peers.

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The provision of early childhood education programs in the USA to children in low-income families and communities of color has been shown to help to reduce achievement gaps, improve the health of low-income students, and promote health equity.

Income

Non-wealthy Americans have suffered from lack of healthcare cost coverage and even those who are privately insured have had their wage gains undermined by rising premiums. This higher risk of poor health in those who are financially disadvantaged is clearly seen in the 2011 National Health Interview Survey, where the highest proportion of adults in the USA with self-reported poor health were found to be earning low incomes, below $35,000/year.

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The Medicare and Medicare plans offer some support for healthcare to those on lower incomes, but they do not capture the whole socioeconomically disadvantaged population. Some Americans may have insurance provided by their employer, but equally, job insecurity is felt more keenly by those earning on the lower end of the spectrum, leading to a potential negative feedback loop of poverty.

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The Earned Income Tax Credit (EITC) provides financial assistance for low-income workers and has demonstrated an association with decreased low-birthweight infants and infant mortality. This is a stop-gap initiative, however, and policy change is required to ensure more permanent downstream effects on income and health.

Physical Environment

Neighborhoods with unfavorable social conditions – unsafe surroundings, substandard housing, and limited access to sidewalks and parks – were found to contribute to a 20-60% increased risk of child inhabitants being obese or overweight.

High levels of environmental pollution are known to cause direct risks to health, particularly to those at a socioeconomic disadvantage.

Housing mobility programs are offered regionally in the USA to assist those living in lower-opportunity areas to relocate to areas with higher earning potential and safer environments. However, affordable housing is in short supply and jurisdictional bureaucracy can lead to administrative barriers preventing individuals and families to move to a better location.

Food Security

Multiple studies have found that food insecurity can be one determinant, among others, of a patient’s health challenges and poorer food choices can be associated with those from low socioeconomic status. With suboptimal diet comes increased health risks, especially those connected to metabolic syndrome and cardiovascular diseases.  

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During the Covid-19 pandemic in the USA, people who lost their jobs and received federal unemployment insurance to supplement their income, experienced a reduction in food insecurity. This demonstrates the potential impact of implementing a nationwide safety net program to protect against the most disadvantaged being plunged into poverty and being unable to access sufficient healthy food.

Community

Research has linked social isolation and loneliness to higher risks for a variety of physical and mental conditions including chronic diseases such as hypertension, heart disease, and mental health disorders. Encouragingly, OECD indications suggest that, on average, Americans experience generally strong social support.

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However, important consideration must be given to racial and cultural minority communities, where Black and Hispanic communities can experience particularly increased health risks. Studies have shown promising trends in intergenerational communication within these ethnic racial groups, but increased language and cultural inclusion needs to be implemented within healthcare systems to ensure equitable healthcare access to all communities.

Healthcare System

A 2017 survey of Medicaid plans found that over half of responding states reported including social determinants of health data in their current or future programs, which shows a promising shift towards acknowledgment of how important socioeconomic factors are in healthcare provision.

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However, with almost 10% of the population uninsured, and prices of pharmaceuticals and administration being the major differentiators in overall healthcare costs between the USA and other high-income countries, the US healthcare system caters predominantly to those who can afford the excessive costs.

How Can Digital Therapeutics Help Redress the Balance?

Digital therapeutics (DTx) offer multiple benefits and opportunities and can steer the healthcare system towards a more sustainable, value-based system that offers access to people from all socioeconomic backgrounds.

Create Healthcare Accessibility

DTx solutions are uniquely accessible by design, with a majority being offered through a smartphone application. Digital download of software means that patients do not need to attend a brick-and-mortar establishment to receive their treatment. This is particularly helpful for those in geographic isolation that may struggle to attend in-person appointments, and those who do not have access to, or the financial ability to pay for transport. Through a DTx solution, people can be reconnected with their healthcare provider to receive ongoing care.

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The proposed Access to Prescription Digital Therapeutics Act is now more important than ever, too. Making prescription digital therapeutics (PDTx) available through national health insurance provisions like Medicare and Medicaid would not only allow greater access to a wider range of supportive therapy for more than 44% of Americans receiving state healthcare support, it would also set a precedent for private insurance companies to increase their coverage of PDTx too, opening up DTx solutions as an accessible, mainstream tool in healthcare nationwide.

Optimize Current Treatments

A substantial number of pharmaceuticals are on the market, but waning treatment adherence can mean these medications are not being used to their full effect.

DTx solutions can aid a patient in keeping track of taking their medicines at the right time, every time, ensuring that the treatment is pharmacologically optimized.

Where a DTx differs from a mere recurring task reminder, is that quality education based on the latest scientific research is also provided to the patient to help inform them about their condition and their medication, ensuring compliance through genuine understanding of the importance of keeping to a treatment regimen.

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Additionally, if a treatment is no longer producing the desired outcomes and symptom management, a DTx can help gather that data so that a healthcare professional can reassess the treatment plan, ensuring the right prescriptions are made for the right patient.

Improve Behaviors and Public Policy

While DTx are designed to motivate an individual to adopt healthier habits and shift their behavior to support a healthier lifestyle, the real strength of DTx for addressing social determinants of health lies in their ability to collate insightful patient information. This information could then be combined with existing environmental and social data to influence public health policy change.

Health behaviors matter within a causal frame, which starts with foundational social and economic conditions, whose impacts are mediated through behaviors that in turn affect human organ systems, resulting in poor health. It is only through an appreciation of the full causal chain, taking into account structural racism, segregation, poverty, unstable housing, and a range of other foundational determinants, that we can design interventions that plausibly have the potential to improve health and narrow health gaps.
‍Sandro Galea, MD, DrPH
_{Epidemiologist and dean of Boston University School of Public Health}

Conclusions

Overall health is inseparable from the socioeconomic and environmental factors that underpin it, and as such, greater focus on alleviating the burden of those factors is required in order to achieve health equity. Governments can reduce healthcare spending by reallocating budgets to address each social determinant of health at its root, and in doing so begin to improve healthcare outcomes, population life expectancy, and quality of life.

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