1.2: Social Determinants of Health Intersect with Healthcare

FIGURE 1.1 Factors Influencing Health Outcomes (Adapted by Hassmiller & Wakefield, 2022; Castrucci & Auerback, 2019)

While opportunities to advance health equity through clinical care continue to be important, addressing how SDOH influences health outcomes is critical to improving the nation’s health and well-being (Whitman et al., 2022). Historically, health care has focused on improving access to care, and although access to quality health care is vitally important, upstream factors identify strategies that promote health equity.

Upstream factors seek to create community-level actions and improve community conditions by addressing SDOH, including but not limited to food insecurity, housing insecurity, insurance coverage (or lack thereof), and economic instability. Examples of upstream interventions include community participatory research; education; public policy, law, and regulations. Upstream factors are akin to primary prevention measures. Upstream factors catch individuals and families before they fall into the stream.

Midstream factors include risk reduction efforts that parallel secondary prevention measures. Midstream factors seek to identify diseases early before the onset of signs and symptoms and provide tools and resources to assist an individual in improving their own health. Midstream factors are individual actions that reduce the risk of illness or injury. Midstream factors include self-care strategies, screenings, referrals, and behavioral health interventions. Midstream factors are actions that help individuals to successfully navigate the stream.

Downstream factors include service actions that reduce the severity of an existing condition or injury and improve an individual’s quality of life. Like tertiary prevention, downstream factors focus on rehabilitation, restoration, and repatterning. Tertiary prevention strategies are implemented to optimize functioning and reduce disability from an existing condition or injury (rehabilitation), establish optimal functioning from existing conditions or injury (restoration), and adjust personal knowledge, beliefs, and attitudes to function in an altered capacity due to an existing condition or injury (repatterning). Examples of downstream interventions include physical or occupational therapy, chronic disease management programs, and support groups. Downstream factors teach individuals to navigate the rapids and attempt to catch individuals before they go over the waterfall at the bottom of the stream.

SDOH Contributes to Health Disparities

Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among individuals or specific aggregates. Health disparities are preventable differences that impede individuals or aggregates from achieving optimal health. SDOH largely influences health disparities and is further accentuated by marginalization, prejudice, and discrimination related to race, ethnicity, sexual orientation, gender identity, age, disability, socioeconomic status, geographic location, poverty status, and employment.

Equality and Equity

Health equity is an important element in reducing health disparities. Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health. Achieving health equity requires ongoing societal efforts to address historical and contemporary injustice, overcome economic and social barriers to healthcare access, and eliminate preventable health disparities. Additionally, we must change the systems and policies that have resulted in the generational injustices that give rise to racial and ethnic health disparities (CDC, 2022).

There is a distinct difference between equality and equity. Equality suggests that individuals and aggregates are given the same opportunities and resources and assumes that individuals and aggregates are equal in status, rights, and abilities. Equality does not consider SDOH or individual circumstances. Equity, however, promotes social justice and fairness. Equity takes into consideration SDOH and individual circumstances and allocates resources and opportunities proportionately so individuals and aggregates can thrive.

A common illustration demonstrating the differences between equality and equity shows four individuals with varying ability, age, and stature. All four individuals are given the exact same bicycle (equality). However, the bicycle does not accommodate the needs of a person in a wheelchair, the bicycle is too small for a tall-statured individual and is too big for a young child. The bicycle is an appropriate size and can be competently used by only one of the four individuals. Equity implies that individual circumstances are considered, and different bicycles are allocated to each of the four individuals that meet the needs so they can be effectively and competently used based on their ability, age, and stature.