Diagnosed with type 1 diabetes at age 9, Felicia Hill-Briggs, PhD, is now a clinical psychologist and behavioral scientist who is keenly interested in why disorders such as diabetes unevenly affect different populations. Here, she discusses how unequal distribution of social resources, or social determinants, can lead to disproportionately negative health outcomes, and what can be done to address such inequities.

Q: What are social determinants of health?

A: There are three related terms that are important. Health disparities is the term used to describe health differences between people based on race, ethnic group, or socioeconomic status. It is any health difference that is attributed specifically to disadvantage.

Health equity is defined as the absence of avoidable, unfair, or remediable differences among groups of people. It is what we are striving for. And from health equity comes the term social determinants of health, which are those avoidable, unfair, and remediable causes of health disparities. Social determinants are the things that we can change with our policies, because they are the result of social and economic systems.

The World Health Organization defines social determinants as the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels. In that definition, you really can hear the scope and gravity of social determinants of health. They are deemed to be the primary contributors to unfair and avoidable differences in health status that we see both within countries, between countries, and between populations within countries.

Q: What are the key social determinants?

A: Some of the key social determinants that you’ll see across all frameworks include

• socioeconomic status, which includes education, income, and occupation
• the neighborhood and physical environment, such as housing, the built environment, and environmental and toxic exposures
• the food environment, which involves such factors as food insecurity and food access
• health care, including access to affordable, quality care
• social cohesion and social capital, including how inclusive a society is versus how it might alienate, isolate, or discriminate against its members, and whether all members of the society have equal leverage.

Q: Does the social determinants framework help move us away from a focus on blaming individuals for their health status?

A: That’s exactly right. It has traditionally been the case that you look at a patient and say, “they are homeless right now” or “they have not had the benefit of a good education” or “they aren’t buying the healthiest food.” Very much the onus for health was placed on that person. What’s being recognized now is that health status can have systemic causes, and that’s why I love the WHO definition. It makes it clear that these are the conditions into which people are born, based on systems and laws that were put in place. It opens the door for very different ways to start thinking about what we’re going to do to address these disparities. The scope of how we intervene now comes from a very different perspective than “blame the person” even if there are 2 million of that kind of person.

Q: How might social determinants affect interactions between people with diabetes and health care professionals?

A: I think social determinants stump health care professionals, for example, when they have a patient who is housing insecure or has no means to pay for the medication that would be best for them, or have no access to refrigeration for their insulin because they are unable to pay the electric bill. Health care professionals want to be able to connect the patient to resources, whether it’s social workers, community partnerships, or social service agencies that can help. But there’s no clear way to ensure the patient gets the support he or she needs, and adequate resources to address the social determinants the patient is facing at the time are often not available.

In addition, populations that are impacted adversely by social determinants of health can sometimes experience biases held by health care professionals. We know from the research that health care professionals tend to spend less time speaking with patients from minority backgrounds or lower socioeconomic status. Sometimes health care professionals have attributed nonadherence to poor motivation toward good health. Similarly, patients from groups impacted by social determinants may perceive they are either not understood or listened to, or report feeling dismissed or not believed. Sometimes they even feel blamed for their life circumstances. That’s where mistrust can be born. It comes both from patient experience as well as historical atrocities that have been experienced by specific groups.

Q: How might social determinants affect the course of diabetes in an individual, a demographic group, or community?

A: Your risk for diabetes differs based on whether or not you’ve completed high school, your income, and whether you come from a group that has historically faced discrimination such as Native Americans, indigenous people, African Americans, and people of Latinx heritage. Risk also differs based on access to affordable care and quality care. These are all factors that are independently associated with diabetes prevalence.

Because these are conditions in which one is born and lives, social determinants of health have an impact across the full continuum of diabetes outcomes—likelihood of having prediabetes, risk of type 2 diabetes, prospect of gestational diabetes and of that diagnosis evolving into type 2 diabetes, prevalence of diabetes complications, and even premature mortality from diabetes. The nature of social determinants is such that it affects the course of diabetes for individuals, communities, and populations.

Q: How can health care professionals address health disparities?

A: There’s increased awareness that implicit bias is happening now, particularly given the disparities that COVID-19 has made so apparent. Health care systems more and more are arranging opportunities for their health care professionals and other staff to increase awareness about their own implicit biases that may contribute to differential treatment in persons from underserved populations.

Specifically to address social determinants, the National Academies of Science, Engineering, and Medicine has put out a report on this, A Framework for Educating Health Professionals to Address the Social Determinants of Health (2016). The National Academies has also published another report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health (2019), which emphasizes that the health care system cannot solely focus on the clinical aspects of care. Rather, it is responsible for making sure social needs care is integrated into health care, by partnering in appropriate ways to ensure that patients have access to resources for social needs. This report talks about education and training, evidence-based interventions, and using data to understand better what the needs are and for whom, and to monitor the types of interventions that are being done to make sure they’re working.

Q: How are researchers addressing social determinants of health?

A: The NIDDK produced a publication, New Research Directions on Disparities in Obesity and Type 2 Diabetes (2019), that specifically addresses the current status of and future recommendations for research on disparities in obesity and type 2 diabetes.

The American Diabetes Association has published a scientific review of the social determinants of health specific to their impact on diabetes. It also covers the intervention literature—what has been tested, what has worked, and what has not worked so far. It has very specific recommendations on the kinds of research that’s needed to inform practice.

A great deal of research has already been done. Early studies focused on interventions that increase the individual’s access to care despite their social determinant conditions. Out of this line of research, interventions were developed such as the use of community health workers and neighborhood and patient navigators. These interventions brought into the health care paradigm people from the community who serve as a bridge between the traditional health care system and patients from underserved communities. The research shows that people with diabetes benefit from the support and interventions provided by community health workers. This may include help with home-based education or reinforcement, connecting with local social services or community health resources, scheduling of appointments, or attending appointments with people.

A shift in research focus is now occurring to get more at the root causes of health disparities and the social determinants that drive them. Addressing these root causes will require system-based interventions rather than individual-level approaches. Let’s talk about education as an example. Fewer years of education, and lower literacy, which is a measure of quality of education, are each associated with higher type 2 diabetes prevalence. So, one intervention approach has been to adapt health communications, such as diabetes education materials, for low literacy (e.g., a fifth-grade reading level). This strategy compensates for a larger problem of lower education quality, particularly in underserved communities.

An example of an intervention that addresses the root cause of this social determinant would have the health care and education sectors partner with policy makers to improve equity in the quality of education across neighborhood economic strata.

Another example is what we do with the data that researchers collect on social determinants that impact a neighborhood, community, or population. Traditionally, researchers publish these data in a professional journal and readers of the journal are the primary audience. But with the rise of dedicated population health institutes and centers within health care organizations, you’re more inclined to see those researchers also seek to share their findings with local policy makers and advocate for national legislative changes to create greater health equity.

How are the social determinants of health shaping the health of your patients who have diabetes? Share below in the comments.