Researchers and policy makers use a lot of jargon to describe the social determinants of health. Here, we offer some handy definitions.
The theory that the accumulated burden of chronic stress creates a common pathway to the onset and progression of many different diseases. Measures of allostatic load reflect how well or poorly the cardiovascular, metabolic, nervous, hormonal and immune systems are functioning, with higher scores indicating greater vulnerability to illness. Scores are based on readings of blood pressure, body mass index, kidney function, blood sugar, cholesterol, C-reactive protein and other tests.
Broken Windows effect
The so-called Broken Windows theory has led to initiatives that try to reduce violence by restoring deteriorating neighborhoods, removing or securely sealing abandoned buildings, and greening vacant lots. The idea is that abandoned places give cover to criminal activity and signal that no one is in control. Researchers have found significant associations between the risk of violent assault and the presence of abandoned buildings and vacant lots, even after controlling for demographic and socioeconomic characteristics of the neighborhoods. But it’s not yet clear if property restoration efforts are an effective way to reduce crime.
The ability of health care providers to deliver care and services that take into account the cultural needs of a diverse patient population. Language, health literacy, customs, beliefs, practices and communication are all key factors in providing such care.
Developmental origins of health and disease
From conception through infancy and early childhood, exposures to certain stresses can alter the trajectory of development in ways that increase vulnerability to disease in adulthood. Exposure to endocrine disruptor chemicals in the womb, for example, or a disadvantaged mother’s poor diet can modify an infant’s lifelong disease risk. These early life exposures may act in subtle ways. They don’t have to grossly disrupt development or directly trigger disease to make people more vulnerable to heart disease, weight gain and other health problems decades later. One way this happens is through epigenetic processes that change the activity of genes.
The disproportionate burden of pollution and other harmful environmental exposures falling mainly on disadvantaged neighborhoods and people with less wealth, social status, and influence.
Differences in health status experienced by groups of people disadvantaged because of their race, ethnicity, religion, socioeconomic status, gender, age, mental health, physical disability, sexual orientation, geographic location, or other characteristics historically linked to discrimination or exclusion.
An ideal envisioned by public health experts in which all people can achieve their best health without being disadvantaged by various factors. The goal is for people to have the same and equal opportunities in order to reach their full health potential. However, social determinants such as economic, social or environmental issues can lead to differences that can create gaps among different groups of people, or health disparities.
Health in all policies (HiAP)
This public health strategy emerged in Europe and is now gaining traction in the U.S. It calls upon political leaders and policy makers to explicitly consider the health impact of the priorities they set in education, taxes, recreation, transportation, housing, and other arenas beyond strictly defined health care or public health.
Healthy People 2020
Health People 2020 is a U.S. federal initiative to improve the nation’s health. Key for health care journalists, though, is its online data search offerings across topic areas, a trove of potential story ideas or data to inform a narrative.
Hispanic Community Health Study (SOL Study)
The Hispanic Community Health Study (also known as the SOL Study) is an epidemiological project to study health of Hispanic Americans in the U.S. Although Mexican Americans represent the vast majority of the more than 16,000 adults recruited for it, researchers also enrolled people of Cuban, Dominican, Puerto Rican and Central and South American descent. The project has been run out of four institutions: the University of Miami (Coral Gables, Florida), Albert Einstein College of Medicine (Bronx, New York), San Diego State University (San Diego, California), and the University of Illinois at Chicago.
Since the study's launch in 2006, researchers have collected data on baseline health markers such as blood pressure, cholesterol levels and diabetes diagnosis to study cardiovascular disease and cancer risk among participants. For epidemiologists studying health disparities among ethnic and racial groups, the study has been a boon, in part because it has allowed them to study quality of health differences among Hispanic American groups.
Findings from one study that looked at diabetes rates, for instance, showed that Mexican American, Puerto Rican and Dominican adults were more likely than South American adults to have diabetes. According to results from one study, Cuban adults were less likely to be obese compared with their Mexican American and Puerto Rican peers.
HCHS/SOL is sponsored by several institutes, centers and departments affiliated with the National Institutes of Health, including the National Heart, Lung, and Blood Institute (NHLBI).
Learned stereotypes and prejudices that operate automatically and unconsciously when interacting with others. Also referred to as unconscious bias. When a person’s actions or decisions are at odds with their intentions this is implicit bias.
Also known as the wealth gap, the divide between the rich and the poor has come to broadly define income inequality. Such gaps are measured based on household disposable income, most notably by the Gini index, according to the Organisation for Economic Co-operation and Development. Sometimes called "economic inequality," the wealth gap can vary from county to county, state to state and even nation by nation, and offers an indication of how resources are spread in a society.
Index of disparity
Used in statistical analysis. The index is developed based on using the usual categories of social determinations such as education or income, but correcting them for population weights. How big each category is reflected in a graphic representation of the proportion of a population that is reflected in each ordered group within the category. An example of how such a graphic might look is here, taken from this paper, whose authors initially described this tool.
One of the key factors in the social determinant of health, decisions that a person makes and how they act can impact their risk factors, health status and disease outcomes. Examples of such behaviors include whether or not to use tobacco, have unprotected sex, abuse drugs or consume alcohol. One’s diet and physical activity levels are also considered individual behaviors as are some other public health measures such as hygiene and hand washing. Related to Behavioral risk factors and Health behaviors.
Jackson Heart Study
The Jackson Heart Study is a longitudinal project to study heart and stroke risk among Black adults; it has been called by some researchers the Framingham of Black Americans. Launched in 1998, the study is a collaboration of four entities: Jackson State University, Tougaloo College, the Mississippi State Department of Health and the University of Mississippi Medical Center. More than 5,000 adults ages 35-84 were recruited for the project, and a separate cohort was selected to study the health of relatives of participants. By 2017, about a fifth of the participants had died. For more than 20 years now, researchers and physicians have been collecting baseline health data such as blood pressure, cholesterol level and diabetes diagnosis. And investigators have collected information on income level, educational attainment, health care access and other social determinants of health. Participants are also sharing their experiences with racism to enable researchers to study the effects of racism on overall health. The Jackson Heart Study receives funding from the National Heart, Lung, and Blood Institute (NHLBI) and the National Institute on Minority Health and Health Disparities (NIMHD).
Sustained exposure to lead can cause long-term health problems, most notably neurological damage. While no level of lead in the blood is safe, the U.S. Centers for Disease Control and Prevention’s “advisory” level for concern is 10 µg/dL to 5 µg/dL for children and adults. Other U.S. agencies, however, have set their own level for acceptable lead levels – in the blood, air, food, water, soil and paint – that would trigger regulatory action. A known toxin, lead can impact brain development and cause behavioral problems, particularly among children. Its health impacts are cumulative.
Initiatives that set out to tackle health inequalities often pay lip service to the social determinants of health (quality education, safe neighborhoods, reliable employment). But public health officials tend to drift “downstream” to focus on individual behaviors (smoking, diet, alcohol, drugs) and to ignore the “upstream” drivers of these behaviors — the fundamental causes.
Feeling alone can have both psychological and physical impacts, from causing aggression or social anxiety to sleep loss, changes in the brain, and elevated stress hormones. Loneliness in modern society has grown to become a public health concern as isolation and changes on social and community structures change the way people live. Some studies also suggest there may be a genetic component to why being alone may weigh more on certain people.
Maternal mortality rate
The number of women who die each year per every 100,000 live births. To classify as maternal-related, the death must be linked to childbirth or the management of the birth. It cannot be due to an accident or another incidental cause. Estimates of the rate vary, but in the United States it ranges from 21 in 2010 (CIA World Factbook), 17.3 in 2013 (U.S. Centers for Disease Control and Prevention) and 14 in 2015 (World Bank). Some other analyses in peer-reviewed journals have estimated an even higher rate. There is also considerable fluctuation between U.S. states, and country-to-country. In 2015, Sierra Leone had the highest rate worldwide, while Greece, Poland, Finland and Iceland had the lowest rate, according to the World Bank.
Members of this generation of young adults include those born between 1992 and 2000. According to the U.S. Census Bureau, there were 83.1 million millennials in 2014, representing more than 25 percent of the U.S. population.
The manifestation of life events that are “extreme and unprecedented” that cross a moral line and can cause harm to individuals involved in the act. Similar to psychological trauma, moral injury can cause anxiety, anger, guilt and even self-harm, among other injuries. It can affect a range of workers from soldiers and police to journalists and emergency personnel. Experts have said while moral injury and post-traumatic stress disorder (PTSD) can overlap, moral injury involves some form of transgression, although more research is needed.
This up-and-coming field looks at how nutrients from food can impact how one’s individual genes are expressed. This field of study looks at how diets can impact disease as well as illness prevention. Scientists are also looking at how food and its nutrients can protect genes or damage them, a concepts known as “genome health.” Nutrigenomics’ role is being studied in relation to obesity and diabetes as well as maternal health, Crohn’s disease and other conditions.
A term used in the health assessment of an entire group of people. “Population” often refers to those in a certain geographic area or with the same characteristics, but it can also refer to those cared for by a particular health care provider or whose care is covered by the same insurer or other payer. Additionally, it could refer to primary care patients or another set of patients in the health care system. Although sometimes interchanged with the term public health, it invokes a broader connotation regarding efforts to promote health and prevent disease.
An alternative way to compare the health of different populations is to add up the potential years life lost (PYLL) due to premature death, defined by a standard cut-off age. If the standard age is defined as 70, a death at age 5 counts as 65 potential years of life lost, while a death at age 60 counts as 10 potential years of life lost.
Sometimes referred to as psychoendoneuroimmunology, psychoneuroimmunology (PNI) is the study of the interaction of the brain and the body. More specifically, it examines how physiological issues can impact one’s propensity for disease; how stress can weaken the immune system and cause illness is one example.
Although sometimes used interchangeably with the term population health, “public health” is increasingly used to reference a narrower set of actions linked to or taken by official government agencies and other organizations.
Higher social standing may help people build psychological resources, or a reserve capacity, to cope with stressors more resiliently so as to minimize damaging physiological responses.
The ability to recover or “bounce back” from difficult situations or challenging circumstances. Such capacity could be at an individual level or a collective one such as a local community. The power to respond to certain challenges such as stressors, crises or other conditions can play a role in both mental and physical health. It is also contributes to one’s overall well-being. Factors that could potentially influence resilience include social networks, adaptability and interventional actions, among others. However, resilience “is not a trait that people either have or do not have. It involves behaviors, thoughts and actions that can be learned and developed,” according to the American Psychological Association.
In general, “rural” refers to places outside of a city, or as HHS’s Health Resources and Services Administration puts it: “Whatever is not urban is considered rural.” But that leaves out areas such as the suburbs or mostly-rural counties with one city center. The federal government uses more than 15 different definitions for “rural,” according to the Rural Policy Research Institute. The U.S. Office of Management and Budget defines it as a county that does not have an urban core of 50,000 people, so it could include areas with some denser “micropolitan” areas. The U.S. Census Bureau, however, does not use county or other borders, and defines rural as any area that falls outside one with 50,000 or more people or one with a densely settled core of between 2,500 and 49,999 people. Whether an area is classified as rural can impact health policy, for example in determining eligibility for certain grants.
Health and longevity tend to decrease with poverty and social isolation, and increase with wealth and social status. This link between socioeconomic status and health, the SES-health gradient, persists even among people in the middle and upper ranges of social advantage, many studies have shown.
Sometimes confused with gender identity, sexual orientation refers to one’s attraction to other people based on their sex. Heterosexuals are those attracted to someone of the opposite sex. Homosexuals are attracted to someone of the same biological sex, although the term has fallen out of favor – gay or lesbian is the one now used by the AP Stylebook, although it is still used in some medical terminology. Bisexuals are those attracted to both male and females.
Unlike traditional wealth, social capital is a nod to the relationship connections in one’s life that cannot be given financial weight but that can be equally impactful. The collective value of social capital comes from the bonds of human networks that people create. Such a resource can help provide information, assistance and other benefits that do not carry a price tag but have distinct value. As modern society continues to shift, however, the notion of social capital is also evolving. “Today it would be hard to come up with a single definition that satisfied everyone,” according to researchers at the Organisation for Economic Co-operation and Development (OECD) .
Socioeconomic status (SES)
A person’s social class, or place in the hierarchy of power and self-determination can be quantified using measures of socioeconomic status. The typical measures are proxies such as years of education, income level, occupation, and sometimes residential location.
Social determinants of health
The conditions in which people are born, grow, live, work, and age are mostly responsible for health inequalities—the unfair and avoidable differences in health that divide populations. Economic and social disadvantage make people more vulnerable to illness, disability, suffering, and premature death. For convenience, researchers studying the social determinants of health tend to focus on a limited set of markers of social status, such as income, education, occupation, race or ethnicity, and neighborhood qualities (home ownership, property values, degree of segregation).
Social determinants of health (income, education, social class, etc.) are sometimes referred to as “structural determinants” by those who want to emphasize their primary role in shaping health inequalities. Structural determinants exert their effects through intermediary determinants such as housing and neighborhood quality, stressful living circumstances, access to care and support, and health behaviors.
Targeting with universalism
Providing programs and services in a way that they will be available to everyone, including (and maybe especially) targeting higher-risk or often-excluded populations.
Social disadvantage appears to accelerate aging at the cellular level as indicated by the length of telomeres, the protective sections of DNA at the tips of chromosomes that shorten with age. For example, children who experience chronic stress from a disadvantaged life have shorter telomeres than their advantaged peers, according to a recent study of 9-year-old African-American boys. Adults who completed less than a high school education had significantly shorter telomeres than those who graduated from college, in another study. The evidence is far from conclusive, however. Some investigators have found inconsistent correlations between telomere length and socioeconomic status.
A method of care or treatment that seeks to examine a person’s past history of trauma and focus on how it has impacted their behavior or health. This focus on past traumatic events is used in a range of fields, including medicine, education and criminal justice. While trauma-informed approach can be integrated into models used by physicians, therapists, counselor, judges, teachers and others, specific trauma intervention programs have also been created. Overall, assessing past trauma and how it has impacted a patient’s situation aims to help better address their needs and choose the best care.
Traumatic stress injury
Some military experts, psychiatrists and other advocates have been pushing for the renaming of post-traumatic stress disorder to post traumatic stress injury, or TSI, as a way to reduce stigma and increase treatment. Although the American Psychiatric Association did not adopt the term when it revised its mental illness manual in 2013, the term is still used among some veterans groups, clinicians and others who say it helps people seek care.
Uncontrollable risk factor
While there are some things people can do that can either increase or decrease their risk for disease, there are other factors that can have an impact but cannot be controlled. These include age, gender and race as well as other heredity factors that are part of one’s genetic make-up that show up in family history or DNA testing.
Medically underserved populations are those who lack access to health care services such as low-income people, the homeless or other subgroups who face barriers to care from economic, cultural, language or geographic challenges. Certain regions can also be underserved when an area faces a shortage of care providers. Also referred to by the federal government as Medically Underserved Areas and Populations (MUA/Ps).
The U.S. health care system is really more of a “sick care” system. Recognizing this, some health professionals have started trying to assess and improve the “upstream” social and environmental conditions that shape health outcomes. The movement gets its name from a parable about children being swept down a river. Rescuers make heroic efforts to save one child after another from drowning until finally it dawns on them to venture upstream to stop whoever is throwing the children in the river. The upstream movement is exemplified by HealthBegins, an online community founded by Dr. Rishi Manchanda, author of the book The Upstream Doctors; and the Canadian nonprofit Upstream, directed by Dr. Ryan Meili, a family physician in Saskatoon.
Cities in America have sprawled so much that researchers call them “metropolitan statistical areas,” or MSAs. Urban areas are less based on exact city boundaries and more on density to include a wide swath of surrounding suburbs. U.S. federal agencies define metropolitan areas as those with a “core” of more than 50,000 people. That could be a city, or a larger area covering several counties in a state. Specifically, the U.S. Census Bureau also recognizes urban “clusters” that include areas that have at least 2,500 but less than 50,000 people. The New York-Newark area is the nation’s most populated urban area, according to the 2010 Census, followed by the Los Angeles-Long Beach-Anaheim area, and the Chicago area.
Some evidence suggests that greater exposure to adverse social conditions and physical environments produces a chronic stress response that over time accelerates wear and tear on physiological systems. This “weathering” hypothesis has been proposed to explain why African American women who give birth in their twenties face greater risk of infant death than those who give birth as teenagers. The opposite is true for most other women in the United States, who face greater risk as teenagers.
Finding traditional health systems ineffective at addressing the social determinants of health, some communities are trying to establish public trust funds to help deliver preventive health and support. The Prevention and Wellness Trust Fund of Massachusettsis probably the most ambitious to date. The Trust has $60 million to spend over four years on grants to communities, health care providers, regional-planning agencies, employers and other entities. The money comes from a tax on insurers and an assessment on large hospital systems.
The Whitehall Study of British Civil Servants, started in 1967, famously showed that men in the lower employment grades were more likely to die prematurely than men in the higher grades. Whitehall II, launched in 1984, is tracking a larger group and includes women.