Why We Need to Talk About the Social Determinants of Health
Written by: Gabriela Olguin-Flores, RD, LD
At the start of every new year, we witness the rise of all things related to health and well-being. As I write this blog during the early days of January, upon opening the App Store I find “10 Great Healthy Eating Apps” alongside the Must-Have Apps List that includes TikTok and a plethora of dating apps. Scrolling down, different apps are suggested to harness productivity or reach fitness goals. None of these apps are inherently good or bad, and we are not here to judge or critique what you download on your phone. However, it is a disservice to not bring up all the determinants- especially the social determinants- of an individual’s health during the time of the year that focuses on and promotes how the individual can- and should- make changes to enhance their overall health.
The Impact of Healthism
Before we jump into the different determinants of health, I want to acknowledge the central theme of healthism we are all witnessing whether we know it or not. Amid the new self care and holistic well-being wave seen in the 1960s and 70s, sociologist Robert Crawford described healthism as “the preoccupation with personal health as a primary- often the primary- focus for the definition and achievement of well-being; a goal which is to be attained primarily through modification of lifestyles.” He goes on to write about how healthism “situates the problem of health and disease at the level of the individual. Solutions are formulated at that level as well.” His critiques on the effects of healthism are continuing to play out 40 years later.
In 2024 healthism can sound something like this: Only when we download all the food and movement apps, keep up with health-promoting habits and behaviors, go to the doctor office regularly, and appear the way society deems “healthy” is when we can achieve health by healthism standards. Forget about genetics, communicable diseases, autoimmune diseases, environment, education, access to resources, or social status impacting your health. As long as the individual is the only one responsible for their health status, blame can be placed upon the individual when they are not considered “healthy.” By healthism standards, the onus of improving health is placed on the individual instead of calling upon community and government to intervene.
Exploring Determinants of Health
Now that we have a better understanding as to what healthism is and how it can manifest in our life, we can think more critically about the determinants of health beyond individual behavior. As a clinician, one of my favorite pieces to understand from the person I’m sharing space with is what their definition of health is, how it came to be, how accessible is it, and where does it fall on their priority list? If you happen to be a dietitian working with clients one on one, I highly recommend this conversation to be brought up within initial sessions as many people work from the belief that health needs to be a certain body size or are taking on the full responsibility of their health status, which will impact stress and food. Rarely is someone’s definition of health the absence of disease or injury alone. Nowadays many will reference mental health and physical health, however this still can place the onus of health on the individual. “If only I spent more time taking care of myself, then I might be healthy.” When we have a better understanding of how the social determinants of health work, this statement sparks consideration as to why that person does not have the time, bandwidth, or enough resources to take care of themselves. What other determinants of health can be impacting the individual that are out of their control? Perhaps them spending more time can only achieve a certain level of health without outside influence. Let’s take a look at those factors.
The Five Main Categories
Healthcare design studio Goinvo created a visualization of the different factors that have correlated with health outcomes for an individual after reviewing the literature from the following organizations: NCHHSTP, World Health Organization, Healthy People, Kaiser Family Foundation, NEJM, Health Affairs, Institute of Medicine, and New South Wales Department of Health. These were the 5 main categories they determined:
· Genetics 22%
· Medical care 11%
· Social circumstances 24%
· Environment 7%
· Individual behavior 36%
Their website is linked below and goes in-depth of what factors make up each main sector including income and literacy levels, quality of social support, community culture norms, level of crime in your location, exposure to firearms, and so much more. It can feel useless to discuss individual behavior change when a person is faced with a new chronic disease. It can feel useless to discuss eating pattern changes when a person is in burn-out from their job that does not pay them a livable wage. It can feel useless to discuss exercise routines when someone’s safety is threatened due to being discriminated against. A person can implement all the health-enhancing behavior changes they can but what they cannot fully control may have more impact to their health status. Knowing this information is crucial when discussing health and health outcomes.
Improving Patient-Provider Conversations
Especially as medical providers, the way questions are asked can show bias that may decrease the likelihood of patients feeling secure enough to return to medical offices. Far too often assumptions have been made about the way people eat or move their body. These assumptions do not serve the medical provider or the patient. Instead of asking “how much of X food do you eat?” or “how much exercise do you do in a week?” which can elicit feelings of shame, consider asking “What is your relationship to food like these days? Do you think you are eating enough throughout the week?” or “What kind of exercise do you enjoy and how often are you able to engage in a way that feels good for you?” These examples allow patients to give more context around the challenges they could be facing in their day to day that may be impacting their health even more than the food they eat or exercise they get in. Any change that can make for more fruitful conversation between patient and provider is worth considering.
Reflection Questions
· What is your work-in-progress definition of health and does it have to be binary (ie a person can only be healthy or unhealthy)?
· Is it important to you to know someone else’s health status?
· Is it fair to assume a person’s health status by appearance alone?
· What do you think about someone who does not want to or cannot access health?
· As Da’Shaun Harrison points out in Belly of The Beast: The Politics of Anti-Fatness as Anti-Blackness, the World Health Organization defines health as: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. What populations may never achieve health by this definition?
References:
Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness by Da’Shaun Harrison, 2021
Crawford R. Healthism and the Medicalization of Everyday Life. International Journal of Health Services. 1980;10(3):365-388. doi:10.2190/3H2H-3XJN-3KAY-G9NY
