An Equitable Approach to Structural Determinants of Health
How much control do you have over your health? Let’s say heart disease runs in your family. In order to avoid that prognosis, you decide to exercise regularly, eat a heart-healthy diet, and regularly visit your primary care doctor. You believe that by taking into account your genetics and your behavior, you can maintain good health while avoiding the chronic conditions that affect your family members.
While diet, exercise, and health care access are important, they aren’t the only factors that influence your predisposition to certain conditions. Both acute and chronic exposures to social and environmental factors impact our health. The World Health Organization (WHO) defines social determinants of health as the “conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” These include stressors occurring via physical, social, economic, environmental, and political structures.
According to the Kaiser Family Foundation, social determinants of health can include:
- Economic stability (employment, income, expenses)
- Physical environment (housing, transportation, walkability)
- Education (literacy, higher education, vocational training)
- Food (access to healthy options)
- Community (social integration and engagement, support systems, discrimination)
So much of what impacts the health of an individual occurs externally and then manifests internally. Where people live, their housing quality, the types of transportation available to them, state or national policies that limit or expand people’s access to health care or health coverage, their communities’social norms, and the discriminations they face are all factors that affect people’s health and quality of life. The distribution of resources and power within and between communities also shapes the social determinants that affect the health of people within those communities.
Both the availability and accessibility of resources can also be affected by social and environmental determinants. Even though, for example, you know that maintaining a balanced diet is important to your health, your ability to access healthy food is dependent on where you live, available transportation to food stores, and your budget. Your choices are dependent on the options your environment offers.
Health is also dependent on the distribution of power at the population level. According to Barry Levy and Victor Sidel, both past presidents of the American Public Health Association (APHA), “Social injustice occurs when those who control access to opportunities and resources block poor people, powerless people, and others from gaining fair and equitable access to these opportunities and resources.”
Much of the focus of public health has been on behavior change at the individual level. While this is a crucial component to improving health outcomes, it is not always adequate in addressing barriers to health equity. Many of these barriers stem from the systemic level. For behavior change to take place at the individual level, people must have the self-efficacy, and the opportunity, to make sustainable changes in their behaviors. Injustice limits this self-efficacy, and creates structural barriers to life and health opportunities, which then limits the extent of sustainable behavior change. In other words, health behaviors take place and context — and when the context is unjust and inequitable, change to advance public health needs to address that context.
Often the terms inequity and inequality are used interchangeably. Yet, they represent very distinct concepts. In health, equality means everyone is treated the same and is given access to the same resources. However, equity means people have access to the resources they need to maintain a healthy life. An equity perspective recognizes the relative social advantage and disadvantage different populations face.
The American Public Health Association defines health equity as everyone having the opportunity to attain their highest level of health. According to the Robert Wood Johnson Foundation (RWJF), “Health equity means that everyone has a fair and just opportunity to be healthier.” RWJF adds that achieving health equity “requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”
Equity is the process through which equality is achieved. The online MPH@Simmons program looks at public health through the lens of equity because this lens takes into account the structural social, economic, and environmental factors that impact people’s lives. Equality alone doesn’t always address the social determinants of health at the systemic level. Our role as public health professionals extends beyond offering generic solutions to each individual.
Effective population health policies and structures can remove barriers that limit self-efficacy and opportunity of individuals and communities. Fighting prejudice, discrimination, and oppression starts with understanding what they are and where they come from. Achieving equity in health care and health outcomes requires learning from both individuals and communities in order to understand their particular social determinants of health and how they can be addressed structurally at a population level.