Description
Read Social Determinants of Health: How Social and Economic Factors Affect Health from the Los Angeles County Department of Public Health.
Imagine you work in a department that deals with health services and epidemiology in a large city and wants to implement programs in your new home, which is a small city that exhibits some of the negative determinant factors of health outlined in the paper.
Write a plan in 700 words that you can present to the public health authorities in your community. The plan must address the following:
How to increase awareness of the specific problems affecting the community
How to effectively build, support, and lead partnerships with government and non-government agencies to affect change
How to use, adapt, or enhance existing community resources to implement the programs
A review of “Health in All Policies” (HiAP) to determine its applicability to your community
The means to evaluate the effectiveness of the program at designated future time intervals to ensure sustainability
Please be mindful your paper is formatted using APA guidelines, and includes a title page, and reference page.
Format your assignment according to APA guidelines, APA style 7th edition.
Submit your assignment.
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Social Determinants of Health
How Social and Economic
Factors Affect Health
January 2013
Our Social Environment
Health and health problems result from a complex interplay of a number of forces. An individual’s healthrelated behaviors (particularly diet, exercise and smoking), surrounding physical environments, and health
care (both access and quality), all contribute significantly to how long and how well we live. However, none
of these factors is as important to population health as are the social and economic environments in which
we live, learn, work, and play. We refer to these factors collectively as the “social determinants of health.”
This report (first in a series) focuses particularly on the “social environment,” defined as the combination of
social and cultural institutions, norms, patterns, beliefs, and processes that influence the life of an individual or community.1 Included are two eye-opening scenarios (“One Path” and “A Better Path”) to illustrate how
social determinants of health can greatly affect the lives of individuals. In addition, a series of recommendations introduce ways to move forward in realizing our vision of “Healthy people in healthy communities.”
How Do Social Determinants Affect Health?
Social determinants play a crucial role in the health of each individual in Los Angeles County as well as collectively in our community. Inequities in the structure of societal resources vary and can be striking. Such
inequities can mean the difference between life or death, or a life filled with vigor and good health or one
plagued with chronic disease and poor health.
Education level, employment, income, family and social support, and community safety are all components
of social and economic determinants of health. For a glimpse of how these complex factors can influence a
person’s daily life, read the following scenario:
One Path
A low birth weight infant is born. Why? He was born 10 weeks early,
weighing two pounds. His teenage mother grew up in a family where
high-fat meals with few fruits and vegetables were the norm and in a
family situation marked by violence and substance use. She did not have
access to family planning services, and hers was an unplanned pregnancy.
At the time, she worked for minimum wage in a neighborhood fast-food
restaurant in a locality that did not have a “no-smoking” ordinance in
effect, and although not a smoker herself, she had extensive exposure to
secondhand smoke. Her employer, a small business owner, did not provide health insurance but did provide his
employees with no-cost meals on both ends of their shifts.
When her over-the-counter pregnancy test was positive, she tried to find a health care provider who would see
her, but there was no obstetrical care available in her immediate community, and the closest facility that took
care of uninsured women was located some distance away. She did not have a car, and there was no public
transportation in her neighborhood. She knew she needed to provide additional nourishment for her fetus, so
she began to eat larger amounts of the high-saturated fat, high-salt foods that were available at her job.
Even if she had been able to access prenatal care, she might have had difficulty. Her neighborhood had no
place where fresh fruits and vegetables were available. Her street had no sidewalks and poor walkability. Without nearby parks or recreational facilities, regular exercise was not easily accessible. And she needed her job, so
exposure to secondhand smoke would not have diminished.
Nevertheless, had she entered the medical care system earlier, her pregnancy-related hypertension would
have been identified and controlled. Instead, at 29 weeks of pregnancy, she developed a severe headache and
visual problems, and she was rushed by taxi to the regional hospital where she was diagnosed with severe
pre-eclampsia. When her blood pressure could not be adequately controlled, an emergency team delivered her
premature son. His immature lungs were supported for several weeks by a ventilator in the neonatal intensive
care unit and eventually he was sent home, with significant cognitive deficits. The stressed educational system
was unable to provide the individual educational support needed and at 15, he dropped out of high school.
2
Los Angeles County Department of Public Health
What Determines Health
While the previous scenario is fictional, unfortunately it is all too plausible. The U.S., despite spending far
more on medical care than any other country in the world, has poorer health outcomes than most other developed countries. The U.S. ranks 34th among the world’s nations in infant mortality.2
It is possible, however, to envision a different and more promising ending to this story if a number of changes
were made in how our society understands and promotes the basis of health. In contrast to “One Path” above,
read “A Better Path” on page 19, to see how social and economic determinants of health can positively affect
the health and longevity of Los Angeles County Residents.
Models or “logic models,” though necessarily approximate and oversimplified, can help us think about this
complex interplay of factors and where we might take action to improve population health. The diagram
below, (Figure 1) from the effort to develop a new framework of health goals for the nation, “Healthy People
2020,” is one such model and is referred to as the ecologic or social-ecologic model of health.1
Figure 1.
Action Model to Achieve Healthy People 2020 Goals
Determinants of Health
Ind
Bro
ad
so
c
L
Soc
ial
,
Across life span
Outcomes
• Behavioral outcomes
• Specific risk factors,
disease, and conditions
• Injuries
• Well-being and
health-related QOL
• Health equity
es
els
lev
al
c
lo
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Innate individual
traits: age, sex
race, and
biological
factors
l conditions a
enta
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ro
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en
• Policies
• Programs
• Information
tworks
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ty
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Interventions
c, cultural, hea
omi
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a
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dual Beha
ivi
al, national, s
glob
ta
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the
,a
at
nd
Assessment, Monitoring,
Evaluation & Dissemination
It is important to note that this model includes a time dimension reflecting the impact of these factors not just
at any given point but across the entire course of a lifetime, or “the life course.” Research shows, for example,
that poverty in childhood has long-lasting effects limiting life expectancy and worsening health for the rest
of the child’s life, even if social conditions subsequently improve.3 At the same time, health-promoting social
environments can enhance health status and health outcomes at any point across the life course.
In the course of its history, public health has focused on what was believed to be the most important source of
mortality, disease, injury, and disability. In the late 19th and early 20th centuries, public health concentrated
particularly on the physical environment. Improvements in, for example, clean water supplies, healthier housing, sanitation, workplace safety, and safe food led to sharp increases in average life expectancy.4,5 The later
decades of the 20th century concentrated on expanded access to medical care, resulting in further expansion
of life years, particularly life expectancy once one reaches age 65.6 In recent decades, research has increasingly
shown how powerfully social and economic conditions determine population health and differences in health
among subgroups, much more so than medical care.7
Social Determinants of Health: How Social and Economic Factors Affect Health
3
Figure 2. County Health Rankings Model
Health Outcomes
Mortality (length of life) : 50%
Morbidity (quality of life) : 50%
Tobacco use
Health behaviors
(30%)
Diet & exercise
Alcohol use
Unsafe sex
Clinical care
(20%)
Access to care
Quality of care
Health Factors
Education
Social & economic factors
(40%)
Programs
and Policies
Physical environment
(10%)
Employment
Income
Family & social support
Community safety
Environmental quality
Built environment
Adapted with permission from www.countyhealthrankings.org/our-approach.
How much do the different broad determinants of health contribute? One thoughtful recent effort, combining the best recent research and analysis, is presented in Figure 2.8,9 A population’s health is shaped 10% by
the physical environment, 20% by clinical health care (access and quality), 30% by health behaviors (themselves largely determined by social and physical environments), and 40% by social and economic factors. The
specific indicators used by the County Health Rankings for each of these four domains are shown in the right
column.
The social and economic factors are not only the largest single predictor or driver of health outcomes, but also
strongly influence health behaviors, the second greatest contributor to health and longevity. The lower the
social and economic position of a population or community, the more common are unhealthy behaviors and
the more difficult it is to practice healthy ones. Conversely, the better the social environment, the more possible and likely it is to adopt and sustain healthier behaviors.
Chart 1 illustrates how education and health behaviors interact to impact health outcomes.10 Being in less
than very good health is the health benchmark (50.9% of LA County residents and 45.2% of U.S. residents
report that they are in less than very good health). Health behaviors (physical inactivity and smoking) were
associated with a smaller difference in health status at the lower educational levels, perhaps because lower
education status itself was a much more important contributor to health than the health behaviors.
4
Los Angeles County Department of Public Health
Percent with Suboptimal Health
Chart 1. Percent of Adults Reporting Suboptimal Health by Education Level and
Participation in Healthy vs. Unhealthy Behaviors, Los Angeles County, 2007
90
83.9%
Unhealthy Behaviors
Healthy Behaviors #
75.6%
60
62.5%
59.0%
49.7%
40.3%
53.6%
37.5%
30
42.2%
23.7%
0
LA County
Less Than
High School
High School
Some College
College or Postor Trade School Graduate Degree
#Healthy Behaviors= non-smoker & meets physical activity guidelines
Results are age-adjusted to 2000 US Standard Population. Self-reported health status: Suboptimal is poor, fair or good.
Includes adults age 25-74 years. Source: Los Angeles County Health Survey, 2007.
This chart also illustrates that higher levels of education are not only associated with better health, but that in
general, higher educational attainment is correlated with better health at each step along the ladder or
continuum, controlling for behaviors. The same graduated relationship holds for the other major social
determinants, such as income and employment. This phenomenon is called the social gradient of health.
What’s in This Report (and What’s Not)
This report gives a snapshot of how a few key social environment indicators vary by city and community
across Los Angeles County. Comparisons are made by standard demographic categories as well by comparing how the County is doing relative to California and the nation. The selected indicators include some of the
most powerful predictors of health: education, income/poverty, housing burden and economic hardship overall. There are other important social indicators as well, including those related to employment and working
conditions; community cohesiveness, social support and civic engagement; community safety; and legal and
social equity. Standard, consistent measures for some of these domains, such as those related to social cohesion and justice, are unfortunately not yet available across LA County communities. Others are highly variable, as with unemployment, and current values could be misleading. Still others, such as a fuller exploration
of housing and of food security, will be subjects of future reports.
Examples of how these complex problems have begun to be tackled by public and private organizations are
included. The are primarily intended to be illustrative of the kinds of actions that can be taken.
How This Information Can Be Used
Together with recent and forthcoming reports on various risks, health status, and outcomes, this report brings
focus to the considerable gaps and disparities in the social environment that largely determines differences in
average health status from city to city across LA County. This, in turn, emphasizes that overall health
cannot be substantially improved and disparities reduced without more comprehensively and directly adSocial Determinants of Health: How Social and Economic Factors Affect Health
5
dressing these “upstream” determinants. Individual cities and communities as well as Countywide agencies
and organizations can use these data as a starting point for examining the reasons behind these disparities,
setting achievable goals for improved health for all residents, and taking appropriate action.
Study Methods
Selecting Indicators
Analysts in the LA County Department of Public Health conducted a comprehensive review of the literature
and available databases for social determinants indicators that met key criteria: strong evidence for correlation
with health status and outcomes; statistically valid and reliable; representative of the County’s entire population; and sufficiently detailed to allow geographic and demographic breakdown. While the measures presented in this report are clearly critical ones, other promising indicators could not be included because a measure
and data source that presently met the above criteria could not be identified.
One broad measure used below is the Economic Hardship Index (EHI),11 which is itself a combination of six
indicators:
1. Crowded housing (percentage of occupied housing units with more than one person per room)
2. Percent of persons living below the federal poverty level
3. Percent of persons over the age of 16 years who are unemployed
4. Percent of persons over the age of 25 years without a high-school education
5. Dependency (percentage of the population under 18 or over 64 years)
6. Per capita income
Each component is equally weighted and standardized across all cities/communities. The index can range
from 1 to 100, with a higher index representing a greater level of economic hardship. The 117 cities and communities were ranked by economic hardship, with 1 being the least level of economic hardship and 117 being
the greatest.
Additionally, city/community data are presented for the following individual indicators:
1. P
ercent of persons over the age of 25 without a high-school diploma or its equivalent (the same as one of
the EHI components, but highlighted separately as well)
2. Housing burden (percentage of households spending more than 30% of their income on housing)
3. Median household income
4. P
ercent of people living in households with an income of less than 200% of the federal poverty level. In
2009, this level amounted to an annual income of $21,660 for one person or $44,100 for a household of
4 persons, and it approximates the income needed for a household in LA County to meet its basic costs
without public assistance or subsidy, known as the “Self-Sufficiency Standard.”12
These four indicators expand the information yielded by the EHI. Each city/community is ranked for each
of these indicators, with 1 meaning, respectively, the smallest percentage of persons without a high school
diploma, lowest housing burden, highest median household income and highest percentage of households
meeting the Self-Sufficiency Standard (i.e. lowest percentage below 200% of the Federal Poverty Level).
Data Sources
The data come from the U.S. Census Bureau’s 2005-2009 5-Year American Community Survey (ACS). The
ACS is an ongoing survey that provides data every year to help communities, state governments and federal
agencies plan investments and services. Using combined five-year results allow the comparison across 117 different incorporated cities, Los Angeles city council districts and unincorporated communities in LA County.
6
Los Angeles County Department of Public Health
Findings
Education
Among all residents of Los Angeles County in 2005-2009
who were more than 25 years of age, 24.5% have less than a
high-school education (Table 1). This proportion is significantly greater than in the United States as a whole (15.4%)
and greater than the statewide proportion for California
(19.5%).13 The lack of a completed high-school education could be considered a “cumulative or final dropout
rate.” School dropout rates are inconsistently measured and
reported, but this census-based measure shows how many
individuals by age 25 do not have a high-school diploma
or its equivalent; i.e. dropped out at some point and never
went back to finish.
Housing
Over half (50.7%) of households in LA County are classified as “housing-cost burdened,” meaning that more than
30% of income must be devoted to housing. This measure
combines both renters and homeowners, each representing about half the County’s households. The limit of 30%
of gross income for acceptable housing costs has been used
for several decades in both rental subsidy programs and in
the granting of federally guaranteed mortgages. This level of
housing burden is the second highest in the nation among
major metropolitan areas, after Miami, for both renters and
homeowners considered separately.14
Examples of Communities Taking Action
Shasta County, CA
The county Health and Human Services Agency, Public Health, decided to address the
county’s rank as the second least healthy county in the state by focusing on the strong link
between education and health and, specifically, the county’s low proportion of residents
with a college education. The public health agency is assigned the lead in the Shasta County
College and Career Readiness Initiative, a collaboration among the Health and Human Services Agency, the county Office of Education and College OPTIONS – itself a public-private
partnership among higher educational institutions, local school districts and local philanthropies. The project is training school leaders, counselors and parents to help get middle and
high school students ready for college, and making structural changes in college policies and
financial aid that will facilitate increased enrollment.15
Social Determinants of Health: How Social and Economic Factors Affect Health
7
Income and Poverty
The median household income in LA County for 2005-2009 (in 2009 inflation-adjusted dollars) was
$54,828. This is somewhat higher than for the U.S. as a whole, $51,425, but lower than the statewide median
for California, $60,392.
The proportion of LA County residents living in households with incomes below twice the national poverty level
(200% Federal Poverty Level or FPL) is 37.3%. The proportion of LA County individuals below the FPL, which is
uniform across the nation regardless of local cost of living,
is 15.4%, compared with 13.5% for the nation and 13.2%
for California. When adjusted for cost of living, Los Angeles
County’s poverty rate is 26%, higher than any other county
in California.16 Furthermore, the poverty rate in Los Angeles County is not decreasing and is nearly twice as high as it
was in 1969.
Economic Hardship
The Economic Hardship Index (EHI) ranges from a low of 12.6 in Hermosa Beach to a high of 83.8 in Los
Angeles City Council District 9 and is presented both in the main table (Table 1) and as a map of the cities
and communities (Map 1).
Examples of Communities Taking Action
City of Richmond, CA
Recognizing that the intersection of violent crime, unemployment and “revolving-door”
incarceration negatively affect the overall health of the community, the City of Richmond
and community partners obtained funding for the Safe Return Re-Entry Project. Richmond
stands out as an area receiving disproportionately high numbers of people returning from
prison. Upon release, former inmates grapple with a variety of urgent needs, from getting a new ID to finding a living wage job to safe, affordable housing. These needs are
largely unmet, contributing to Richmond being regularly ranked among the areas with the
highest violent crime and recidivism rates. The project aims to improve community health
and safety by improving the current system for reintegrating former inmates into the
Richmond community, using policy research and advocacy to establish a one-stop referral
center for people returning from prison, increase the amount of accessible medium-term
housing and revise the personnel and contracting policies to level the playing field for applicants with past convictions. The city and state are active partners in a collaboration led
by a faith-based community organization and a nonprofit research and policy institute that
applies science-based solutions to economic development and social equity issues.17
8
Los Angeles County Department of Public Health
Table 1. Key Social and Economic Indicators, by City and Community, ranked by Hardship.
Los Angeles County, 2005-2009
City/Community
Los Angeles County
Los Angeles City
Hermosa Beach
Palos Verdes Estates
Malibu
Redondo Beach
Manhattan Beach
San Marino
El Segundo
La Cañada Flintridge
Santa Monica
Agoura Hills
Sierra Madre
LA City Council District 5
West Hollywood
LA City Council District 11
Calabasas
South Pasadena
Walnut
Beverly Hills
Rancho Palos Verdes
Diamond Bar
Claremont
Culver City
La Crescenta-Montrose
San Dimas
Arcadia
View Park-Windsor Hills
Torrance
Cerritos
Lomita
Glendora
Lakewood
Signal Hill
Burbank
LA City Council District 4
LA City Council District 12
Hacienda Heights
Monrovia
Santa Clarita
La Verne
Temple City
Rowland Heights
La Mirada
East La Mirada
Altadena
East San Gabriel
Pasadena
West Carson
LA City Council District 3
Glendale
Whittier
LA City Council District 2
Charter Oak
Alhambra
West Covina
Quartz Hill
San Gabriel
Duarte
Monterey Park
Carson
Covina
Artesia
Gardena
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