The Social Determinants of Health (SDOH) is a central dogma to the field of public health. There are many different definitions of SDOH from reputable organizations, however, in its simplest form, it refers to the social and economic conditions in which people are born, grow, work, live, and age - working as a system to influence the health of populations. Linda Holdbrook joins the Public Health Insight Podcast to discuss some of these SDOH as identified by the World Health Organization and the importance of incorporating these determinants to achieve effective public health practice. As a prelude to our next episode, we ask the question whether racism or racial discrimination, should replace ‘race’ as a social determinant of health. What do you think?
We would love it if you followed us and shared your thoughts with us through direct messages on Instagram, Twitter, Facebook, or by emailing us at ThePublicHealthInsight@gmail.com
Icon made by Freepik from www.flaticon.com
The Social Determinants of Health (SDOH) is a central dogma to the field of public health. There are many different definitions of SDOH from reputable organizations, however, in its simplest form, it refers to the social and economic conditions in which people are born, grow, work, live, and age - working as a system to influence the health of populations. Linda Holdbrook joins the Public Health Insight Podcast to discuss some of these SDOH as identified by the World Health Organization and the importance of incorporating these determinants to achieve effective public health practice. As a prelude to our next episode, we ask the question whether racism or racial discrimination, should replace ‘race’ as a social determinant of health. What do you think?
We would love it if you followed us and shared your thoughts with us through direct messages on Instagram, Twitter, Facebook, or by emailing us at ThePublicHealthInsight@gmail.com
Icon made by Freepik from www.flaticon.com
[00:00:00] Sully: Public health is a population-based field of science focused on preventing disease and promoting health. Every week, we will be engaging in interactive discussions and analysis of the latest public health issues affecting you and your communities all around the world. This is the Public Health Insight podcast.
[00:00:24] Wil: Hi, my name is Wil, and I'm here today with Gordon, Sully, and a special guest who will be introduced later. Before we move on is important to note that the views expressed in this podcast are our own and do not represent any of the organizations we work for.
[00:00:38] In this episode, we will be talking about the social determinants of health and discuss why they must be considered in order to improve the long-term health and wellbeing for individuals and populate.
[00:00:49] We will then examine the ongoing COVID-19 pandemic from a social determinants of health lens and reflect on some important lessons learned.
[00:00:57] Our guests holds a master [00:01:00] of a public health degree from Western University and is a public health professional based in Calgary, Alberta with experience in patient advocacy, health promotion, and suicide. She is passionate about working towards health equality, health equity, particularly in racialized communities through addressing systemic barriers and challenging acceptance. Please welcome back. Our friend and colleague Linda Holbrook.
[00:01:26] Linda: Whew.
[00:01:27] Wil: Hello,
[00:01:29] Linda: Thank you for having me again.
[00:01:30] Gordon: Our colleague and new cohost.
[00:01:33] Yes, it's on it. You can't back out of it now. It's on there.
[00:01:39] Linda: If you're offering then I'm down.
[00:01:43] Sully: All right, we got it here. It's official.
[00:01:47] Wil: I wanted to start our discussion off today by taking a high-level look at what are the social determinants of health and I think as public health professionals, we realize how important this concept is.[00:02:00]
[00:02:00] So maybe let's start off by some loose definitions and hear what this term might mean for everyone and how they understand the social determined.
[00:02:08] Linda: For me, when I think of the social determinants of health, I like to first start with how health has normally been conceptualized, the traditional or historical definition where it was more so just a biological thing or genetics.
[00:02:22] So it's there's something wrong with your body. You take this medication and then you're fixed. Your problem is solved, but the social determinants offers a broader lens. And these are factors that are beyond just genetics and biology. It's more in regards to the social and economic factors.
[00:02:42] So things like your environment and your education level, income, even things like racism, all those can impact your health and it doesn't have anything to do with just your genetics.
[00:02:55] Wil: Starting point for us to springboard this discussion off of, and [00:03:00] just adding to what you said, Linda, when I think of social determinants of health, I agree with you in that it's the aspects of health that's outside of the traditionally held beliefs of biology and genetics and the scientific things like that.
[00:03:14] Another thing that I wanted to add is that it's also related to the social side or things like the political system and the different social policies or various policies that are in place that play a role in the governance and side of things and things like, even things like economic policies economic systems, things like that, which influence how individuals. As public health professionals, I think we understand that these things have a broad effect on people's health.
[00:03:44] Gordon: Yeah, and that's a good point because that's a reason social is part of the phrase, right? Because determinant of health, you think of biological and genetic factors that determines someone's propensity for getting, certain types of diseases, but social [00:04:00] determinants of health looks at other human beings, interact with communities, interact with organizations, interact with institutions, and then how that plays a role in our ability to be healthy. And I want to go back to the genetic example in particular, because we're actually learning now, genetics was traditionally thought to be a one-way thing where genes just determined someone's, but we're seeing that environment, the environment can also influence how your genes are expressed in the new kind of scientific field of epigenetics.
[00:04:30] So we're seeing that we're seeing that people living in stressful conditions, it also impacts the way that. Their genes are expressed and that can potentially be passed down to their offspring in the concept of kind of intergenerational trauma and things like that. So even some of the traditional concepts, we're finding out that we've been thinking about it wrong all along.
[00:04:49] Sully: Yeah it's as simple as we are influenced by our environment. That's what it comes down to
[00:04:54] Linda: Also, I like how power for the social determinants are because they can act [00:05:00] as a buffer. Gordon, as you were saying on how our genes are expressed and so it can be protective factors or risk factors.
[00:05:07] So the more we educate ourselves on these concepts, then we can improve people's health or even see how these factors are reducing people's health.
[00:05:16] Gordon: And I think something in this definition will always says it's, you're looking at the causes of the causes, right? In one example, I was watching a video on I think it was a Ted talk.
[00:05:25] You guys know? I love my Ted talks. So yeah, so he was going to say, okay, what is the cause of a heart attack? And then he's a doctor might say, okay, it's when plaque builds up in your arteries and then, the blood gets obstructed and then, cuts off circulation and get a stroke and all that stuff. But he's okay, what caused that to happen in the first place? And then he goes up to. Maybe it's healthy B behaviors, maybe, people don't have access to good quality food or it's not affordable. And then you go up another level. Okay. Why don't people have access to these foods? And then you go to an equal distribution of wealth and you cut, you go up the ladder till you find the more, [00:06:00] most upstream cause of the phenomenon you're observing.
[00:06:04] Wil: Now that we've presented what our understanding of this term is. I just wanted to share a couple of definitions that I had here. So just to yes, I guess set the scene for the rest of our discussion. So the world health organization defines the 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.
[00:06:28] These forces and systems include economic policies, development agendas, social norms, social policies, and political systems. For us in Canada, the Canadian public health association has a very simple definition for the social determinants of health, which is, I think what we've said is captured very well in this is that the social and economic factors that influence people's health, very simple.
[00:06:51] Gordon: There's no ceiling on it. There's no box.
[00:06:53] Wil: It's like you hear it and that makes sense, but it's like opening another door to a whole new complete new [00:07:00] discussion here. So depending on the organization or the governing body or whoever I've seen reports out there or lists with, things like 12 social determinants of health and others organizations say 10, we got 15, I think aside from like the specific numbers, I think there are certain determined.
[00:07:20] Which can be agreed across the board that have very significant impact on individual and population health. So maybe let's go through some of these in detail and talk a bit about how they might relate to health, because I think some of them makes a lot more sense than others and are easier to make that connect.
[00:07:41] But others, I don't see that connection as clear. So let's go through some of these I guess I can start with the first one here that I've listed and it's education. I would say prior to my exposure to public health or the broader field [00:08:00] of population health or whatever, I would have never drawn that connection between education and health.
[00:08:06] And if the only connection I would have drawn is that we learn about health in education, but yeah let's talk about it.. What do you guys think is the key connection here? Like how is how health related to education.
[00:08:18] Gordon: Yeah. So I think for in general, when you're determining social determinants of health, you look at kind of certain factors that are similar across the board for people who seem to do very well and thrive in life.
[00:08:32] And for people who don't do very well and don't thrive in life, right? So these are some of the factors that are commonalities, that, that determines. Ability to be prosperous in terms of health and and wealth or not. So in a case of education, I know from research that for people who don't finish high school across the board, in terms of chronic disease, any and as well as good paying jobs, they do less well.
[00:08:57] So that's just one example of educational attainment [00:09:00] determining your health.
[00:09:01] Linda: Just to build on that, I agree, I'd say education can determine the type of. You have access to which then influences your income and then which can also influence the ability to, afford certain types of food or certain places to live.
[00:09:17] But I think another aspect where education can come in is with health literacy. And often you hear medical professionals, or, if you read an article it's geared towards a certain audience, it's very high level. So depending on your level of education, that information may not be accessible to you.
[00:09:37] So there's a there's another factor that education can impact all through health literacy.
[00:09:43] Gordon: So it affects your ability to access or utilize healthcare and even one thing I'm being on as well, because from my experience in the pharmacy. So maybe you finally navigate your way to getting the healthcare you need.
[00:09:56] Maybe you don't, you have an underlying condition that you need to be addressed. [00:10:00] So problem solved, right? You go to the doctor, here's a prescription, then you get the prescription and it says, take TID, PRN, and it's just okay, so I'll just take three of these because I feel like, oh, I don't feel well.
[00:10:13] Maybe I'll just take another pill. That's not really clear on the bottle. So even health literacy comes in with access and even treatment management or management of your disease. If you're not privy to the correct information, you're going to mismanage your health and then end up back where you started.
[00:10:30] Linda: Knowing that you are allowed to ask certain questions, because if you don't ask certain questions, that information is not given to you. And in the past I worked with clients with chronic diseases and we worked and had to navigate the health system together. And so often patients would have questions, but they didn't feel they were allowed to ask it. And I recognize I had a place of privilege coming from an educated background, knowing that we are allowed to ask these questions. And so I was [00:11:00] able to use that position to help advocate for the people that I worked with. But it's not often something that you think you're allowed to do because there is that level of authority versus, a physician versus a client- and yeah, the education plays a bit.
[00:11:15] Wil: Those are some really great points, and especially that last point about understanding that you have the authority, I see that tying in with almost being educated on your individual rights and that kind of brings in the whole legal side of things and it makes a lot of sense because we tend to think of education. Usually only as, going to school elementary, high school, middle school, or, post-secondary or whatever. Yeah. Like you guys mentioned with health literacy and even just the, your understanding of rights, these are all part of being educated and these are all things that are taught to us.
[00:11:50] And I think that's so very important aspect of that connection between health and education, linking back to something that Gordon previously [00:12:00] mentioned earlier at related to income and job opportunities, employment. I think that's also another very important social determinant of health and, things like having a permanent job, that's also safe, things like that.
[00:12:18] It's being able to, go and work, not only a job that will pay you well, but also in an employment environment that is void of any occupational hazards or other risks. Let's talk a bit about this determinant for a bit.
[00:12:33] Gordon: So even if you go back to, I don't know when it was, I wasn't born, but the whole asbestos crisis, you remember as vessels, right?
[00:12:42] There's probably hundreds of thousands of people that have gotten, different types of cancer because of asbestos in their kind of working environment. So that alone right there. And then it goes back to what will was saying earlier to teach. Why something is more, is distinct from another in terms of okay, income and education, [00:13:00] because you can look at it this way, income determines your ability to get educated, which then determines your ability to get, higher paying jobs that are more safe in some cases. Then that feeds into your ability to the education piece with understanding your rights with how to access health services and health literacy. So it all comes back to that but in terms of occupational hazards, to one of the reasons why social determinants of health, it's an well needed discussion is because you have to look on what types of groups are, the ones that are most likely to work in high-risk jobs, right? And then, that brings you to other questions such as, race or ethnic minorities or low levels of educational attainment, which is why we have to address this at the structural level, because the reason social determinants are our thing is.
[00:13:50] Overwhelmingly, you can recognize that there's a certain pattern happening, right? There's, people of color tend to live in poor housing. So if you're [00:14:00] someone who, you're not really a critical thinker and you're not willing to go deeper than that, you say, okay, these guys, maybe they don't like to go to school and everything like that, but you have to really go back and look at the reasons why the situation is how it is maybe generations ago. They didn't have the opportunity to build up wealth from their grandfathers and their great-grandfathers to be able to send children to school. They weren't able to purchase. Homes in the same way, as you could say the white population, so they don't didn't have the same opportunities to accumulate wealth and then send their children to school so you have to look at it as a system.
[00:14:34] Linda: If we don't stop to ask why we see these patterns, we run that risk of saying this attribute of let's say lower education or poor housing is inherent to a certain population. But if we ask why then like you were saying, we see more of a systems issue of what caused that pattern to happen in the first place.
[00:14:55] Gordon: Right one hot topic, is affirmative action, right? In terms of [00:15:00] things like med school. And it's a very hot topic because, getting a higher education. Should be more of a meritocracy or a merit based system. So people wonder, okay. If my grades are good and your grades are good, why should you get in?
[00:15:11] Because you look different than me. And this is where you have to look at this, the social terms of health, because people were at a structural disadvantage from the start. And this is where the fight for equity comes in. Some people need more resources to get to the same level as other groups, because they're not historically disadvantaged.
[00:15:30] So I just want to bring that up as well.
[00:15:32] Wil: What you said earlier, Gordon, about how this. Oh know, this all operates within a system. I think that's something that I want to highlight and hopefully I have our listeners keep at the back of their mind throughout this discussion that even, despite the fact that we were right now picking out individual determinants and analyzing the relationship with health, an important message that we want to convey is that the, all of these determinants.
[00:15:58] No can be [00:16:00] linked with one another. For example, income is often considered like that, like one of the most important determinants of health because of its ability to affect. The other determinants, right?
[00:16:10] Gordon: It's like a, it's like an equalizer in a sense.
[00:16:12] Wil: Exactly what you said earlier about, having a level of income, which allows you to go to school now, which will in turn affect your job prospects.
[00:16:22] And then how you know that job prospects, once again, loops back around having no income again, which affects your ability to have access to housing, ability to have access to food, things like childcare and and all that on all sorts of things. So I think I'm coming to income. Let's say let's talk about, a bit about that
[00:16:42] Linda: I like to think about how, when you, I guess let's say you're struggling to pay for rent or buy groceries. I just think about, the grad student life, where you have a limited income and it's stressful and you're trying to study at the same time and especially around finals season. Yeah, that stress, [00:17:00] it impacts you, you maybe you're not sleeping well, you're not eating well, all of it.
[00:17:03] So imagine two, let's say you're living below the poverty line. Really struggling to make ends meet not only for yourself, but perhaps a family. You have children. It's not just a one time thing. It's chronic stress. And, research is showing that elevated cortisol levels that constant stress has negative impacts on your health as well.
[00:17:25] So then having health conditions that again, you may struggle to be able to pay for it's just a cycle. And so well, like you were saying, income is not just an isolated incident. And yeah, I think to an extent everybody can agree that income is important, but we don't often make the connection of how it relates to everything else.
[00:17:46] Wil: Yeah. It's a personal experience of mine was when I was doing my masters, I remember, and I think looking back, I was very fortunate enough to be in a financial situation at the [00:18:00] time where I, when finals or midterms or whatever came around and I was swamped with work. I was able to, still often not ordered take out or whatever, and still.
[00:18:10] I have the food to nourish my body and, can help me get through, the busy season, but I know, and, recognizing the privilege and the situation I was in, I could have easily been, in, in a different situation where I didn't have that financial security. For example, if I didn't have the financial security, I would have had to think about, cooking or even just like even finding food right on top of all the schoolwork and everything like that.
[00:18:35] Gordon: Or getting a job while you're going to school and stuff like that.
[00:18:39] Wil: Yeah and I think it's. It's additional, like Linda said, additional stresses and pressures placed on top of you. I guess when income is something that you have to worry about.
[00:18:50] Gordon: To touch on the, the social gradient in terms of the social exclusion aspect of it, because. If you're of a lower socioeconomic status or lower income, [00:19:00] it's not only that it affects you because you're not able to buy what you need or, get your gym membership that you need and stuff like that.
[00:19:07] People often compare themselves to others. If the grad, master of public health class, and everyone else is well off and you're the only one that, has to work, maybe two jobs going to school that is going to affect you mentally as well. So it also affects your self worth in a sense when you're amongst your peers or in society and how, the energy that you feel back and that kind of, that influences your health in a mental self sense as well, a hundred percent, for sure.
[00:19:33] Sully: Like maybe in some aspects and come discrepancies is more important to talk about than pure income levels.
[00:19:42] Wil: Yeah. And so I think, as I mentioned earlier people often consider income August the most important social determinant as it is able to seep into the other determinants. But I'd like to consider the topic of race and race as the determinant of health and recently [00:20:00] in the news or in just public discourse.
[00:20:02] We've heard a lot about. The disproportionate use of things like police brutality or even unarmed individuals. What I want to argue is that I would consider a race and even more important determinant of health den income, because how I see it as that race, which is unfortunate, but like race is one of those things.
[00:20:21] Has the ability to influence an individual's income, which not a lot of things can do. And if we go off the previous definition, that income is so important. If race can influence that, then does that make race even more important? I don't know just some thoughts that I hadn't wanted to ping it off you guys and see.
[00:20:39] Linda: I would say if you want to talk about the causes of the causes and this may be more of a semantics issue, but I think that to say race is the determinant of health is it incorrect and so many, the Canadian public health agency and others will say that race is the determinant of health, but to be black or Latino or Asian, like that [00:21:00] itself is not a risk or protective factor.
[00:21:03] I would say it's like, racism is the determinant of health. It's that structure of inequity. And hierarchy that our society has created is the determinant of health. And so sometimes it gets tricky because we'll see statistics that say, indigenous people are this and black people are this. These groups have higher rates of this disease than that, but we don't say why and so it creates that narrative of, oh, if I see somebody from this ethnicity, I'm just going to think they're more like it reinforces those biases and so I think that's something as a public health community, we could try to work towards. Instead of pathologizing a race, we talk more about the system of an equity.
[00:21:49] Gordon: Yeah you just got me thinking cause it's almost like it's a more appropriate word then. Discrimination as a determinant of health, and then you can piece of, gender based discrimination and then, race [00:22:00] based discrimination. But I want to go back to what Wil said, and this has been on my mind, because I there's been people talking about okay. There's like social justice, equality, and equity and it's it's almost like it's a hierarchy where. Equity is better than equality and then social justice is better than all of them, but I argue that they're all important and the reason they're all important, right?
[00:22:22] So if you have a person of color and then you have a white person going for the same job they grew up with in affluent neighborhoods, had the same education, same gender. All else equal. And in the white person gets a job over the black person then right there, race was the determinant of whether the person got the job.
[00:22:41] But then what Linda is saying too, that it's not that it's race in of itself. It's just how society views race. It's how society views race and that leads and then if you if someone is disadvantaged because of a race, that means discrimination took place, hence why might discrimination might be a more appropriate determinant of health to call it.[00:23:00]
[00:23:00] Linda: And like maybe specified the type of discrimination so we know how to address the problem, but sometimes we run the risk of saying, this problem is inherent to black people or inherent to Asian for indigenous people but that's not the case.
[00:23:13] Gordon: We're going to have to publish a paper on this.
[00:23:18] Narrator: Thank you for listening to the Public Health Insight podcast, your go to space for informative conversations, inspiring community. If you enjoy our content and would like to stay up to date, follow us on Instagram, Facebook, Twitter, and LinkedIn, to learn more about our community initiatives and how you can support us.
[00:23:33] Visit our website at thepublicofinsight.com joined the PHI community and let's make public health viral.