Opinion | Does the General Public Understand the Social Determinants of Health?

Most doctors in the U.S. now understand that their patients cannot live healthy lives when nutritious foods, safe housing, and other basic needs are out of reach. Recognizing this, health systems and payers have spent billions of dollars on programs that address non-medical needs, such as housing instability and food insecurity.

But the fundamental idea that health is primarily a function of economic, social, and environmental factors is only beginning to enter the public conversation — and its slow dissemination may be hurting both the health of the public and the healthcare system at large.

In general, people have viewed and continue to largely view health as a product of their own individual choices. In a 2017 survey, conducted by the Pew Research Center, U.S. participants were asked which factors are most important in preventing serious disease. Participants were most likely to mention controllable factors, such as healthy eating habits and physical exercise. “Safe and healthy housing conditions,” were the least likely to be mentioned.

Perhaps in part because of these beliefs, Americans are less supportive of President Biden and Congress focusing on education, transportation, and other social sector activities compared to their support for addressing healthcare costs. This is true even as many Americans worry about conditions like diabetes and heart disease, which may be tied to a relative lack of investment in the fundamental drivers of health.

To be fair, advocacy that makes healthcare services and medications, such as insulin, more accessible, is necessary, but it means very little to the person living in a food desert without a refrigerator who cannot store their insulin. All this together makes it critical for the public to link the concept of health not only to daily choices and behaviors, but also to the result of these decisions in the context of modifiable socio-political, economic, and environmental conditions.

Doing so may spur individuals concerned about health to demand political action related to these drivers — safer and affordable housing; accessible, nutritious grocery stores; living wages, and more. It may also encourage those with means to spend more on meeting these needs, which could reduce individual healthcare spending down the line.

Improving public understanding of the complex factors that drive health can also benefit health systems in their effort to improve health and reduce healthcare costs. In recent years, various non-medical interventions have fallen short of success, in part due to suboptimal patient uptake. Uptake of interventions, which can include health literacy classes, meal programs, and employment assistance, is a function of various factors, such as program capacity, trust, and physical access (e.g., transportation to and from the program site). Awareness of the connection between any of these programs and health is a less obvious but equally important factor that may improve participation rates and, most importantly, improve patient health.

Furthermore, data show that when the public understands certain drivers of health, everyone benefits. For example, one campaign raised dismally low awareness of human papillomavirus (HPV) and its harmful consequences. These science-based communications campaigns and tools, state laws requiring Departments of Public Health to distribute information to parents explaining HPV and its link with cervical cancer, and hospital-led initiatives on HPV prevention likely all contributed to the reduction of cervical cancer rates in young adults over the past few decades.

It’s no wonder that organizations within the U.K. have recently launched efforts to effectively communicate the concept and implications of determinants of health to their communities.

All this points to an important course of action for the U.S.: a commitment to better educate the public about the fundamental determinants of health. One current and concrete approach to this would be advancing H.R. 379 – Improving Social Determinants of Health Act of 2021, which has remained stalled in the House Subcommittee on Health. This Act would authorize the CDC to carry out a program focused on fundamental determinants of health to improve health outcomes and reduce health inequities.

Lawmakers could authorize some of its appropriated funding for state and local municipalities to improve awareness of what contributes to health. Advancing H.R. 379 could be one of the bipartisan pieces of legislation passed through the divided House, given the recent creation of the Congressional SDOH caucus led by both Democrats and Republicans.

Even without Congressional support, payers and providers who deploy programs that address the fundamental determinants of health could independently improve awareness. Regulatory and legislative flexibilities, such as Medicare Advantage Supplemental Benefits and Medicaid “in lieu of” services, that allow payers and providers to invest in social services could be used as a mechanism to fund public education campaigns.

Outside of institutional level efforts, clinicians and their care teams could provide their patients with pamphlets describing the determinant(s) of health impacting their wellbeing. For example, care teams could provide patients suffering from food insecurity with a printout of Feeding America and Humana’s “Understanding Food Insecurity” section in their Resource Toolkit. Additionally, care teams, specifically case managers, social workers, and other allied health professionals skilled in understanding the social context of their patients, could inform patients about these determinants and their implications at the point of care.

Americans experience the worst health outcomes of any high-income nation. We’re also more likely to die younger. An understanding of what makes up our health may help us, as a nation, live healthier lives. A bold effort to advance our understanding of health in the 21^st century can help get us there.

David Velasquez is a student of medicine, public policy, and business at Harvard University in Boston. Sandro Galea, MD, MPH, DrPH, is a professor and dean at the Boston University School of Public Health.