While physical wellness, mental wellness, and medical care contribute to ones’ health, health is comprised of so much more than “the absence of disease” (United States Department of Health & Human Services, 2015, n.p.). In fact, research suggests medical care is only responsible for 10-15% of preventable mortality; the remaining 85-90% is derived from social and physical environments (Braveman & Gottlieb, 2014; Sederer, 2015). As a result, it is critical to examine social determinants of health. In this edition of the Capstone e-Newsletter we do just that by first examining the construct of social determinants of health, and then exploring a new tool for human service organizations to measure it with the Social Determinants of Health Index.
What Are Social Determinants of Health and Why Are They Important?
Healthy People 2020, which identifies objectives for improving health, defines social determinants of health as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (United States Office of Disease Prevention and Health Promotion, n.d., n.p.). Social determinants of health recognize that many factors can contribute to health beyond just health and safety. By examining social determinants of health we are better able to create social and physical environments that promote the health of everyone – it is necessary for health equity.
Some of the many social factors that impact health include:
- attitudes and norms
- social exclusion
- public policies
- health care access
- food security
- neighborhoods and communities
- relationships and social capital
- income inequality
- natural environment
- built environment
People with disabilities in particular face a number of disparities and poorer outcomes compared to non-disabled peers due to an “increased risk of exposure to socio-economic disadvantage” (Emerson et al., 2011, p. 146). People with disabilities are more likely to live in poverty, face social isolation, and have trouble finding affordable accessible housing. Ableism also impacts people with disabilities’ health and outcomes (Emerson et al., 2011).
The Development of the CQL Social Determinants of Health Index
In order to facilitate people with disabilities’ social determinants of health, one of the first steps is to measure their social determinants of health. In fact, the United States Department of Health & Human Services (2015) even calls the lack of “availability of high-quality data for all communities ultimately a health equity issue” (n.p.).
At CQL | The Council on Quality and Leadership we recently developed a new tool to measure social determinants of health using the Personal Outcome Measures® (Friedman, 2019). In order to create the measurement tool, we cross-walked the Healthy People 2020 Social Determinants of Health with the Personal Outcome Measures®, and ran an exploratory factor analysis with 1,078 Personal Outcome Measures® interviews with people with disabilities from 2017 (Friedman, 2019). This index was also outlined in the recent report released by CQL titled ‘Building The Framework For IDD Quality Measures,’ which establishes an understanding of value-based quality measures for people with IDD to ensure that as the industry moves to managed care, the quality metrics utilized are meaningful to people with IDD.
The CQL Social Determinants of Health Index
The analysis findings resulted in the creation of The Social Determinants of Health Index. The Social Determinants of Health Index is comprised of three factors:
Choice & Engagement
- People interact with other members of the community
- People participate in the life of the community
- People perform different social roles
- People choose where they work
- People choose where and with whom to live
- People exercise rights
- People are treated fairly
- People are respected
- People experience continuity and security
Health & Safety
- People have the best possible health
- People are safe
Analysis of approximately 1,100 interviews with people with disabilities indicated the average person had a score of 49.6% of social determinants present. As indicated by the Index, people frequently score higher on Health and Safety, compared to Choice and Engagement, or Person-Centeredness (see Table below).
The Social Determinants of Health Index (n = 1,078)
Choice & Engagement
Health & Safety
Scores for each Social Determinants of Health by Indicator
|Indicator||Choice & Engagement||Person-Centeredness||Health & Safety|
|People interact with other members of the community||59.6%|
|People participate in the life of the community||45.9%|
|People perform different social roles||36.0%|
|People choose where to work||33.6%|
|People choose where and with whom to live||26.4%|
|People exercise rights||45.3%|
|People are treated fairly||54.1%|
|People are respected||52.3%|
|People experience continuity and security||49.5%|
|People have the best possible health||66.2%|
|People are safe||76.8%|
Social Determinants of Health and Quality of Life
The development of the Social Determinants of Health Index allows us to examine, and ultimately, help facilitate, quality of life in new ways. For example, when we examined the relationship between the social determinants of health and overall total personal quality of life outcomes, findings revealed the higher people scored on the social determinants of health index, the more quality of life outcomes they had present (see figure below).
Relationship between Social Determinants of Health and Personal Outcomes
(The indicators involved in The Social Determinants of Health Index were removed from the total outcomes count to minimize collinearity.)
By utilizing the Social Determinants of Health Index we are also able to look at the relationships between specific outcomes and social determinants of health. For example, people who have friends have significantly higher social determinants of health index scores than people without friends (66.5% versus 38.9%). People who choose their services also have significantly higher social determinants of health index scores than people who do not choose their services (71.2% versus 39.7%).
As we found that social determinants of health are important to quality of life, we also explored how social determinants can be facilitated. To do so, we looked at the relationship between organizational supports and social determinants of health. Findings revealed the more organizational supports people receive, the significantly higher their social determinants of health (see figure below).
Impact of Organizational Support on Social Determinants of Health
Using The Index To Facilitate Quality Service Provision
The Social Determinants of Health Index can be used to examine the social determinants of all the people human service organization support (aggregate) or of an individual person.
To calculate an organization’s aggregate data on social determinants, we have created an excel document which includes built-in analysis. To utilize the Index, organizations complete the following table with the percentage of outcomes found present for each indicator during Personal Outcome Measures® interviews. The average of the percentages for the entire table reveals the overall social determinants of health score. Meanwhile, the average score for each of the three columns reveals the factor scores for Choice and Engagement, Person-Centeredness, and Health and Safety.
You can then utilize the findings from the Social Determinants of Health Index to provide targeted services and supports to people. Those areas with the lowest percentages are those that can be prioritized for action to help facilitate people’s social determinants of health. Social determinants of health are critical to health equity and quality of life.
- Braveman, P., & Gottlieb, L. (2014). The social determinants of health: it’s time to consider the causes of the causes. Public health reports, 129(1_suppl2), 19-31.
- Emerson, E., Madden, R., Graham, H., Llewellyn, G., Hatton, C., & Robertson, J. (2011). The health of disabled people and the social determinants of health. Public health, 125(3), 145-147.
- Friedman, C. (2019). The social determinants of health index. Manuscript submitted for publication.
- Sederer, L. I. (2015). The social determinants of mental health. Psychiatric services, 67(2), 234-235.
- United States Department of Health & Human Services. (2015). Healthy people 2020: an opportunity to address societal determinants of health in the United States. Washington, DC: Author. Retrieved from https://www.healthypeople.gov/sites/default/files/SocietalDeterminantsHealth.pdf
- United States Office of Disease Prevention and Health Promotion. (n.d.). Social determinants of health. Retrieved from: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
Introducing The Social Determinants of Health Index