Social determinants of health: The impact of social factors on BIPOC health outcomes

When we think of the factors that impact our health, factors like age, sex, genetics, and behaviors are often the first to come to mind. While these are all drivers of an individual’s overall health and key predictors for chronic conditions, what tends to be left out are social determinants of health.

You probably have heard the phrase social determinants of health (SDOH) thrown around at some point, but what does that really mean and why do social factors have such a big impact on our health?

In this article, we will dive into how SDOH have contributed to worse health outcomes for Black women and men in the US compared to white people and the continued work that needs to be done to address structural racism in the healthcare system. Read on to learn:

• What are social determinants of health (SDOH)?
• What social factors impact outcomes for Black women’s health and Black communities in general?
• How do SDOH vary for Black vs. white communities?
• What can we do as individuals to make a difference?

SDOH are one of the fundamental causes of disparities in health and are estimated to drive 80% of health outcomes (1). The World Health organization defines SDOH as

The conditions in which people are born, grow, live, work and age, and the wider set of forces and systems shaping conditions of daily life (2).

When thinking about SDOH there are not only tangible factors like your level of education, safety of your neighborhood, or your access to healthy foods, but also intangible factors like social norms and cultural biases.

What social factors impact health outcomes?

Let’s start by looking at a list of a few social factors related to health outcomes from the CDC (3):

• How a person develops during the first few years of life, also known as early childhood development
• How much education a person obtains and the quality of that education
• Being able to get and keep a job
• What kind of work a person does
• Having food or being able to get food, otherwise known as food security
• Having access to health services and the quality of those services
• Living conditions such as housing status, public safety, clean water, pollution, and more
• How much money a person or household earns (referred to as individual income and household income respectively)
• Social norms and attitudes (e.g., has the person experienced discrimination or racism? Is there a distrust of government?)
• Residential segregation, or physical separation of races/ethnicities into different neighborhoods
• Social support
• Language and literacy
• Incarceration
• Culture (general customs and beliefs of a particular group of people)
• Access to mass media and emerging technologies (cell phones, internet, and social media)

All of these factors have two common themes - first, they are influenced by social circumstances and second, they tend to be problems that need to be tackled upstream and in tandem with the healthcare system (think: policy and collaborations with community partners).

How do these factors influence health outcomes?

To understand this further, let’s run through a hypothetical situation:

Made with Made by Pollie with Visme Infographic Maker

Keep in mind that this scenario assumes that you have health insurance and access to a doctor, which is a privilege in and of itself. We could keep adding on to this hypothetical example that is all too common for lower income BIPOC families. There are so many additional social circumstances that influence not just how you get to a doctor's appointment but also how you are able to live your life and the direct impact it has on your health.

Black communities have disproportionality worse health outcomes compared to white communities.

It’s not new that racial disparities exist in health, yet they have continued to be present. COVID-19 is a timely and unfortunate example which shows even though racial disparities are well documented in healthcare, they still continue to prevail. Let’s explore a few statistics that highlight this stark reality:

• Black women are 3x more likely to die from pregnancy-related complications than white women in the US (we recently wrote a blog post on this) (4). Blacks represent only 12% of the US population, but account for 43% of HIV diagnoses (5).
• Black adults are 60% more likely than white adults to have been diagnosed with diabetes by a physician and in 2017, Black adults were 2x as likely as whites to die from diabetes (6).
• Blacks have the highest mortality rate of any other racial and ethnic group across all cancer types combined. From 2012-2016, while Black women were just as likely to have been diagnosed with breast cancer, they were 40% more likely to die from the disease compared to white women. Black women are also 2x as likely to be diagnosed with stomach cancer and 2.2x as likely to die from the disease compared to white women (7).
• Current data from COVID-19 demonstrates Black people are disproportionately impacted compared to white people. For example, COVID-19 deaths for which race and ethnicity data were available in New York City, indicated the death rate for Black people was 92.3 deaths per 100,0000 versus 45.2 per 100,0000 for white people (8).

The Kaiser Family Foundation completed an analysis that shows Black and American Indian or Alaska Native individuals continue to have worse outcomes across most measures of health status. In this study they looked at physical and mental health status, birth risks, infant mortality rates, HIV and AIDS diagnosis and death rates, and chronic condition prevalence and death rates (9).

Figure 1: Number of measures for which each ethnicity fared better, the same, or worse compared to whites

A wide range of research has explored why Black people have disproportionately worse outcomes across disease states compared to white people and many point to an underlying impact from social factors.

A recent study that looked at prostate cancer mortality rates found social factors and access to healthcare were more likely than genetics to contribute to the 2.5x higher prostate cancer mortality rate in Black men compared to white men (10). Not only are Black men more likely to have cardiovascular disease and obesity, but also they are more negatively impacted by social factors. The study’s co-senior author Daniel Spratt, MD says “the data show that black men don’t appear to intrinsically and biologically harbor more aggressive disease. They generally get fewer PSA screenings, are more likely to be diagnosed with later stage cancer, are less likely to have health insurance, have less access to high-quality care and other disparities that can be linked to a lower overall socioeconomic status” (11).

There are also contributing intangible factors like racial bias within the US healthcare system which can be traced back to centuries ago. When slavery was abolished, Black people were given no resources or help to start their lives and over the next century, “racist scientific theories advanced notions of African American's biological, physiological, and moral inferiority” (12). As the healthcare system evolved in the US, institutional racism prevailed and the disparities in health care between Blacks and whites only continued to grow.

What can we do to make a change?

At Pollie, we have always been committed to democratizing hormonal health specifically, but it’s important for us to shed light on disparities within the broader healthcare landscape. Let’s walk through some tangible actions and next steps.

Advocate for public policy changes

Healthcare is extremely political in the US. Actions like expanding health coverage through the ACA Medicaid expansion have been shown to make a difference in increasing coverage compared to states that did not expand. Even though whites, Hispanics, and Blacks all had larger coverage gains in states that implemented Medicaid expansion compared to states that did not, as of 2018, Blacks and Hispanics (and other ethnicities) remained more likely to be uninsured compared to whites. This is in part because a greater share of Black people live in states that did not expand Medicaid and therefore more Blacks fall into the ACA coverage gap compared to whites (13). Continuing to advocate for policies on a local, state, and federal level are imperative to not only increasing access to healthcare services, but supporting policies that factor in SDOH.

Implement population health strategies

Historically, SDOH data have not been collected as part of the patient journey. The information, if even available, lives in disparate systems and pulling it all together can be challenging for health systems and payers. Population health management tools can help aggregate data to paint a meaningful picture on what social services might be needed within a population. Community Health Plan Washington is a great example of how a health system can implement a population health SDOH strategy. In 2017 they worked with the state to create new codes that identified social needs in order to start collecting this information. Using population health tools, they were able to combine these new data that live in separate EHRs with census data to understand the needs of their patient populations. “Now, the organization can work in partnership with the providers and staff at community health centers to disseminate resources to patients” (14).

Engage community partners

Health systems and payers must place increased emphasis on collaboration with community partners to address the right issues that are impacting their communities: whether it be increasing access to healthy foods, improving quality of housing, or increasing educational resources.

Support innovation in digital health

NowPow is an exciting example of a digital health company tackling SDOH. As an example, Horizon Blue Cross Blue Shield of New Jersey is using NowPow’s platform to partner with the state’s largest health systems “to manage networks of community resources and to track referrals to those resources. Having that care navigation element will close gaps in referrals and ensure members are receiving the services they need” (15). The program is designed to implement local approaches based on meeting the needs of a given population.  

Final thoughts

The evidence is clear: there is systemic racial bias within our healthcare system, and it needs to be addressed.

In 2019, a study was published in Science about racial bias in health algorithms. The study looked at a commonly used algorithm to predict which patients with complex medical needs should receive extra care. Researchers found the algorithm underestimated the health needs of the sickest Black patients because the algorithm was basing its data on the total medical costs spent on white patients compared to Black patients.

Less money is inherently spent on Black patients due to a variety of factors, “and the algorithm thus falsely concludes that Black patients are healthier than equally sick white patients.” The study estimates that this bias in the algorithm reduces the number of Black patients identified for extra care by more than 50% (16).

This study, among many others, reinforces that structural racism still persists today not just within how doctors treat patients but also within the technology we have deployed. There is much work to be done to address these disparities, ensure they don’t continue to prevail, and improve access, quality, and health outcomes among Black and non-Black people of color communities in the US.  

Note from Pollie: If you want to learn more about racial bias within women’s health as well as ways to make an impact as an individual, we recommend you check out our articles on Black maternal mortality and endocrine disruptors in the Black community. We look forward to making this a continuing discussion.

References

1. Hood, C. M., K. P. Gennuso, G. R. Swain, and B. B. Catlin. 2016. County health rankings: Relationships between determinant factors and health outcomes. American Journal of Preventive Medicine 50(2):129-135.
2. “About Social Determinants of Health.” World Health Organization, World Health Organization, 25 Sept. 2017, www.who.int/social_determinants/sdh_definition/en/.
3. “About Social Determinants of Health.” World Health Organization, World Health Organization, 25 Sept. 2017, www.who.int/social_determinants/sdh_definition/en/.
4. Peterson, Emily E, et al. “Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016.” CDC, US Department of Health and Human Services/Centers for Disease Control and Prevention, 6 Sept. 2018, www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6835a3-H.pdf.
5. Published: Feb 07, 2020. “Black Americans and HIV/AIDS: The Basics.” KFF, 7 Feb. 2020, www.kff.org/hivaids/fact-sheet/black-americans-and-hivaids-the-basics/#footnote-448622-3.
6. “Office of Minority Health.” Diabetes and African Americans - The Office of Minority Health, minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=18.
7. “Office of Minority Health.” Cancer and African Americans - The Office of Minority Health, minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=16.
8. “COVID-19 in Racial and Ethnic Minority Groups.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 4 June 2020, www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-ethnic-minorities.html.
9. “Health Disparities Are a Symptom of Broader Social and Economic Inequities.” KFF, 12 June 2020, www.kff.org/coronavirus-policy-watch/health-disparities-symptom-broader-social-economic-inequities/.
10. Dess RT, Hartman HE, Mahal BA, et al. Association of Black Race With Prostate Cancer–Specific and Other-Cause Mortality. JAMA Oncol. 2019;5(7):975–983. doi:10.1001/jamaoncol.2019.0826.
11. Imhoff, Jordyn. “Study Explores Why Prostate Cancer Mortality Is Higher in Black Men.” University of Michigan, 23 May 2019, labblog.uofmhealth.org/lab-report/study-explores-why-prostate-cancer-mortality-higher-black-men.
12. Gamble, Vanessa Northington. “"There wasn't a lot of comforts in those days:" African Americans, public health, and the 1918 influenza epidemic.” Public health reports (Washington, D.C. : 1974) vol. 125 Suppl 3,Suppl 3 (2010): 114-22.
13. Artiga, Samantha, et al. “Changes in Health Coverage by Race and Ethnicity since the ACA, 2010-2018.” KFF, 5 Mar. 2020, www.kff.org/disparities-policy/issue-brief/changes-in-health-coverage-by-race-and-ethnicity-since-the-aca-2010-2018/.
14. Sokol, Emily. “Addressing Social Determinants of Health Requires Population-Based Data.” HealthPayerIntelligence, 7 June 2020, healthpayerintelligence.com/news/addressing-social-determinants-of-health-requires-population-based-data.
15. Minemyer, Paige. “How Horizon BCBSNJ Is Expanding Its Social Determinants Program amid COVID-19 .” FierceHealthcare, 26 May 2020, www.fiercehealthcare.com/payer/how-horizon-bcbsnj-expanding-its-social-determinants-program-amid-covid-19.
16. Obermeyer, Ziad, et al. “Dissecting Racial Bias in an Algorithm Used to Manage the Health of Populations.” Science, vol. 366, no. 6464, 2019, pp. 447–453., doi:10.1126/science.aax2342.

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