Social Determinants of Health 2014-2015 Chapter 2: Social Determinants of Health 63 2014-2015 Health of Boston Social Determinants of Health Beyond individual physiology and health-related behaviors, there are other economic, environmental and social factors that influence health. Collectively, we refer to these as social determinants of health. Social determinants are societal influences that help to describe the circumstances in which people are born, grow up, live, work and age (1). Social determinants of health are uniquely experienced by individuals, differentially impacting health experiences and ultimately contributing to health inequities (2). Research has identified a wide range of social factors that are associated with differences in health outcomes (2): Employment Access to Health Resources Access to Healthy Food Income Access to Health Care Housing Conditions Exposure to Violence Transportation Options Insurance Coverage Environmental Safety Education Occupational Safety These social determinants of health impact an individual’s life in many specific ways, for example, the quality of education available to them, their ability to find and maintain employment and the type of work (including levels of exposure to occupational hazards), access to safe and stable housing, and access to health care and the quality of those services (3). The resulting life experiences, in turn, directly influence physical and mental health and contribute to health inequities. Our report describes how many health-promoting resources, such as income, employment, education, and home ownership, are unevenly distributed within our city among those of differing races and ethnicities, socioeconomic status, and geographic locations. Social determinants of health can be described in terms of three broad context areas: economic, environmental, and social. Economic Conditions and Health Economic factors that influence health occur on both community and individual levels. On the community level, economic factors believed to be associated with health outcomes include collective income, poverty rates, employment opportunities, community investment, tax base and spending priorities for local tax dollars (2). On an individual-level, the opportunity to obtain a meaningful job 64 Social Determinants of Health 2014-2015 with few occupational hazards, address financial needs, and remain food secure are paramount to maintaining good health. Economic resources enable health purchasing power including the ability to attain resources to manage or control disease (4). Lack of economic opportunity can create a vicious cycle where children who grow up in poverty are less able to acquire the needed resources for health and are more likely to experience mental, emotional, and behavioral disorders as a result (5). The effects of coping with daily economic hardship can trigger a physical response which may damage immune defense, dysregulate physical processes, and accelerate aging or the onset of chronic disease (6,7). The opportunity for a quality education is widely recognized as a leading influence of acquiring higher economic position and is associated with better health outcomes. Educational attainment is associated with improved working conditions and higher income, which in turn allows for improved housing, nutrition, control of hazards and stress, as well as direct health benefits from having quality health insurance, retirement benefits, and adequate sick leave (8). Educational attainment is also closely linked to improved health knowledge, literacy, and behaviors, all of which are associated with improved health awareness and disease management (8). Environmental Conditions and Health The “built environment”, or physical structures and infrastructure of communities and homes, can profoundly impact the safety and lifestyle options of the residents (9). Neighborhood safety, desirable areas for physical activity, close proximity to providers of affordable and nutrient-dense foods such as fruits and vegetables, clean air, access to formal health services, transportation options, and affordable housing are all essential to helping individuals attain full and vibrant health. Conversely, a density of retailers selling tobacco and alcohol, the presence of deserted and rundown lots, and industrial pollution serve to diminish safety and health (1,8). Physical inactivity, which increases the risk of diabetes, high blood pressure, and obesity, can be spurred by environmental conditions that produce fear and concern of victimization such as the presence of crime, or by a lack of well-kept sidewalks and walkability in neighborhoods (10). Children living in such physical environments are more likely to become overweight and obese (11). Communities with fewer physical assets and less desirable living conditions experience poorer overall health, including higher levels of depression, infant mortality, low birth weight, child maltreatment, and homicide rates (12). The built environment serves to mediate an individual’s perceptions about the health opportunities available to them, their ability and likelihood of engaging in healthy behaviors and their ability to buffer toxic and stressful exposures. 65 2014-2015 Health of Boston Social Conditions and Health Social conditions encompass the social relationships, family structure, and cultural dynamics within which defined groups of people function and interact (13) (14). The “acceptability” or “norms” for positive behaviors can also be developed within these networks, and may influence health-related behaviors (15). Social conditions also include social capital, which refers to the individual and communal time and energy available for community improvement, social networking, civic engagement, and other activities that create social bonds between individuals and groups (16). Social capital can be formed through an individual’s level of trust and sharing within communities, while dense social networks and civic engagement provide structure for social capital (17). The presence of social capital, support, trust, and reciprocity have been associated with improved overall psychological well-being and improved perceptions of personal health (18). Social conditions also encompass perceptions of community members about their social surroundings. Crime rates, housing patterns, and law enforcement policies can all influence a person’s perceptions of the value and safety of their social environment, as well as their tendency to engage positively in their community (2). When social relationships or conditions breed an environment of fear, suspicion, discrimination, and/or racism, a chronic stress response may occur to the detriment of health (19, 20). Chronic stress can create long-term elevation in stress hormones, implicated in the development of anxiety, depression, digestive problems, heart disease, sleep problems, weight gain, and problems with memory and concentration (21). Encouragingly, however, positive social ties tend to naturally reduce the negative effects of stress in a person’s life by encouraging more healthful behaviors and “buffering” stressful influences (22, 23). This section presents data on educational attainment, employment, income, and housing status and the association of these factors with specific health outcomes. 66 Social Determinants of Health 2014-2015 Education Education is a very general term used to refer to the experience and/or result of learning undertaken primarily in institutional settings such as schools and colleges (24). The number of years of schooling is often used as a measure of education, and is associated with income status. Education is associated with health in many ways. Higher educational attainment is associated with improved working conditions and income, which in turn allows for improved housing, nutrition, control of hazards and stress, as well as direct health benefits of quality health insurance, retirement benefits, and sick leave (8). Educational attainment is also closely linked to improved health knowledge, literacy, and behaviors, which are, in turn, associated with improved health awareness and disease management (8). Individuals with more years of formal education tend to have healthier behaviors and better health outcomes. Education also helps promote and sustain healthy lifestyles and positive choices that support and nurture personal development, relationships, and community well-being (25). Although educational attainment is associated with adult socioeconomic status (SES), many studies suggest that schooling has an important effect on health independent of SES (26). Additionally, parental level of education attainment is a significant predictor of child health, with children of more highly educated parents having better overall health than children with less educated parents (27). Despite Boston’s reputation as an education hub, racial inequities in educational attainment exist. Data presented in this section show that a larger percentage of Black and Latino residents have fewer years of education than White residents. Inequities are also reflected in the graduation rates for males and females. This section presents data on educational attainment and selected health indicators associated with educational attainment. 67 2014-2015 Health of Boston Figure 2.1 Educational Attainment, Boston and 30% Massachusetts, 2012 20% 10% Ages 25 and Over and 25 Ages Percent of Population Percent 0% Less Than High High School Some College/ Bachelor's Graduate or School