Social determinants of health and health and wellness coaching
Social determinants of health (SDOH) are social factors that impact a person’s health and wellbeing. The United States Offices of Disease Prevention and Health Promotion, Health and Human Services, and Centers for Disease Control consider SDOH to be significant barriers to health equity in the United States. These government offices are working to address underlying problems that directly relate to SDOH. Unnatural Causes, a seven-part docuseries exploring racial and socioeconomic inequalities in health, identifies specific health challenges Americans currently face and some of the societal influences that impact individual health. The Creighton University Health and Wellness Coaching/Integrative Health and Wellness curriculum* focuses on whole person health and promotes the actualization of health equity across the globe. Health coaches can contribute to health equity by having an awareness of SDOH and how those determinants impact clients and patients, and by supporting clients and patients as they navigate challenges due to their SDOH.
Social Determinants of Health
Social determinants of health (SDOH) are, “…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.” The United States office of Disease Prevention and Health Promotion breaks SDOH down into 5 categories: 1) neighborhood and built environment, 2) health and health care, 3) social and community context, 4) education, and 5) economic stability. Examples of SDOH include: access to health care services, public safety, social support, language/literacy, culture, transportation options, public safety, and access to educational, economic, and job opportunities. The National Partnership for Action (NPA), an initiative of Health and Human Services (HHS), is dedicated to eliminating racial and ethnic health disparities because people of color in America are overwhelmingly more vulnerable to developing chronic illnesses due to SDOH. Initiatives like the NPA reveal our country’s great need to reconcile its deeply rooted systemic racism so that we can provide equity in more than just health care and live in a country that truly prioritizes equality. SDOH are important for health coaches because they help create a comprehensive understanding of what is happening in a client’s/patient’s life and equip the health coach to be a more effective facilitator of change.
Social determinants of health (SDOH) explain in part why some American communities are healthier than others and, “…why Americans more generally are not as healthy as they could be.” Understanding how social determinants impact health can help Americans improve laws and policies that currently oppress and marginalize poor communities of color and increase better health outcomes for all Americans. The American government system is broken and built off racist and discriminatory ideologies. Observing SDOH can help Americans pinpoint the sectors of society that are failing large communities of color so those sectors can begin co-creating community support with established community leaders of color.
Each of the five determinants of health is made up of underlying factors that bring more context and clarity to understanding how Americans can start working toward better health outcomes. See Table 1 below to view each of these underlying factors. Each factor is a dense and complex issue on its own, and according to Healthypeople.gov, “This organizing framework [the 5 categories of SDOH and their underlying factors] has been used to establish an initial set of objectives for the topic area as well as to identify existing Healthy People objectives that are complementary and highly relevant to social determinants.” Healthypeople.gov also reports the following “emerging strategies to address social determinants of health”: 1) health impact assessments to review needed, proposed, and existing social policies for their likely impact on health, and 2) application of “health in all policies” strategy, which introduces improved health for all and the closing of health gaps as goals to be shared across all areas of government.”
Table 1: Underlying factors resulting in social determinants of health
Examples of social determinants of health (SDOH) are varied and dependent on the underlying factors that directly affect them. SDOH that impact a person’s access to transportation could include neighborhood and built environment, social and community context, or economic security, or a combination of the three. Dealing with one of these categories of SDOH would make it difficult to stay healthy but many people live with an overlapping matrix of SDOH and they suffer greatly as a consequence. The next paragraph offers a brief visualization exercise to invite the reader to explore personal biases and connect empathetically with a person who experiences multiple SDOH.
Visualize a parent who uses the bus in a city with poor public transportation and has unreliable childcare. Review Table 1 and think about which underlying factors impact this parent and the children. List them all on a piece of paper. As you write each underlying factor down, think about each barrier this parent might come up against every day. Imagine the parent’s face. Think about the parent’s life story. Pause now, before reading on, to reflect on this imaginary person. Who is this person? How is this person dressed? Male or female? Young or old? Educated? Employed? What types of resources are accessible to this person? What is not accessible? Which other features did you attribute to this person? Did you make any assumptions about who she/he is? Did you judge this person? If so, which judgments did you make? Can you think of some stereotypes that help create false narratives of people and assumptions about their needs and capabilities? Can you see how this might impact their overall health and wellbeing?
The National Partnership for Action to End Health Disparities (NPA) is a faction of the Health and Human Services department of the United States government. Founded in 2006, the NPA developed an initiative devoted to eliminating ethnic health disparities. The NPA set these five primary goals (summarized by the words in bold) based on input from thousands of leaders from the community, state, tribal, business, national, and federal sectors: 1) increase awareness of significant health disparities, 2) strengthen and broaden leadership for addressing health disparities, 3) improve the health system and life experience for underserved populations, 4) improve cultural and linguistic competency and the diversity of healthcare workforce, and 5) improve data availability and diffusion of research and evaluation outcomes.
The National Partnership for Action (NPA) has identified five top priorities for action to help advance these goals. These actions include: 1) strengthening access to quality health care, 2) supporting the implementation of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, 3) educating youth and emerging leaders about health disparities, 4) strengthening the nation’s network of community health workers, and 5) promoting the integration of health equity in policies and programs. The NPA is working hard to problem solve the issues of health inequity, and it is clear they recognize the impact of racism and marginalization on societal health and plan to implement change on a policy level.
The American Public Health Association’s (APHA) past-president, Dr. Camara Phyllis Jones, defines racism as, “…a system of structuring opportunity and assigning value based on the social interpretation of how one looks (which we call “race”), that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources.” On their website, the APHA states that in order to achieve health equity, “…we must address injustices caused by racism.” The APHA calls for racial healing (#RXRacialHealing) and defines this as, “…a healing and heart-centered approach to get rid of the false belief that any people are superior to others based on their skin color.”
Wealth and poverty also appear to have an impact on health equity in the United States. Americans who live in poor communities are at a higher risk for chronic stress and disease progression. Poor communities typically have less access to economic and educational opportunities and often lack direct access to fresh produce and reliable transportation. Neighborhood infrastructure in poor communities are often neglected and this can make it difficult for residents to feel safe and/or comfortable exercising on their streets and sidewalks.
Families in wealthier neighborhoods do not have these struggles and their health does not suffer in the same way. Countries, such as Sweden, have policies set in place that support citizens when they are unable to make a living. All citizens have healthcare and education, and various “safety nets” are set in place to support individuals and families when experiencing financial strain. Swedes have better health than Americans, more wealth than Americans, and they have created a successful template for other countries to follow.
As a health and wellness coach, it is important to be aware of social determinants of health (SDOH) and how they impact clients’ and patients’ lives. Everyone has a unique story that impacts their current health and it is part of the health and wellness coach’s job to get a complete picture of that story by understanding which life factors impact client/patient health. Health and wellness coaches need to have an awareness of what is realistically accessible to clients and patients when co-creating wellness programs, and they need to be able to empathize with some of the challenges their clients and patients face daily. This does not mean health and wellness coaches should profile their clients and make assumptions about their lives based on how they look. Rather it invites coaches to use evidence-based research to show greater sensitivity to clients’ and patients’ needs and encourages coaches and clients/patients to think creatively when problem-solving together.
Unnatural Causes
The primary things I learned from Unnatural Causes are: 1) We have hard evidence showing that social determinants of health greatly impact communities of color, 2) Americans continue to problem-solve solutions for health inequity rather than address racist biases that directly threaten equity, 3) Stress, as a direct result of systemic racism, continues to directly impact the health and well-being of people of color in our nation, 4) I am not immune to these statistics and I already see how they pay a toll on my health and well-being.
As I watched the documentary, I was most impacted by the observation that African Americans suffer a high risk of chronic stress as a result of oppressive racism in our country. Chronic stress weakens the immune system and makes people more vulnerable to developing chronic diseases and comorbidities. We, African Americans, are more likely to die at an early age from high blood pressure, diabetes, and stroke. If we know racism is an underlying cause for the chronic stress that threatens the lives of Americans, then we should be addressing racism as a social determinant of health (SDOH) and openly investigating the ways it upholds inequities in our communities. We need to officially debunk the myth of race and begin looking at practical and compassionate alternatives to policies that uphold “white supremacy.”
The docuseries, Unnatural Causes, validates so much of what I feel and experience every day as an American woman with brown skin, and it was hard for me to see my personal struggles mirrored back in something as mundane as a school assignment. The irony of being an African American studying health issues that exist as a direct result of racist agendas in America causes me deep pain and frustration. It is painful to be a person of color and exist in a culture that produces great deals of stress fueled by racism and racist systems. We (health professionals) acknowledge racism as a health hazard and then thoughtlessly provide solutions for health rather than solutions for racism.
The question is not, “What are we going to do about health disparities in America?” The question is, “What are we going to do about racism in America?” For that, we must examine our biases, change our behaviors, and deconstruct systems of racism within the government and the private sectors. Price puts it well in her New York Times article titled, Kirsten Gillibrand is Right: Racism is About White People. She says, “Here’s a solution for white people: Don’t answer questions on race by listing the struggles of people of color. Talk about what you can or will do to decrease support for white nationalism among whites.” I would add that European Americans need to stop creating solutions for communities of color as though they know what is best. Instead, European American interests should prioritize empowering and uplifting leaders in communities of color and supporting community organizers who are already investing time, energy, and resources into their beloved community spaces.
Considering what I have learned throughout the Health and Wellness Coaching curriculum, the Unnatural Causes docuseries validated and reinforced the issues and topics we researched and discussed in the program curriculum. I recall learning about social determinants of health and health inequity in HWC 591: Lifestyle Medicine. The impact of race and socioeconomic status on health in America came up in both HWC 650: Health Behavior Modification and HWC 760: Advanced Health and Wellness Coaching. And we explored the importance of purpose and how purpose impacts well-being as a major theme in HWC 501: Personal Development for the Health and Wellness Coach.
Creighton University’s mission is to engage the whole student — mind, body, and spirit — in the learning experience. Cura personalis means “care for the individual [whole] person.” This phrase is at the core of Creighton’s mission and values and an ongoing theme in the Health and Wellness Coaching curriculum at Creighton University. The Creighton mission is intended to support students as emerging leaders in society who have “…the wisdom, judgment, confidence, compassion, and faith to work for a more just world.” The Creighton mission is inspired by Catholic values and a Jesuit philosophy on education. I am proud of my education at Creighton and grateful for the opportunity to attend a university that values the whole person in health and in education.
The questions I have that still need to be answered are, when are we going to acknowledge the degree to which American policies comply with “white supremacy” and the impact it has on innocent American lives? And, why is it so hard for us to admit (on policy and institutional levels) that we have been irresponsible in health care? When will we see effective change, and when will we see racial and economic reconciliation for those who have been marginalized in our American communities?
Conclusion
Social determinants of health (SDOH) can be great barriers to individual health and global health equity. In the United States, there is a strong correlation between socioeconomic status, race, and health, and the country is working to identify the source of SDOH and problem-solve solutions that result in better health outcomes for Americans. The Unnatural Causes docuseries reports disparities in health across racial and socioeconomic lines and suggests that government policies must change to support all citizens if the United States is to have health equity. Creighton University’s mission and Health and Wellness Coaching/Integrative Health and Wellness program aligns with this message of solidarity and “whole person” approach to healthcare. Health coaches are in a unique position to elevate health equity by challenging their personal racial/socioeconomic biases and opening up to understanding the unique and whole individuals who are their clients.
References
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14. Price, M. Kirsten Gillibrand is right: racism is about white people. August 1, 2019. https://www.nytimes.com/2019/08/01/opinion/2020-candidates-race.html. Accessed April 7, 2020.
*I, Betty McGuire, wrote this paper in April 2020 for my capstone course in Creighton University’s Health and Wellness Coaching master’s program.
