Social Determinants of Health

Societal factors like discriminatory policies, educational opportunities, poverty, and racism affect a person’s risk of firearm injury

For many patients, zip code is a better predictor of their health than genetic code.

The clinician’s core role is to provide health care to individual patients. Nonetheless, recognizing the underlying social, economic, and political factors that shape population health, including firearm injury risk, can help clinicians make informed recommendations, address the root causes of the problem, and prevent future firearm injury among their patients.

The social ecological model

What are the Social Determinants of Health?

According to the social ecological model—a popular public health framework—people are situated within multiple, intersecting spheres of influence, ranging from the micro-level (individual) to the meso-level (relationships and community) to the macro-level (societal), which influence their health and development.1 While the medical profession typically operates on the individual level, an approach incorporating the social determinants of health directs attention to the outer spheres of influence. Identifying upstream factors can enable clinicians to understand and address the underlying conditions (or root causes) that contributed to their patients’ health problems in the first place and tailor their therapeutic interventions to the individual’s situation.

The World Health Organization defines the social determinants of health as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”2 These forces and systems include political institutions, economic systems, social policies, and cultural values, which control the distribution of money, power, and access to resources in society. Put another way, social determinants of health are the non-medical factors that influence health outcomes, some of which include:

  • educational opportunity
  • income
  • housing stability
  • work conditions
  • physical environment
  • discrimination
  • social support and inclusion
  • access to health care

Research estimates that roughly 60% of premature deaths in the US are attributable to social, environmental, and behavioral factors outside of clinical care.3 A smaller proportion are due to genetic predispositions (30%) and shortfalls in the availability and quality of medical care (10%). Many of the conditions driving the need for medical treatment are preventable, and addressing these conditions is essential to promoting health and preventing injury and disease.

Recognizing the social determinants of health can enhance clinicians’ understanding of who’s at risk of firearm injury and how to prevent it.

Structural Inequities & Firearm Violence

The social determinants of health play a fundamental role in shaping health inequities—the unjust and avoidable differences in health status between different groups.4 Some people face more obstacles than others in accessing the resources and opportunities needed to experience their full potential for health, safety, and wellbeing. These marginalized and excluded groups include people of color, people living in poverty, religious minorities, sexual and gender minorities, people with physical or mental disabilities, and women.

Firearm injury and death are no exception. Firearm violence and suicide disproportionately impact socially and economically disadvantaged groups, and growing evidence suggests that firearm violence is both a cause and a consequence of inequality.5-12 Decreased economic prospects, substandard education systems, and housing instability contribute to a lack of community safety and social cohesion, which increases the risk of violence perpetration and victimization. Conversely, firearm violence diminishes the stock of physical, human, and social capital and affects economic activity, safety conditions, and the capacity of local governments, causing further inequality. Without systemic changes that address these broader societal factors, the cycle of inequality and firearm violence continues.

Many of the policies and practices that contribute to the unequal distribution of firearm violence are rooted in structural racism, a form of inequity. Structural racism refers to all of the ways that societies foster racial discrimination through interconnected systems such as housing, education, employment, health care, and criminal justice.13 These systems reinforce discriminatory beliefs, values, and the distribution of resources. Though they might not explicitly mention race, policies such as restrictive zoning laws, mandatory minimum sentencing, and the criminalization of mental illness and substance use often reflect racist intent or have racist consequences, or both. These, in turn, fuel firearm violence and other adverse health outcomes among communities of color.

Click below for some examples:

Redlining & Residential Segregation

Redlining is a key example of structural racism that has had enduring impacts on residential segregation, economic deprivation, and other conditions that foster gun violence.14-18 Redlining refers to lending and insurance discrimination based on the location of property within a minority or disadvantaged neighborhood. The term “redlining” comes from the red lines drawn on 1930’s “residential security maps” delineating areas mortgage lenders and insurance providers frequently refused to service. Over 200 residential security maps of US cities were created by the Home Owners’ Loan Corporation (HOLC) as part of President Franklin D. Roosevelt’s effort to stem housing foreclosures in the wake of the Great Depression by purchasing and refinancing home mortgages. The red zones, which often contained dilapidated housing stock and large Black, foreign-born, or Jewish populations, were rated the least “desirable” neighborhoods for financial investment. In contrast, lending was encouraged in predominantly white and more affluent areas.

The HOLC maps are a striking visual representation of the racial prejudice and xenophobia that were prevalent at the time, perpetuated by the real estate and appraisal industry, and promoted by the US government. In effect, redlining drastically limited the ability of Black and immigrant families to become homeowners, thereby depriving them of one of the most powerful mechanisms of wealth accumulation in the US. Research estimates that the maps accounted for 15% to 30% of the gaps in racial segregation and homeownership, and 40% of the gap in house values, observed between “D” and “C” neighborhoods between 1950 and 1980.16

Residential security map of Philadelphia. Green = “A” grade (most desirable), Blue = “B” grade, Yellow = “C” grade, Red = “D” grade (least desirable). Image from Mapping Inequality.

Though formally outlawed in 1968 with the passage of the Fair Housing Act, the effects of redlining, and the discrimination that continued to exist in other forms after the Fair Housing Act, are visible today. Several studies have found strong associations between redlining and contemporary gun violence.17,18 For example, data from Philadelphia indicate that firearm violence in 2013-2014 was eight times higher in historically red-zoned areas (least “desirable”) as compared to green-zoned (most “desirable”) areas, even after controlling for sociodemographic characteristics of neighborhoods at the time the HOLC maps were produced.17 These results suggest that disparities in firearm violence are not fully explained by present day or historical demographic characteristics. Rather, these disparities are greatly influenced by discriminatory systems and practices, including real estate appraisal systems, employment practices, justice system practices, and investment in business and residential land development.

Poverty & Income Inequality

Income inequality, which is closely related to residential segregation, is also associated with firearm violence. Research shows that areas with a greater gap between the rich and the poor experience more firearm homicide, assault, and robbery, partially due to a lack of social cohesion—the sense of connectedness and relationships—among community members.6,7 More generally, rates of firearm homicide and suicide tend to be higher in places with higher levels of poverty and socioeconomic deprivation.12,19 Research suggests that economic interventions that help alleviate financial stressors can reduce health disparities between socioeconomic groups. A recent study, using data from all 50 states and the District of Columbia from 1990 to 2015, found that a $1 increase in minimum wage was associated with a 6% reduction in suicide among adults with a high school education or less, particularly when unemployment was high.20

Addressing the Social Determinants of Health

Clinicians can make an impact beyond individual patient care by advocating for changes in policies and practices related to social determinants of health.

Patients’ health outcomes, including firearm injury, are not simply the product of individual choices and behaviors. They are shaped by larger, societal forces that expand or constrain opportunities for achieving optimal health, safety, and wellbeing. Taking a broader view of patients’ health that considers their social context (including the supports and barriers in their environment) can help clinicians identify the root causes of health problems and make relevant and meaningful recommendations informed by the patient’s life circumstances. Clinicians can use online resources, such as the Area Deprivation Index Map (which shows neighborhoods’ level of disadvantage based on address), to better understand the conditions in the places where their patients live. Practicing cultural humility during patient encounters can increase clinicians’ awareness of the cultural, social, and structural factors that shape their patients’ experiences and opportunities.

Clinicians can also consider the non-medical resources that can be mobilized to assist patients. They can use screening tools, for example this Health Leads Screening Tool, to identify patients’ unmet social needs. Programs that integrate culturally-affirming social services with medical care, often using specialized case managers or community health workers, may improve patient outcomes by connecting patients with local resources, including food and housing assistance, legal services, mental health services, transportation, child care, and job training. Hospital-based violence intervention programs, which utilize violence intervention specialists, are an example of such programs that are specifically designed to disrupt the cycle of violence by treating violently injured patients’ complex social service needs and reducing their risk of violent reinjury.

Physicians can use their platform as respected authority figures in public discourse to voice the needs of their patients and to advocate for policy and practice change that targets structural inequities. They can collaborate with other sectors (e.g., lawyers, urban planners, community-based organizations) and community members to facilitate local changes. These efforts can promote more equitable health care systems and improve the conditions of daily life that place some communities at higher risk for firearm violence.

 

Dr. Nicole Kravitz-Wirtz and Dr. Shani Buggs from the UC Davis Violence Prevention Research Program contributed to this content.

 

Page last updated April 2021. 

References

  1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. (2021). The social-ecological model: A framework for prevention.
  2. World Health Organization. Social determinants of health.
  3. McGinnis, J. M., Williams-Russo, P., & Knickman, J. R. (2002). The case for more active policy attention to health promotion. Health Affairs.
  4. Braveman, P., Arkin, E., Orleans, T., et al. (2017). What Is health equity? And what difference does a definition make? Robert Wood Johnson Foundation.
  5. Feldmeyer, B. (2010). The effects of racial/ethnic segregation on Latino and Black homicide. The Sociological Quarterly.
  6. Kennedy, B. P., Kawachi, I., Prothrow-Stith, D., et al. (1998). Social capital, income inequality, and firearm violent crime. Social Science & Medicine.
  7. Rowhani-Rahbar, A., Quistberg, D. A., Morgan, E. R., et al. (2019). Income inequality and firearm homicide in the US: a county-level cohort study. Injury Prevention.
  8. Wilkinson, R. (2004). Why is violence more common where inequality is greater? Annals of the New York Academy of Sciences.
  9. Abt, T. (2019). Bleeding out: The devastating consequences of urban violence--and a bold new plan for peace in the streets. Basic Books.
  10. Tita, G. E., Petras, T. L., & Greenbaum, R. T. (2006). Crime and residential choice: a neighborhood level analysis of the impact of crime on housing prices. Journal of Quantitative Criminology.
  11. Irvin-Erickson, Y., Bai, B., Gurvis, A., et al.(2016). The effect of gun violence on local economies. Urban Institute.
  12. Kim, D. (2019). Social determinants of health in relation to firearm-related homicides in the United States: A nationwide multilevel cross- sectional study. PLoS Med.
  13. Bailey, Z. D., Krieger, N., Agénor, M., et al. (2017). Structural racism and health inequities in the USA: evidence and interventions. Lancet.
  14. Nelson, R. K., Winling, L., Marciano, R., et al. Mapping Inequality: Redlining in New Deal America.
  15. Hillier, A. E. (2003). Redlining and the Home Owners’ Loan Corporation. Journal of Urban History.
  16. Aaronson, D., Hartley, D., & Mazumder, B. (2020). The effects of the 1930s HOLC “Redlining” maps (Working Paper No. 2017-12). Federal Reserve Bank of Chicago.
  17. Jacoby, S. F., Dong, B., Beard, J. H., et al. (2018). The enduring impact of historical and structural racism on urban violence in Philadelphia. Social Science & Medicine.
  18. Benns, M., Ruther, M., Nash, N., et al. (2020). The impact of historical racism on modern gun violence: Redlining in the city of Louisville, KY. Injury.
  19. Steelsmith, D. L., Fontanella, C. A., Campo, J. V., et al. (2019). Contextual factors associated with county-level suicide rates in the United States, 1999 to 2016. JAMA Network Open.
  20. Kaufman, J. A., Salas-Hernandez, L. K., Komro, K. A., et al. (2020). Effects of increased minimum wages by unemployment rate on suicide in the USA. Journal of Epidemiology & Community Health.
For more information, see these peer-reviewed articles.

Maani, N. & Galea, S. (2020). The role of physicians in addressing social determinants of health. JAMA.

Armstead, T. L., Wilkins, N., & Nation, M. (2019). Structural and social determinants of inequities in violence risk: A review of indicatorsJournal of Community Psychology.

Jacoby, S. F., Dong, B., Beard, J. H., et al. (2018). The enduring impact of historical and structural racism on urban violence in Philadelphia. Social Science & Medicine.

Rowhani-Rahbar, A., Quistberg, D. A., Morgan, E. R., et al. (2019). Income inequality and firearm homicide in the US: a county-level cohort study. Injury Prevention.

Allchin, A., Chaplin, V., & Horwitz, J. (2018). Limiting access to lethal means: Applying the social ecological model for firearm suicide prevention. Injury Prevention.

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