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Addressing Social Determinants of Health Requires a Holistic, Targeted Approach

Liz Seegert August 13, 2018
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Social determinants of health are interconnected. Community partnerships can help address multiple challenges inside and outside the health system.

Longevity starts at home, in our neighborhoods and communities. Where we live, work, play and age predict health more any other factor, including genetics. The conditions that impact our lives, the “social determinants of health,” help explain why some people live long, relatively healthy lives, and others may become frail, battle multiple chronic conditions or die prematurely.

Social determinants of health include socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, according to the World Health Organization.

Recognition is growing that healthy aging requires broad approaches that address these issues, both inside and outside the health system. Partnerships among businesses, community-based organizations, institutions and government can mitigate disparities that influence health and aging.

“Social determinants are best assessed by zip code or census tract,” said Toni Miles, Professor of Epidemiology at the University of Georgia College of Public Health. To understand the challenges, it’s important to listen carefully to folks in the community, because you’ll hear things like, “these are the choices that are available to me” or “these are the obstacles that I encounter.”

“If people want to make a change, it’s figuring out in their local environment how that change can be accommodated,” said Miles.

Over 25 million Americans age 60 and older are economically insecure, living at or below 250 percent of the federal poverty level ($29,425 per year for a single person), according to the National Council on Aging (NCOA). Older adults struggle with housing and health care costs, inadequate nutrition, lack of access to transportation and more. When measured under the Elder Economic Security Standard Index, a county-by-county measure of the income needed by older adults to maintain independence and meet their daily living costs while staying in their own homes, millions more older people are barely squeezing by. Even if they’re not officially considered “poor,” one major health event could wipe out their savings.

Reducing housing hardship is critical for healthy aging

Housing costs are a huge challenge for many for older people. They often spend a disproportionate amount of monthly income on rent or mortgage and related expenses. A 2014 report from the Joint Center for Housing Studies at Harvard found that a third of adults age 50 and older and 37 percent of those 80 and older, pay more than 30 percent of their income for housing. Some are severely burdened, paying more than half of their income on housing. The NCOA estimates that one-third of senior households have no money left over or are in debt after meeting essential monthly expenses.

A June 2018 study from the Urban Institute looked at the relationship between food insecurity, housing hardship and health care use. It found that adults who faced housing insecurity (inability to pay full rent or mortgage and/or utility bills) or housing hardship (dwelling-related problems like leaky roofs or vermin) use more health care and had higher out-of-pocket health spending than adults who did not struggle to meet these costs. Thirteen percent of those 65 and older and nearly 17 percent of adults 50 to 64 reported housing hardships.

“As researchers have gotten more into the issues around social determinants of health, you see that housing is an important factor in people’s health spending,” said Steven Zuckerman, a senior fellow at the Urban Institute and co-author of the study. “Living in substandard housing impacts your ability to pay and is strongly related to medical spending.”

Public transit reduces social isolation

Lack of reliable public transportation is another social determinant of health affecting older people. Transportation can be major challenge for many older adults, particularly those living in suburban and rural areas, Miles said. “They basically become homebound if they can no longer drive.” Some health practices now offer ride sharing services to ensure patients get to appointments, but that doesn’t address larger issues of access to grocery stores, community centers or other services.

It’s easy for older adults to become socially isolated, which can lead to loneliness and poorer health. Sixteen percent of older adults in the U.S. report feeling lonely. That increases risk of depression, exacerbates existing health conditions and increases risk of death, according to Robyn Golden, Director of Healthy Aging, Rush University Medical Center, Chicago. Barriers like poverty contribute that isolation, as does a community that is not age-friendly. Conversely, accessible community supports can actually protect health.

There’s no one-size-fits-all solution

Community organizations can step in to address some of these issues. Others solutions, like new bus routes, must involve policymakers, Golden said in a presentation to philanthropy organizations. While some things, like lack of an elevator in a walk-up apartment building, can’t be changed, many social determinants of health can be improved—such as establishing health care clinics inside senior housing complexes, increasing awareness of available neighborhood social services, incorporating universal design elements into homes, bringing healthier, more affordable food into neighborhoods, and creating safer, greener environments for residents of all ages to play, gather and socialize.

“Just throwing money into an area without understanding what the target is may not help you. The best solutions come from the people themselves,” said Miles. “Ask people what they want and need, not what you think they need.”

Miles said we often see these problems in silos, but socioeconomics, housing, food, education and neighborhood are interconnected. They need to be addressed as a whole, with logical, affordable solutions that take a comprehensive view of longevity.

Liz Seegert

Liz Seegert is an independent health journalist based in New York City. She writes about aging, boomers, policy and related topics for online, print and broadcast media, and also co-produces the HealthCetera podcast.

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