29 Oct What are “Social Determinants” and are they the key to a healthier and happier life?
As readers of my past articles are aware, it’s unusual for me to want to write a somewhat loose and exploratory piece on any subject. In the main, I’d rather dig in to the research and try to bring together the best of what has been said and maybe add a thought or two of my own at the end. However, in the last few weeks I’ve been delving into the often-cited “social determinants of health” subject and in so doing found that the data and thinking seems to be all over the place. Even worse, this is true not just in the United States but in other countries such as Canada, the UK, Australia, Singapore, China and elsewhere, and even with large international bodies such as the World Health Organization or WHO. So what’s the core problem here?
Perhaps first and foremost the term “social determinants” seems to be used as “everything that might influence a person’s health other than physical ones”. This includes variables such as the state of local roads or a person’s housing situation, proximity to toxins or waste, or the quality of the local air, or even items such as a person’s location, economic status or level of literacy. This is using the word “social” in its widest possible sense of “relating to society” and I personally think this inhibits our opportunity to take a good and important question (do factors other than physical problems have an impact on health and by how much?) and start to really get a lock on some possible answers. After all, the ultimate goal here is surely to better understand a whole range of non-physical health influencers and ultimately assess these for their relative impact. If we can do this well, we have a chance to make political, economic, and social changes, at a policy level, and give individuals much stronger guidance on what to do as organizations, families and as individuals.
In most circumstances, when we have a lot of variables that all play to a greater or lesser extent in an equation, the assessment of impact task would best be performed by a large research institution, such as the WHO or a university, and there are some studies out there that are at least interesting. However, because we have not defined our terms well in my view, in the rest of this article I want to try to change this and “wax philosophically” to try to create a model that we can potentially all buy into as a base. We can perhaps all then be on the same base page in getting more rigorous university type research done to ultimately prove that these loose guesses are somewhere near the truth. So let’s start that journey.
To start with, let’s list the factors that are often cited as contributing in any way (small or large) to an individual’s health and/or happiness. Because this is a very long list, I’d like to present it in 10 clusters and then describe what kind of factors lie underneath each of them:
Determinants of Health and Happiness
I am not suggesting that these 10 clusters are either comprehensive or the right number-perhaps there are 8 or 12 clusters and better ones at that. Neither am I am suggesting that the items under each of these clusters are comprehensive or equivalent. They are merely indicative of what I believe broadly seems to belong together as a category in order to start to be able to build a future model.
The benefit of building such a chart is that it can get anyone interested in this subject (and that should be a lot I hope, as we are talking about what leads to better human health and happiness) thinking about contributing factors. For example, this chart presents what could be seen as “harder” or more “contextual “ factors on the left than on the right. The chart naturally should also get people thinking about which individual clusters may have the greatest or perhaps the least impact or which individual items within a cluster may have the greatest or least impact. For example, “Levels of sadness/loneliness/depression”, in the personal behavior cluster above, has been the subject of enormous particular attention by governments all over the world in recent times, which would suggest it has a greater impact than say “Access to/dependency on new media” in the same category (although it would be good to see some harder research on this and some quantification).
Of course, the problem with charts such as this as that they offer a lot of variables (in this cases 60 items that all play into health and happiness in some fashion). For this reason I’d like to propose one further model, based on the above data, which may prove helpful. For this I base my thinking on the already familiar and well-regarded (albeit often academically contested) “hierarchy of needs” model developed by Dr. Abraham Maslow over 65 years ago, shown below.
This five-stage model states that a lower level must be satisfied and fulfilled before an individual can mentally transition a higher level (even though these levels are somewhat overlapping). This means that although an individual gains most from moving to the top of the pyramid, this is built on ensuring that lower levels or basic needs (or the ones at the level below in each case) have been met. Take a basic or lower level need away, almost like sucking oxygen out of the room, and people quickly lose focus on higher level needs until that is back to “normal”.
In adopting the same broad model at 5 stages, I propose that there are 5 levels of “Determinants of health and happiness” as follows:
- Environmental determinants
- Local Living determinants
- Physical determinants
- Personal determinants
- Social determinants
Once again these are not wholly discreet as there are clearly some overlaps and many issues within categories can relate in different ways to others. However, each layer does represent a very unique impact or determines health/happiness outcomes in different ways.
Given the above, the pyramid (in graphical form) looks as follows:
Just like Maslow’s hierarchy, this pyramid suggests that determinants of health and happiness are impactful from the bottom up, with the most basic needs having to be in place, or at least relatively stable, before individuals can gain the benefit of the thinking about the impact of the next level. For example, a roof over a person’s head in a place that is warm or cool enough, with access quality power and clean running water is likely to have a significant and immediate negative impact on health and happiness if these are missing or not present or woefully inadequate.
In this model, examples of factors are listed under each of the 5 levels of the pyramid, starting with highly tangible external conditions, often beyond an individual’s easy capacity to influence or control (such as air quality or access to public transport).
At the next level (and more readily influenced by an individual, at least relatively) are local living conditions (such as whether a home has sufficient heat or a person is in debt or not).
At the next level we move into an individual’s physical determinants of health, some of which are relatively difficult to influence (such as genetics) but including some that could be changed with some effort and focus (such as addictions).
For my purposes here, environmental, local living and physical determinants (the bottom 3 layers) are not “social” ones, as they are likely to prevail and influence people because of factors such as political decisions, economic circumstances and national and local policy choices (which can reflect legal, cultural, technological and other considerations). For me then, truly “social determinants” are the ones at the top two levels, but even here they can be spilt in two.
Personal determinants are more self-determined than the bottom three, and reflect circumstances that an individual can often change if they are determined (although admittedly often with only considerable effort). This includes factors such as literacy and education levels as well as the type, quality and stability of work.
Finally, at the top of the pyramid are pure “social determinants” or those factors that mainly relate to the quantity, quality and frequency of relationships with others. This includes not only time spent with friends and family but social pastime participation and even the level of spirituality or altruism felt towards others.
Lastly, it will be noticed that I have assigned percentages to each of these 5 levels to indicate the likely impact of each layer or tier of the pyramid as a whole. This is not only somewhat paradoxical, because the lowest levels of the pyramid are incredibly impactful when individual determinants are altogether absent (a homeless person, living in poverty with no work is likely to quickly experience greater physical and mental health problems, for example and even fall into cognitive decline or depression) but also almost entirely hypothetical (based only loosely on some limited research done to date). However, these guesses serve to provide a starting point for people to perhaps plan to conduct more rigorous studies to come up with more accurate numbers.
But even without this deeper discovery, and accepting that these are only loose estimates, the impact of the top layer is proposed to be greatest (at a guess of 30%) and personal determinants next at 25%, making over half of the impact on our health and happiness based on social and personal determinants of health. This would clearly suggest that we should focus much more of our time and effort on these two layers and on the individual sub-categories that are under each of them.
In practical terms this entails that we are likely to get “more bang for our buck” by focusing much more on items such as building up people’s self-esteem and confidence, getting them more involved socially (through games and pastimes with others perhaps), developing better approaches to deal with loneliness and social exclusion and even encouraging more civic participation. And all of this becomes increasingly important as people age and their personal and social networks change and often deteriorate.
A good example of this impact is grief when a family member or friend passes away (or in some older people this can even happen when a pet dies). Quite apart from being sad, it can lead to more social exclusion, a decline in physical health in some circumstances and even a deterioration in people’s living conditions (people may not be motivated to shop or clean as much as they did for a while, for example, and the person’s health may consequently suffer further as a result).
In summary, my contention is that this new 5-level health and happiness determinants pyramid can be a useful model to better focus our conversation about impacts on health other than physical ones (around which we already have a burgeoning and expensive healthcare industry, in most countries) and start to make changes that take these factors into account according to their impact. Put another way, this simple “Maslow style” hierarchy of determinants can help us to remember two things. Firstly, that we have to ensure that basic needs have to be met at a minimum at the base of the pyramid (environmental and local living determinants) or they will can potentially cause anyone’s health to suffer in a very short space of time. This is often best addressed by political, economic and social policy at a local, state and federal level. Secondly, and even more importantly, assuming these basic needs are minimally met, this pyramid suggests that we should pay much more attention to both personal and social determinants of health (and the extent to which they are positive at individual factor level) and ensure that these are addressed with the appropriate amount of time and attention. In practical terms, this may mean that we need considerably more personal and social support strategies and time for people, and especially when individuals experienced more problems at these tiers. This particularly tends to happen as they reach older age.
Now all we have to do is to measure these factors and suggested tiers more rigorously (for relative contribution and relationship to others in combination) so that we can be confident that our interventions are likely to make people’s lives better in the short, medium and long term. To my mind, this is a worthy goal and has potentially huge societal benefits.
Jon Warner is CEO of Silver Moonshots, a research and mentoring organization for enterprises interested in the 50+ older adult markets. He is also Chapter Ambassador for Aging 2.0 in Los Angeles and Co-chair of the SBSS “Aging in the Future” conference.