Social Determinants of Health


**Based on the attached PDF reading on the social determinants of health for the United States, compose a paper (minimum 5 pages) on successful examples of policy action aiming to reduce health inequities, covering a wide range of issues, including conditional cash transfers, gender based violence, tuberculosis programming and maternal and child health**Key points that MUST be addressed in the paper: – State the problem the country is trying to address – What solutions have been proposed to address the issue cited?- Are the solutions proposed a business case (short-term financial return with supporting evidence), an economic case (long term financial return with supporting evidence) or a social case? (financial return intangible but morally based with supporting evidence)- What economic pressures are impacting the public health resolution proposed?- Discuss the rationale for the economic intervention chosen by the government- Identify the supply and demand issues (two of each) associated with the problem and the solution- Discuss what you might have done differently from a social perspective AND an economic perspective

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– Draft Background Paper 2 –
How can we get the social determinants
of health message on the public policy
and public health agenda?
Translating data into an SDH Information Tool to inform policy
and public health programs: Using existing databases to create
community profiles of social factors that shape Utah’s health
Len B. Novilla
Michael D. Barnes
Carl Hanson
Josh West
Eric Edwards
Brigham Young University; Provo, Utah, U.S.A.
– Draft Background Paper 2 –
This draft background paper is one of several in a series commissioned by the World Health Organization for the
World Conference on Social Determinants of Health, held 19-21 October 2011, in Rio de Janeiro, Brazil. The goal
of these papers is to highlight country experiences on implementing action on social determinants of health.
Copyright on these papers remains with the authors and/or the Regional Office of the World Health Organization
from which they have been sourced. All rights reserved. The findings, interpretations and conclusions expressed in
this paper are entirely those of the author(s) and should not be attributed in any manner whatsoever to the World
Health Organization.
All papers are available at the symposium website at Correspondence for the authors
can be sent by email to
The designations employed and the presentation of the material in this publication do not imply the expression of
any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines
on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific
companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the
World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions
excepted, the names of proprietary products are distinguished by initial capital letters. The published material is
being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages
arising from its use.
– Draft Background Paper 2 –
Executive Summary
For the last 20 years, from 1990-2010, the State of Utah had consistently been ranked among the
top 10 healthiest states in the United States.1 However, a closer look at Utah’s life expectancies
belies problems that run deep into the local levels. Disaggregating state-level data into 29 counties2
and then further down into 61 small areas as to groups or single zip codes,3 revealed disparities in
life expectancies at birth (2009 estimates).4 Within the same county, there was a graded difference
in life expectancies. Some areas have life expectancies over 80 years, far better than the nation’s
and comparable to the five best in the world.5 Yet residents living just three to ten miles away within
the same county, could die three to 10 years sooner (See Table 1),4 with an average life span about
as long as those in developing countries.5 These disparities across counties was key to the drop in
Utah’s 2010 health ranking, from second in 2009 to seventh in the nation in 2010, the lowest it had
ever garnered in the last 20 years.1 Since life expectancies measure health status and summarize
mortality across age groups in a specific area,4,6 these differences in life expectancies point to
inequalities in health stemming from the “causes of the causes,”7 or the living conditions and
processes that determine the overall quality of life, broadly referred to as the social determinants of
health (SDH). Though much more apparent among the vulnerable, at-risk, and underserved
populations, disparities in health occur differentially across social groups, limiting life spans as well
as socio-economic mobility.
Despite the impact of social factors on health, translating the social determinants of health through
policy and practice is fraught with challenges. First, health data are typically reported as individual
indicators rather than being presented comprehensively by geographic area within the context of
non-medical indices that likewise affect health. Without accounting for the relationship between
health outcomes and social determinants, there is no way of fully assessing the impact of policies
and programs on the health of the people. Second, even with years of data collection, there remains
a lack of evidence translation into policies and public health activities consistent with the social
determinants of health principles.8 Public policy agenda and public health efforts remain
dichotomous instead of being coherent and coordinated in the service of health. Thus, driving a
sustainable change that distils into the various levels of governance becomes an almost herculean
The challenge in translating the social determinants of health message lies in linking health policy
with public health practice. The overall purpose of this ongoing study is to translate the social
determinants of health concept into practical approaches that are meaningful at the local levels of
– Draft Background Paper 2 –
governance and constituency in Utah by utilizing data as an SDH information tool for policy and
public health programs. Using health and demographic indicators common across five existing
population metrics, we developed a Community SDH Profile for Utah and its vulnerable populations
down to the small area or zip code-level. This profile was then presented using an open-source data
visualization software to provide policy makers, public health practitioners, and the public a visual
image of how social factors within Utah impact health at the state down to the community level.
Key research lessons in translating the social determinants of health at the local level:
(1) The social gradient is deeper. Inequalities in health resulting in disparities in life
expectancies are evident even at the lowest reportable data level, down to the small area or
zip code-level. The challenge has always been what to do about it.
(2) Communicating contextualized and actionable data. In as much as comprehensive
epidemiology reports are helpful and serve various purposes, to act on the evidence, policy
makers and public health practitioners need simple, precise, accurate, easy-to-understand,
easy-to-learn, visualize-able information at their constituents’ level.
Where reliable data are already available and regularly reported; use technology and existing
health metrics to support the SDH message. A succinct and visualize-able demographic and
health landscape that focuses on vital priorities and trends at the community level can be a
mechanism by which the social determinants of health message could be recognized, acted
upon, directed, and evaluated9 down to the local levels of governance.
(3) Framing the message according to local needs: “What’s wrong? Why does it matter? What
should be done about
about it?”10 The problem is not always the lack of data as much as how data
are communicated. How we communicate the evidence is strategic in engaging both policy
makers and the public. Presented wisely, used effectively, directed to the right audience,
within the context of the social determinants of health, data can persuade, elicit interest,
help inform, engage, advocate, and initiate action. Existing data framed in a manner that
speak to community needs and issues that the people can connect with and in a language
that people can understand are much more likely to resonate across the political spectrum.
(4) Keep repeating the message.8 The social determinants of message can get lost in a flurry of
competing political and health issues. Marketing the message calls for repeatedly
– Draft Background Paper 2 –
disseminating and reiterating the information to counter the fatalistic mindset towards
(5) Engaging the right people in doing the right thing: Having a shared vision and focus of
improved health and reduction of health disparities. The social determinants of health result
from “the way we organize our affairs in society.”7 These factors are so intricately embedded
in the realities of daily living that reducing the inequities we have created means partnering
with the right people from various sectors —those who share a vision and have the skills,
courage, and resolve to bring about change in the system or with the system.11,12
How can we bring the social determinants of health message on the public policy and public health
Where are the disparities in Utah communities?
Utah faces challenges that could be very well addressed at the public health and policy levels.
Breaking down Utah’s 2010 seventh healthiest ranking in the nation, revealed that the state’s
lowest measures stemmed from public and health policies such as lack of health insurance, low
public health funding, and low immunization coverage. In these measures, Utah ranked 24th, 33rd,
and 30th respectively out of 50 states.1 Its high geographic health disparity in death rates from one
county to another was close to the bottom at 44th.1 Likewise, high school graduation rate went down
by 12 percent, from 88.6 percent in 2009 to 76.6 percent in 2010 while children in poverty
increased from 8.8 percent to 13.9 percent.1 In addition, disaggregating the average life expectancy
in the state as to counties and small areas revealed as much as a ten-year difference in life span in
communities within the same county (See Table 1).4
Social factors exert a combined effect on individual and population health. Paramount to effecting
long-lasting changes in the social milieu will be the concerted efforts from various government and
non-government sectors. However, linking policy efforts with public health practice at various levels
of governance remains a challenge.
– Draft Background Paper 2 –
Social Determinants of Health (SDH)
The disproportionate burden of disease in a population could not be completely explained by the
biology of the disease. Biological factors explain only 45 percent of the prevalence and distribution of
the disease in a community or a group of people.15 The number of at-risk individuals in the
population continues to grow unless behavior, which is intricately connected to social conditions in
life, is changed. And yet, even if people are aware of their risk factors, it does not always lead to a
sustainable behavior change.16
The conditions in which live, work, and play are so tightly woven into the fabric of our lives that they
serve as the main driving forces that determine the quality of our lives, our health and well-being,
even predict disease and death.7,8,13 These conditions arise from how we interact and “organize our
affairs in society”7 and can be of an economic, political, or cultural nature. Such conditions are
broadly referred to as the social determinants of health.
Why are the social determinants of health important? Research after research has shown that these
intricately-bound realities of daily living, of which the most important is social class,14,15 produce a
health gradient that results in premature death or disease.15,16 Central to these factors are the
structural determinants14 such as income, education, employment, access to resources, living and
working conditions, policy and governance —all of which can decide an individual’s position in
society. The rate and range with which a person can move up or down the social and economic
ladder can create power plays and inequities that eventually impact both individual and communitylevel health.13,14 These not only stratify one’s social standing, but also determine access to resources
and utilization of services. Though much more apparent among the vulnerable, at-risk, and
underserved populations, disparities in health occur differentially across social groups, limiting life
spans as well as socio-economic mobility. Leonard Syme, Professor Emeritus of Epidemiology at the
University of California, Berkeley, argues that despite carefully designed and well-executed public
health interventions, until the social “forces in the community” that lead to health disadvantage are
addressed, a significant and long-lasting impact on population health will not be sufficiently
achieved.15 Such stratifying and limiting forces in society are best tackled at the system level through
a robust public policy and by empowering communities to act.14
– Draft Background Paper 2 –
Utah’s Demographic & Health Status
Utah became the 45th state in the United States in 1896.17 Named after a Native American Tribe, the
Utes,17 Utah has a land area of 82,143.65 square miles.18 It has a population size close to 3 million
or 2,763,885 people with a density of 33.6 individuals per square mile (2010 estimate).18 Although
it is getting increasingly diverse ethnically, Whites still comprise 80.1 percent of the population
followed by Hispanics at 13 percent, Asians at 2 percent, American Indians and Alaskan Natives at
1.2 percent, and Blacks at 1.2 percent.17 The delivery of public health services is organized into 12
local health departments for Utah’s 29 counties.19 Half of these health districts provide services
directed at single counties while the other half provide services for multiple counties.
Utah has consistently been among the top ten healthiest states in the nation. Based on the United
Health Foundation’s two decades worth of annual reporting on America’s Health Rankings, Utah had
ranked first for six consecutive years, from 1993-1998, and again in 2002.1 It was ranked second
four times; third three times; fourth three times; fifth twice, and sixth and seventh, once respectively.
Utah’s strengths included a generally healthy lifestyle as evidenced by the low prevalence of
smoking, binge drinking, and cancer deaths with the sixth lowest crime rate in the country.1 Despite a
high fertility rate, Utah has an impressively low infant mortality rate, the third best in the nation. 1
Each state’s health ranking, as reported annually, represents a broad range of issues that influence
the health of the population, from genetic and personal factors to the social environment in which
the individual, family, and community operate. There are four major groups of determinants that are
measured in ranking the health of each state in the nation: personal behaviors, community and
environment, public and health policies, and clinical care.20 Personal behaviors include individual
attitudes and behaviors as well as habits and practices established and reinforced in a family setting
that affect health. Community and environment are the realities and conditions of daily life that
determine both personal and community health. Public and health policies include factors that
influence the availability of resources and the extent of reach of health programs into the population.
Clinical care assesses the quality, cost, and appropriateness of care obtained by the population.
Utah has performed outstandingly across the nation on personal behaviors.
Data disaggregation and analyses show that the dimensions of Utah’s social environment may have
just as much impact on health as personal behavior.2,4,21 While health behaviors and lifestyle
determine differences in exposure and vulnerability to disease, structural factors in society such as
income, social status, gender, ethnicity, education, employment, and working conditions stratify
one’s social standing by determining access to resources and the utilization of services.14 Breaking
– Draft Background Paper 2 –
down Utah’s 2010 seventh ranking in the nation, the lowest it has garnered in 20 years, revealed
that the state’s performance is dismally low on public and health policies, particularly on
components pertinent to insurance coverage and public health funding. Utah’s lowest measures
stemmed from public and health policies such lack of health insurance, low immunization coverage,
and low public health funding. In these measures, Utah ranked 24th, 30th, and 33rd respectively out
of the 50 states.1 Its high geographic health disparity in death rates from one county to another was
close to the bottom at 44th out of 50 states.1 Likewise, high school graduation rate was down by 12
percent, from 88.6% in 2009 to 76.6% in 2010; while children in poverty increased from 8.8 percent
to 13.9 percent.1
Utah’s health outcomes are currently reported using 176 indicators presented in an online database
known as Indicator-Based Information System for Public Health (IBIS-PH)4,19 managed by the Utah
Department of Health’s Office of Public Health Assessment. This serves as the public health data
source for both numerical and contextual information on the health of the population across the
state, including Utah’s health care system. While IBIS-PH contains many important datasets such as
the BRFSS data, the categorization of health data as to individual indicators versus a contextualized
presentation as to geographical or political boundaries within the framework of social factors limits
users in grasping the relevance of the information. For instance, if a policy maker or public health
practitioner wanted a reliable at-a-glance picture of the impact of various SDH indicators on the
health of their community, he or she would have to sift through the layers of data within the IBIS
Creating a Community SDH Profile for Utah and its vulnerable populations is intended to articulate
the social determinants of heath message by depicting variations in health outcomes across
communities in Utah. Because data are presented visually, policy makers and public health
practitioners can readily spot where inequalities lie between counties and local communities.
Conversely, having a landscape profile of both social and health factors motivates a deeper look into
the dimensions of Utah lifestyle that translate into improved health outcomes such as the
biopsychosocial factors of religiosity, volunteerism, social support networks, and community
The complexity of accounting for each and every interaction within and between the social and
political ecological environments presents challenges in translating data into policy. To help narrow
– Draft Background Paper 2 –
the gap in evidence translation and encourage coherent and coordinated policy and practice efforts,
our SDH Research Team from the Department of Health Science at Brigham Young University sought
to create visualize-able SDH Profile at the community level as an SDH information tool. Our team
consulted with the Pan American Health Organization and the Utah Department of Health Office of
Public Health Assessment in charge of gathering demographic and health statistics for the State of
Utah through the Indicator-Based Information System for Public Health (IBIS-PH).
To identify the best available SDH measures, demographic and health indicators that are already
being collected and monitored in at least two of five existing population databases at the national
and state levels were selected (See Table 2). These population databases included the following:
Utah’s Department of Health Indicator-Based Information System for Public Health (IBIS-Utah); CDC
SDH Directory; Behavioral Risk Factor Surveillance Survey (BRFSS) data; University of Wisconsin’s
County Health Rankings; and the U.S. Department of Health and Human Services’ Healthy People
2020. Once indicators common among these databases have been selected, they were grouped into
six constructs based on The Marmot Review’s Six Policy Objectives on the so …
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