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SOCIAL AND ENVIRONMENTAL FACTORS

CONTEXT

Health is influenced by numerous biological, behavioral, social, cultural, environmental, geographic, economic, health system, and public policy factors, most of which are interdependent at some level. Taken together (when adequately addressed and considered), these aspects can contribute to a more equitable experience of health for individuals and populations. The forces that influence health also contribute to the experience of health care, from prevention to late-life care experiences. Health equity focuses on removing unfair and unjust barriers to health, and health care equity concerns itself with efforts to remove barriers and ensure that all people have the resources and opportunities to access and achieve high-quality health care. By achieving health equity, societies have the opportunity to experience enhanced health and well-being for all, with better overall outcomes and long-term socioeconomic prosperity. The cumulative impacts of health inequities have translated into a decreasing life expectancy in the United States from 2016 to 2019, which was further exacerbated in 2020 by the severe impact of the COVID-19 pandemic, especially on populations with lower socioeconomic status, fewer resources, and disparate opportunities to access high-quality health care (Andrasfay and Goldman, 2021).

COMPELLING RESEARCH QUESTIONS

Numerous knowledge gaps and unanswered questions related to social and environmental factors affecting health and health care were elucidated via the topic briefs and in the meeting discussions. These include the following:

• Where are the knowledge gaps with respect to interventions to tackle social determinants and environmental factors that influence health equity?

• What does a vision of health equity look like across communities and care systems? What action is needed to realize this vision, and how can key national entities/agencies align their efforts and strategic priorities to reduce health inequities?
• What are the most promising trends, innovations, and movements that will promote and sustain health equity, and what investments are needed in order to cultivate research and action on emerging issues in health equity in the next decade?
• How can the research ecosystem, from the workforce to grants and funding, be optimized to promote comprehensive health equity research? Who are the critical partners from other sectors, including justice, education, and public policy, to engage in new research efforts?
• What actions are needed in order to translate evidence into actions, interventions, and policies that change systems and organizations to improve people’s health and well-being?

DISCUSSION HIGHLIGHTS

To introduce the discussion of social and environmental factors, Rachel Hardeman, Ph.D., M.P.H., Associate Professor in the Division of Health Policy and Management and the Blue Cross Endowed Professor of Health Equity at the University of Minnesota School of Public Health, gave an opening presentation centered on three primary areas:

1. Acute and long-standing health inequities that are caused or exacerbated by structural racism
2. Understanding of how the conditions of daily life (social determinants) experienced by historically oppressed groups have their roots in structural racism and affect health and well-being
3. Insights into opportunities for improvement and transformation

Dr. Hardeman offered a broad overview of how racism, operating as an underlying root cause, leads to structural policies, systems, and institutions—for example, in education, housing, employment, and financial access—that can add substantially and inequitably to health risks, health disparities, and poorer health outcomes. Dr. Hardeman also noted that inequities played out in real time as a consequence of the COVID-19 pandemic, with large disparities in cases, deaths, and access to testing and vaccinations in the Black populations of several states. She concluded by describing opportunities for individual and institutional

transformation, inclusive of research, policies, and personal inquiry. At the individual level, each person must think about their own role in dismantling structural racism and understand how racism has shaped discourse around disparities. For academic and research communities, she described opportunities to reframe research questions and methodology, noting that a more diverse set of questions, funded researchers, and research topics will move the entire field forward. Health system contributions to eliminating disparities will require dedicated and sustained attention, including desegregating the workforce and making training in structural racism a core competency in educating the clinical workforce. Finally, Dr. Hardeman offered several policy improvements at the state and national level that could produce meaningful changes, including a White House Office of Racial Equity, a comprehensive response to the COVID-19 pandemic, universal comprehensive single-payer health care, and reparations.

Observing the interplay of these factors with patterns of justice, education, and social cohesion, the breakout group on social and environmental factors identified important related considerations. Person-centeredness is critical, noting that people do not experience social needs in one silo and health outcomes in another. Furthermore, the traditional culture of patient–clinician care organization interaction is contrary to the notion of the patient and family as “customer/owner” of the processes involved. This compounds an already prevalent set of dynamics that can shape individual perceptions about their distance from the locus of control when it comes to their health. The ability to address the myriad factors affected by and adjacent to social and environmental factors is not solely the task of health care institutions—rather, there is a cross-sectoral need to look at all of these factors more holistically.

Noting a trend in cross-sectoral interest in equity arising from the twin forces of the pandemic and heightened awareness of racial injustice, this breakout group also underscored the centrality of sustaining the momentum, given the entrenched nature of the challenges. To that end, the group expressed the importance of bolstering the evidence base on effective interventions that can reduce the panoply of social and environmental factors that contribute to inequities, from implicit bias to food and housing insecurity, and examining both monetary and non-monetary costs of these inequities. Progress will depend on the committed engagement of all stakeholders, including patients, families, and other care partners who are personally affected by disparities, as well as policy makers and organizations that have been providing services to address social determinants of health. Broad collaboration is essential for attaining health justice and systemic transformation.

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