Social determinants of health

International health inequalities

Even in the wealthiest countries, there are health inequalities between the rich and the poor. Researchers Labonte and Schrecker from the Department of Epidemiology and Community Medicine at the University of Ottawa emphasize that globalization is key to understanding the social determinants of health, and as Bushra (2011) posits, the impacts of globalization are unequal. Globalization has caused an uneven distribution of wealth and power both within and across national borders, and where and in what situation a person is born has an enormous impact on their health outcomes. The Organization for Economic Cooperation and Development found significant differences among developed nations in health status indicators such as life expectancy, infant mortality, incidence of disease, and death from injuries. Migrants and their family members also experience significant negatives health impacts.

These inequalities may exist in the context of the health care system, or in broader social approaches. According to the WHO's Commission on Social Determinants of Health, access to health care is essential for equitable health, and it argued that health care should be a common good rather than a commercial product. However, there is substantial variation in health care systems and coverage from country to country. The commission also calls for government action on such things as access to clean water and safe, equitable working conditions, and it notes that dangerous working conditions exist even in some wealthy countries. In the Rio Political Declaration on Social Determinants of Health, several key areas of action were identified to address inequalities, including promotion of participatory policy-making processes, strengthening global governance and collaboration, and encouraging developed countries to reach a target of 0.7% of gross national product (GNP) for official development assistance.

Recent Trends

In recent years, the recognition of social determinants of health has had a growing impact on healthcare and they now account for more variation in health outcomes than medical care itself. Following this change, that the magnitude of the unequal distribution of health-outcomes is no longer singularly biologically determined but rather determined by the condition's one is exposed to through their environment and status. This has been particularly harmful to marginalized groups, such as the elderly, disabled, or chronically ill. These groups rely on the American healthcare system more than the average population yet tend to have limited access due to issues like healthcare affordability which is largely affected by social determinants of health.

Healthcare Technology

According to the World Health Organization, health technologies "include medicines, medical devices, assistive technologies, techniques and procedures developed to solve health problems and improve the quality of life." Used in almost every aspect of the healthcare process, medical technologies encompass everything from simple everyday tools to advanced surgical robotics. While health technologies are designed to enhance healthcare provider's ability to address the needs of patients, they can also exacerbate health disparities.

Medical Devices

Medical devices can be built within biased frameworks, creating unequal standards of care that are influenced by social determinants. The unequal performance of medical devices often stems from the lack of testing on a diverse range of populations. This one-size-fits-all approach assumes the social identity of the user, and these devices might perform worse on people whose identity does not align with this assumption.

This bias is evident in the case of pulse oximetry. A pulse oximeter is a device that uses infrared light to measure blood oxygen content. Pulse oximeters have been found to consistently overestimate the blood oxygen levels in patients with darker skin tones, which can lead to a greater risk of undiagnosed hypoxemia. The design of this device failed to account for variations in skin color, inadvertently amplifying racial inequalities in healthcare.

Accounting for diversity among users can also lead to disparities. In the case of the spirometer, a device that measures lung capacity, correction factors are applied based on race, but there is no scientific evidence to suggest that this should occur. Thus, by including racial adjustments, bias is introduced. Medical devices have the potential to affect various populations, but minority and marginalized groups often face disproportionately negative impacts due to biased design.

Healthcare Algorithms

With the rise of AI, healthcare algorithms have been implemented to aid providers with diagnosis, treatment, evaluation of risk factors, and resource allocation. These algorithms often examine factors such as race and gender, and, in some circumstances, exacerbate race and gender inequalities in health care. An algorithm used to assess kidney function and help providers decide when to refer patients for kidney transplants used race as a factor, and research found that this algorithm overestimated kidney function in black patients and under-referred them for organ transplant. Examples of racial and gender disparities have been found in algorithms used to assess risks of complications for common cardiac surgeries, estimate the viability of potential kidney donors, predict survival rates and life expectancy in rectal cancer patients, access the probability of a successful vaginal birth after C-sections, and many other algorithms.

Many factors contribute to and/or perpetuate the biases in certain healthcare algorithms. Generally, the field of developers of these algorithms tends to be less diverse and less aware of implicit biases. These algorithms tend to be proprietary, hindering the ability of independent parties to access equity issues related to them. Artificial intelligence can also be harder to make sense of and manually control, preventing developers from resolving issues or identifying where algorithms make decisions based on gender or race. Additionally, some algorithms are trained on biased data sets that do not accurately represent the diverse general population. Sometimes the inclusion of race or gender as a factor in these algorithms can exacerbate inequalities in health care as opposed to accounting for them.

Vaccination

Social and economic conditions also influence how many people take vaccines. Factors such as income, socioeconomic status, ethnicity, age, and education can determine the uptake of vaccines and their impact, especially among vulnerable communities.

Social factors, such as living with others, may affect vaccine uptake. For example, older individuals who live alone are much more likely not to take up vaccines compared to those living with other people. Other factors may be racial, with minority groups being affected by low vaccine uptake.

Chronic stress and health

Stress is hypothesized to be a major influence in the social determinants of health. There is a relationship between experience of chronic stress and negative health outcomes. This relationship is explained through both direct and indirect effects of chronic stress on health outcomes.

The direct relationship between stress and health outcomes is the effect of stress on human physiology. The long-term stress hormone, cortisol, is believed to be the key driver in this relationship. Chronic stress has been found to be significantly associated with chronic low-grade inflammation, slower wound healing, increased susceptibility to infections, and poorer responses to vaccines. Meta-analysis of healing studies has found that there is a robust relationship between elevated stress levels and slower healing for many different acute and chronic conditions However, it is also important to note that certain factors, such as coping styles and social support, can mitigate the relationship between chronic stress and health outcomes.

Stress can also be seen to have an indirect effect on health status. One way this happens is due to the strain on the psychological resources of the stressed individual. Chronic stress is common in those of a low socio-economic status, who are having to balance worries about financial security, how they will feed their families, housing status, and many other concerns. Therefore, individuals with these kinds of worries may lack the emotional resources to adopt positive health behaviors. Chronically stressed individuals may therefore be less likely to prioritize their health.

In addition to this, the way that an individual responds to stress can influence their health status. Often, individuals responding to chronic stress will develop potentially positive or negative coping behaviors. People who cope with stress through positive behaviors, such as exercise or social connections, may be less affected by the relationship between stress and health. In contrast, those with a coping style more prone to over-consumption (i.e., emotional eating, drinking, smoking, or drug use) are more likely to see negative health effects of stress. Vape shops are also found more in low socioeconomic status areas. The owners target these areas in particular to gain profit. Since people with low-income status are not highly educated, they are more prone to make poor health behavior choices. Socioeconomic status also has a huge impact in lives of people of color. According to the Kids Count Data Center, Children in Poverty 2014, in the United States, 39% of African American children and adolescents, and 33% of Latino children and adolescents are living in poverty (Kids Count Data Center, Children in Poverty 2014). The stress these racial groups with low socioeconomic status face is higher than that of the same race group from a high-income community. According to the research done on socioeconomic disparities in vape shop density and proximity to public schools, the researchers found that vape shops were located a lot more in the areas with schools where African-Americans/Latinos/Hispanic students were in higher population than the areas with schools where White population was more. The growing number of vape shops in low-income and ethnically diverse communities causes disparities in healthcare by increasing exposure to tobacco and nicotine products. According to research, targeted advertising and increased accessibility add to growing rates of vaping among younger people and underprivileged populations. Policies that control vape store locations and restrict advertising to vulnerable populations have been offered as possible methods to address these disparities in healthcare access.

To combat chronic stress and it's link to chronic health, in-direct healthcare measures to improve quality especially within the medically compromised community have increasingly been incorporated in Medicare and Medicaid services. The Food is Medicine (FIM) is essential in this campaign, providing services such as "...medically tailored meals, medically tailored grocery provisions, and produce prescriptions, with varying levels of nutrition and culinary education...". Medically inclined nutrition allows marginalized communities to access healthy and nutritional food while preventing the further devastating affects of chronic stress which will worsen chronic illnesses. This healthcare access is carried out through RDNs in the United States, for "...the prevention of metabolic diseases in adults and the prevention and monitoring of malnutrition in the elderly.". Locations such as Project Open Hand in San Francisco were the first in the larger campaign, originating in providing nutrition to HIV/AIDs patients who were affected by wasting syndrome. Organizations involved with the FIM initiative have continued to expand their mission, expanding into the Medicaid programs through the Section 1115 demonstration waiver. As many FIM initiatives are set on a temporary basis, there's increasing pressure for steady federal funding to bridge healthcare access for low-income and marginalized members especially as chronic stress has devastating effects on the outcome of the patient. Nutrition plays a large role in stress and chronic disease, especially for medically compromised individuals that transcends just genetic and environmental factors. The Food is Medicine initiative and approach to both direct and preventative healthcare doesn't just improve healthcare outcomes for individuals suffering from chronic conditions but also nutritional security and long-term health outcomes through various FIM pyramidal models. A Food is Medicine pyramid ranges from levels such as "Population-level healthy food policies and programs" to "Medically tailored meal programs", which gives different populations the support they need, creating a system to reduce and prevent chronic stress and health.

The detrimental effects of stress on health outcomes are hypothesized to partly explain why countries that have high levels of income inequality have poorer health outcomes compared to more equal countries. Wilkinson and Picket hypothesized in their book The Spirit Level that the stressors associated with low social status are amplified in societies where others are clearly far better off.

A landmark study conducted by the World Health Organization and the International Labour Organization found that exposure to long working hours, operating through psychosocial stress, is the occupational risk factor with the largest attributable burden of disease, i.e., an estimated 745,000 fatalities from ischemic heart disease and stroke events in 2016.

Theoretical approaches

The UK Black and The Health Divide reports considered two primary mechanisms for understanding how social determinants influence health: cultural/behavioral and materialist/structuralist The cultural/behavioral explanation is that individuals' behavioral choices (e.g., tobacco and alcohol use, diet, physical activity, etc.) were responsible for their development and deaths from a variety of diseases. However, both the Black and Health Divide reports found that behavioral choices are determined by one's material conditions of life, and these behavioral risk factors account for a relatively small proportion of variation in the incidence and death from various diseases.

The materialist/structuralist explanation emphasizes the people's material living conditions. These conditions include availability of resources to access the amenities of life, working conditions, and quality of available food and housing among others. Within this view, three frameworks have been developed to explain how social determinants influence health. These frameworks are: (a) materialist; (b) neo-materialist; and (c) psychosocial comparison. The materialist view explains how living conditions – and the social determinants of health that constitute these living conditions – shape health. The neo-materialist explanation extends the materialist analysis by asking how these living conditions occur. The psychosocial comparison explanation considers whether people compare themselves to others and how these comparisons affect health and wellbeing.

A nation's wealth is a strong indicator of the health of its population. Within nations, however, individual socio-economic position is a powerful predictor of health. Material conditions of life determine health by influencing the quality of individual development, family life and interaction, and community environments. Material conditions of life lead to differing likelihood of physical (infections, malnutrition, chronic disease, and injuries), developmental (delayed or impaired cognitive, personality, and social development), educational (learning disabilities, poor learning, early school leaving), and social (socialization, preparation for work, and family life) problems. Material conditions of life also lead to differences in psychosocial stress. When the fight-or-flight reaction is chronically elicited in response to constant threats to income, housing, and food availability, the immune system is weakened, insulin resistance is increased, and lipid and clotting disorders appear more frequently. The effects of chronic fight-or-flight is described in the allostatic load model

The materialist approach offers insight into the sources of health inequalities among individuals and nations. Adoption of health-threatening behaviors is also influenced by material deprivation and stress. Environments influence whether individuals take up tobacco, use alcohol, consume poor diets, and have low levels of physical activity. Tobacco use, excessive alcohol consumption, and carbohydrate-dense diets are also used to cope with difficult circumstances. The materialist approach seeks to understand how these social determinants occur.

The neo-materialist approach is concerned with how nations, regions, and cities differ on how economic and other resources are distributed among the population. This distribution of resources can vary widely from country to country. The neo-materialist view focuses on both the social determinants of health and the societal factors that determine the distribution of these social determinants, and especially emphasizes how resources are distributed among members of a society.

The social comparison approach holds that the social determinants of health play their role through citizens' interpretations of their standings in the social hierarchy. There are two mechanisms by which this occurs. At the individual level, the perception and experience of one's status in unequal societies lead to stress and poor health. Feelings of shame, worthlessness, and envy can lead to harmful effects upon neuro-endocrine, autonomic and metabolic, and immune systems. Comparisons to those of a higher social class can also lead to attempts to alleviate such feelings by overspending, taking on additional employment that threaten health, and adopting health-threatening coping behaviors such as overeating and using alcohol and tobacco. At the communal level, widening and strengthening of hierarchy weakens social cohesion, which is a determinant of health. The social comparison approach directs attention to the psychosocial effects of public policies that weaken the social determinants of health. However, these effects may be secondary to how societies distribute material resources and provide security to its citizens, which are described in the materialist and neo-materialist approaches.

Life-course perspective

Life-course approaches emphasize the accumulated effects of experience across the life span in understanding the maintenance of health and the onset of disease. The economic and social conditions – the social determinants of health – under which individuals live their lives have a cumulative effect upon the probability of developing any number of diseases, including heart disease and stroke. Studies into the childhood and adulthood antecedents of adult-onset diabetes show that adverse economic and social conditions across the life span predispose individuals to this disorder.

Hertzman outlines three health effects that have relevance for a life-course perspective. Latent effects are biological or developmental early life experiences that influence health later in life. Low birth weight, for instance, is a reliable predictor of incidence of cardiovascular disease and adult-onset diabetes in later life. Nutritional deprivation during childhood has lasting health effects as well.

Pathway effects are experiences that set individuals onto trajectories that influence health, well-being, and competence over the life course. As one example, children who enter school with delayed vocabulary are set upon a path that leads to lower educational expectations, poor employment prospects, and greater likelihood of illness and disease across the lifespan. Deprivation associated with poor-quality neighborhoods, schools, and housing sets children off on paths that are not conducive to health and well-being.

Cumulative effects are the accumulation of advantage or disadvantage over time that manifests itself in poor health, in particular between women and men. These involve the combination of latent and pathways effects. Adopting a life-course perspective directs attention to how social determinants of health operate at every level of development – in utero, infancy, early childhood, childhood, adolescence, and adulthood – to both immediately influence health and influence it in the future.

Improving health conditions worldwide

Reducing the health gap requires that governments build systems that allow a healthy standard of living for every resident.

Interventions

Three common interventions for improving social determinant outcomes, as identified by the WHO, are education, social security, and urban development. However, evaluating interventions has been difficult due to their nature, their impact, and the strong effect they have on children's health outcomes.

1. Education: Many scientific studies have been conducted and strongly suggest that increased quantity and quality of education leads to benefits to both the individual and society (e.g., improved labor productivity). Health and economic outcome improvements can be seen in health measures such as blood pressure, crime, and market participation trends. Examples of interventions include decreasing the size of classes and providing additional resources to low-income school districts. However, there is currently insufficient evidence to support education as a social determinant intervention with a cost-benefit analysis.
2. Social Protection: Interventions such as "health-related cash transfers", maternal education, and nutrition-based social protections have been shown to have a positive impact on health outcomes. However, the full economic costs and impacts generated by social security interventions are difficult to evaluate, especially as many social protections primarily affect the children of recipients. The landmark Cochrane Collaboration Review of the health impact of unconditional cash transfers in low- and middle-income countries found a large body of evidence that these cash transfers clinically meaningfully reduce in the likelihood of being sick (by an estimated 27%), may also improve food security and dietary diversity, and may also reduce extreme poverty and improve school attendance, as well as increase healthcare spending.
3. Urban Development: Urban development interventions include a wide variety of potential targets such as housing, transportation, and infrastructure improvements. The health benefits are considerable (especially for children), because housing improvements such as smoke alarm installation, concrete flooring, removal of lead paint, etc. can have a direct impact on health. In addition, there is a fair amount of evidence to prove that external urban development interventions such as transportation improvements or improved walkability of neighborhoods (which is highly effective in developed countries) can have health benefits. Affordable housing options (including public housing) can make large contributions to both social determinants of health, as well as the local economy, and access to public natural areas -including green and blue spaces- is also associated with improved health benefits.

The Commission on Social Determinants of Health made recommendations in 2005 for action to promote health equity based on three principles: "improve the circumstances in which people are born, grow, live, work, and age; tackle the inequitable distribution of power, money, and resources, the structural drivers of conditions of daily life, globally, nationally, and locally; and measure the problem, evaluate action, and expand the knowledge base." These recommendations would involve providing resources such as quality education, decent housing, access to affordable health care, access to healthy food, and safe places to exercise for everyone despite gaps in affluence. Expansion of knowledge of the social determinants of health, including among healthcare workers, can improve the quality and standard of care for people who are marginalized, poor or living in developing nations by preventing early death and disability while working to improve quality of life.

Challenges of measuring value of interventions

Many economic studies have been conducted to measure the effectiveness and value of social determinant interventions but are unable to accurately reflect effects on public health due to the multi-faceted nature of the topic. While neither cost-effectiveness nor cost-utility analysis is able to be used on social determinant interventions, cost-benefit analysis is able to better capture the effects of an intervention on multiple sectors of the economy. For example, tobacco interventions have shown to decrease tobacco use, but also prolong lifespans, increasing lifetime healthcare costs and is therefore marked as a failed intervention by cost-effectiveness, but not cost-benefit. Another issue with research in this area is that most of the current scientific papers focus on rich, developed countries, and there is a lack of research in developing countries.

Policy changes that affect children also present the challenge that it takes a significant amount of time to gather this type of data. In addition, policies to reduce child poverty are particularly important, as elevated stress hormones in children interfere with the development of brain circuitry and connections, causing long term chemical damage. In most wealthy countries, the relative child poverty rate is 10 percent or less; in the United States, it is 21.9 percent. The lowest poverty rates are more common in smaller well-developed and high-spending welfare states like Sweden and Finland, with about 5 or 6 percent. Middle-level rates are found in major European countries where unemployment compensation is more generous and social policies provide more generous support to single mothers and working women (through paid family leave, for example), and where social assistance minimums are high. For instance, the Netherlands, Austria, Belgium and Germany have poverty rates that are in the 7 to 8 percent range.

Within clinical settings

Connecting patients with the necessary social services during their visits to hospitals or medical clinics is an important factor in preventing patients from experiencing decreased health outcomes as a result of social or environmental factors. This can take the form of community health workers who can support patients with their care plans developed in conjunction with their primary care physicians.

A clinical study done by researchers at the University of California San Francisco, indicated that connecting patients with the resources to utilize and contact social services during clinical visits, significantly decreased families social needs and significantly improved children's overall health.

In addition, within the clinical setting, it was noted that in order to better health outcomes for the patients in any clinical setting, a collection of SHD data should be documented. This helps maintain the connection between healthcare systems and organizations that address these needs that were documented.

Public policy

The Rio Political Declaration on Social Determinants of Health embraces a transparent, participatory model of policy development that, among other things, addresses the social determinants of health leading to persistent health inequalities for indigenous peoples. In 2017, citing the need for accountability for the pledges made by countries in the Rio Political Declaration on Social Determinants of Health, the World Health Organization and United Nations Children's Fund called for the monitoring of intersectoral interventions on the social determinants of health that improve health equity.

The United States Department of Health and Human Services includes social determinants in its model of population health, and one of its missions is to strengthen policies which are backed by the best available evidence and knowledge in the field. Social determinants of health do not exist in a vacuum. Their quality and availability to the population are usually a result of public policy decisions made by governing authorities. For example, early life is shaped by availability of sufficient material resources that assure adequate educational opportunities, food, and housing among others. Much of this has to do with the employment security and the quality of working conditions and wages. The availability of quality, regulated childcare is an especially important policy option in support of early life. These are not issues that usually come under individual control but rather they are socially constructed conditions which require institutional responses. A policy-oriented approach places such findings within a broader policy context. In this context, Health in All Policies has seen as a response to incorporate health and health equity into all public policies as means to foster synergy between sectors and ultimately promote health.

Yet it is not uncommon to see governmental and other authorities individualize these issues. Governments may view early life as being primarily about parental behaviors towards their children. They then focus upon promoting better parenting, assist in having parents read to their children, or urge schools to foster exercise among children rather than raising the amount of financial or housing resources available to families. Indeed, for every social determinant of health, an individualized manifestation of each is available. There is little evidence to suggest the efficacy of such approaches in improving the health status of those most vulnerable to illness in the absence of efforts to modify their adverse living conditions.

A team of the Cochrane Collaboration conducted the first comprehensive systematic review of the health impact of unconditional cash transfers, as an increasingly common up-stream, structural social determinant of health. The review of 21 studies, including 16 randomized controlled trials, found that unconditional cash transfers may not improve health services use. However, they lead to a large, clinically meaningful reduction in the likelihood of being sick by an estimated 27%. Unconditional cash transfers may also improve food security and dietary diversity. Children in recipient families are more likely to attend school, and the cash transfers may increase money spent on health care.

One of the recommendations by the Commission on the Social Determinants of Health is expanding knowledge – particularly to health care workers.

Although not addressed by the WHO Commission on Social Determinants of Health, sexual orientation and gender identity are increasingly recognized as social determinants of health.

With all the different health inequities and differences in quality of care addressed in social determinants of health, the American Hospital Association created the Value Initiative project which helps make healthcare more affordable to people of all types. It does this four different ways:

1. It frames issues regarding the healthcare system and its pricing and affordability.
2. It provides knowledge, resources, and tools for hospitals to supply affordable healthcare and increase value
3. The initiative collects data of hospital experiences to develop new federal policy solutions
4. Builds a platform for the American Hospital Association to discuss with policymakers to find solutions to the lack of affordable care.

This initiative educates the public and makes sure there is transparency in pricing of hospital bills, making sure patients are not billed more than they should be. It also addresses the cost drivers in the healthcare system, and urges for legislators to take action to make healthcare affordable and to prioritize health over profit. This organization asks congress to control the rising costs of pharmaceuticals by encouraging competition between manufacturers, and improving transparency in drug pricing. In this value initiative, they have started the Affordability Advocacy Agenda (AAA) which improves the ongoing policy and advocacy activities. With the COVID-19 pandemic health care spending increased and there was a rise in hospitalizations and therefore a rise in demand for health care providers. The price for care has increased and there aren't enough workers to meet the demand for care. The AAA and congress are working together to provide relief from the pandemic in order to make healthcare more affordable to all.

As of January 1, 2022 there are regulations placed for healthcare providers about no surprise billing. This is the "No Surprises Act" of division BB of the Consolidated Appropriations Act, 2021 and this rule was made by the Biden-Harris administration. Patients should not be billed more than they expected to pay, it is often noticed with emergency services and this rule will stop patients from getting worried about any bills out of their budget, and they will be able to get the proper care they need for their health with peace of mind. The act was passed by congress at the end of 2020 and offers protection against insured Americans getting surprise bills from out-of-network providers. They struggled to find an amount that an insurer should pay to the out-of-network provider, but eventually found an amount and the law is now in effect as of January 2022. When it comes to out-of-network providers, patients often rely on these services in an emergency and then get stuck with the bill afterwards. Air Ambulance bills are a big problem for consumers, not just because they are out of network and cost a lot, but also for their lack of billing transparency. Since the Airline Deregulation Act, which allows air ambulance to make their own prices, federal solutions to this increasing cost of emergency care is needed. A possible solution is to allow air ambulance services to be administered and financed in a way that combines competitive bidding and public utility regulation.

History

Starting in the early 2000s, the World Health Organization facilitated the academic and political work on social determinants in a way that provided a deep understanding of health disparities in a global perspective. In 2003, the World Health Organization (WHO) Europe suggested that the social determinants of health included: the social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transportation.

In 2008, the WHO Commission on Social Determinants of Health published a report entitled "Closing the Gap in a Generation", which aimed to understand, from a social justice perspective, how health inequity could be remedied, and what actions could combat factors that exacerbated injustices. The work of the commission was based on development goals, and thus, connected social determinants of health discourse to economic growth and bridging gaps in the healthcare system. This report made three broad recommendations regarding social determinants of health that needed to be addressed. The first imperative was to improve daily living conditions, including work and home physical environments, early childhood development and education, and social protection across the lifespan. The second recommendation was to disrupt the distribution of power, money, and resources, including social inequities such as gender disparities; this recommendation involves a more active role on the part of government. Third, the report calls for a global acknowledgement of the problem so as to take its full measure, as well as assess the impact of any planned interventions.

The 2010 Affordable Care Act (ACA) established by the Obama administration in the United States, embodied the ideas put in place by the WHO by bridging the gap between community-based health and healthcare as a medical treatment, meaning that a larger consideration of social determinants of health was emerging in the policy. The ACA established community change through initiatives like providing Community Transformation Grants to community organizations, which opened up further debates and talks about increased integration of policies to create change on a larger scale.

The 2011 World Conference on Social Determinants of Health, in which 125 delegations participated, created the Rio Political Declaration on Social Determinants of Health. With a series of affirmations and announcements, the Declaration aimed to communicate that the social conditions in which an individual exists were key to understanding health disparities that individual may face, and it called for new policies across the world to fight health disparities, along with global collaborations.

Socioeconomic factors and STI risk

Socioeconomic status is a key social determinant of health and plays a significant role in the distribution and prevalence of sexually transmitted infections (STIs). Individuals living in lower socioeconomic conditions often face increased exposure to risk factors, including limited access to healthcare services, reduced availability of preventive resources such as condoms, and lower rates of routine screening and early treatment. These barriers can contribute to delayed diagnosis and increased transmission within communities.

In the United States, sexually transmitted infections disproportionately affect populations experiencing socioeconomic disadvantage. According to the Centers for Disease Control and Prevention (CDC), rates of reported chlamydia, gonorrhea, and syphilis are consistently higher in communities with increased poverty levels and reduced access to healthcare services. These disparities are also reflected along racial and ethnic lines, which are closely linked to underlying social and economic inequalities rather than biological differences.

Structural factors, including poverty, housing instability, and limited access to education, further exacerbate STI risk. Communities with fewer healthcare facilities and limited public health infrastructure may experience higher rates of untreated infections. Additionally, stigma and lack of culturally appropriate healthcare services can discourage individuals from seeking testing and treatment.

From a broader public health perspective, these disparities highlight the importance of addressing social and environmental determinants of health. Interventions such as expanding access to affordable healthcare, increasing community-based screening programs, and improving sexual health education are critical for reducing STI burden in underserved populations. These approaches align with a holistic health framework that recognizes the interconnected influences of social, environmental, and systemic factors on health outcomes.

Barriers to STI prevention and screening

Barriers to sexually transmitted infection (STI) prevention and screening are disproportionately experienced by individuals in lower socioeconomic populations. Limited access to affordable healthcare services, lack of health insurance, and transportation challenges can reduce the likelihood of routine STI testing and timely treatment. These barriers contribute to undiagnosed and untreated infections, increasing the risk of ongoing transmission within communities.

Social and cultural factors also play a critical role in shaping access to STI-related services. Stigma associated with STIs, concerns about confidentiality, and distrust of healthcare systems may discourage individuals from seeking testing and care. In some communities, limited access to culturally competent and linguistically appropriate healthcare further exacerbates these challenges.

Addressing these barriers requires targeted public health interventions, including expanding access to free or low-cost screening services, increasing community outreach programs, and integrating STI services into primary care and community health settings. These strategies are essential for reducing disparities and improving sexual health outcomes in underserved populations.