Connecting Health Disparities and Social Determinants of Health

We are pleased to present this special issue of Family & Community Health with its focus on health disparities, health inequities among vulnerable, underserved populations, and how using ecological models can assist researchers and clinicians in promoting health equity. Health disparities are the disproportionate difference in the incidence, prevalence, mortality, and burden of disease adversely influencing the health status of specific populations. These differences, influenced by social determinants of health, shape the environmental context in which people and populations live, work, and play, thus influencing their health, health behaviors, health risks, overall functioning, and quality of life. Social determinants of health include the unmodifiable factors of sex, age, race, and ethnicity and those that are modifiable such as low education and poor health literacy, poverty, limited employment opportunities, discrimination, and limited access to health care. Health inequities are the unnecessary, preventable, and unfair systematic disadvantages leading to the poorer health status of one population in comparison with another.

In 2008, The World Health Organization's Commission on Social Determinants of Health (CSDH) published the final report, Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. This report, based on a review of the evidence on the social determinants of health, aspired to close the health gap and improve the health of countries and the world. The report included 3 overarching recommendations or principles of action: (1) improvement of daily living conditions and (2) challenging the unjust distribution of power, resources, and money. Principle 3 was multidimensional in nature including expansion of the knowledge base, determination of the magnitude of the problem, evaluation of action, increased public awareness, and development of a trained workforce on the social determinants of health.

Ecological models of health behavior demonstrate that behavior has multiple points of influence. An ecological model is similar to nesting dolls, where the smallest size is enclosed within other sizes in the ascending order. An ecological model examines different levels of influence on a person's behavior. The most common models include as the center the intrapersonal (psychological, genetic, biological, etc) level, then the interpersonal (family, friends, colleagues, etc) level, organizational (social organizations, religious organizations, work, etc) level, community (type of cohesion and effectiveness of the community) level, physical environment (streets, sidewalks, parks, etc), and policy (from homeowners' association policy to policies promulgated by the federal government) level. Researchers can examine the influences each levels has on the other levels, or they can study how changing influences in one level can affect overall health outcomes. Social determinants of health are best studied from an ecological lens to understand how individual (intrapersonal) health disparities relate to higher levels such as community, physical environment, and policy. Examining health behavior from this perspective removes any taint of "blame the victim" thinking from planning for improvement in health equity.

One decade later, some countries have experienced a narrowing whereas other countries have experienced a continuation or increase in health disparities and health inequities. However, we believe the CSDH principles of action remain central to the reduction of health disparities and health inequities. It remains to be seen if the closing of the health gap will be achieved within this generation. Only the passage of time will tell. We remain hopeful that more just and healthier nations, countries, and world will be created. We base this belief on the contributing authors and their works included in this issue as they demonstrate a strong commitment and desire to improve the daily conditions of vulnerable populations through education and advocacy, employ ecological models to address health disparities, and conduct vital research to expand the knowledge base or to identify, intervene for, and evaluate their projects on the social determinants of health among the marginalized, at-risk, and disempowered.

-Elizabeth Reifsnider, PhD, RN, FAANP, FAAN

-Yolanda Davila, PhD, RN

Issue Editors