What Is a Social Determinant of Health?

Social determinants of health (SDOH), according to the United States Department of Health and Human Services, include "...the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks" (Healthy People 2030). Social determinants of health include non-medical conditions that influence health outcomes (Centers for Disease Control and Prevention, 2022). Social determinants of health have been categorized around various constructs, some of which include: economic stability (Braveman, 2011; Healthy People 2030), inequality (Marmot, 2005; Marmot, 1999), immigration (Castañeda, 2015), education access and quality (Healthy People 2030), environments (Healthy People 2030), racism (CDC, 2022), access to health care (Healthy People 2030), political systems (CDC, 2022), and social and community context (Healthy People 2030). 

Racism as a Social Determinant of Health

The reason why social determinants of health are important to the 4-H program is because these social (non-health) factors influence youth proximal and distal health outcomes (a.k.a. positive youth development). In her article, "Levels of Racism: A Theoretical Framework and a Gardener's Tale," Dr. Jones describes two flower boxes—one with rich fertile soil and a second box with poor rocky soil. The flowers planted in rich fertile soil flourished, but the flowers planted in the poor soil struggled. The point of this analogy is that people who develop in resource-depleted environments can face greater health challenges compared to people who develop in resource-full environments. In regards to 4-H, youth who develop in better environments (e.g. safe neighborhoods, access to health care, good schools, etc.) stand a greater chance of achieving optimal health outcomes compared to youth who develop in poorer environments (e.g. violent communities, food deserts, lack of reliable public transportation, etc.).

Developmental Contexts as Social Determinants of Health

In the 4-H Thrive Model of Positive Youth Development, Dr. Mary Arnold provides an illustration that describes the process by which youth grow. The illustration has a flower planted in soil. The soil represents the developmental contexts (e.g. 4-H club) that youth interact with in order to learn new life skills and build new relationships. Within this model, the developmental contexts (i.e. soil conditions) can be understand as a social determinant of health. Specifically, the model outlines four developmental context factors that can shape youth outcomes, which includes: sparks (youth finding a particular passion in life), belonging, program engagement, and healthy relationships.

Importance of Youth "Sparks"

Regarding sparks, if the youth has a passion to learn about horses, but there are no horses in their neighborhood, then their ability to learn about horses will be limited. Contrast this with a youth whose family owns a multi-generational farm with several horses and caregivers who can provide mentorship with horse husbandry and other essential animal science skills. The youth who live on acreage with horses will likely learn more about horses than the youth who lives in a neighborhood without horses. This example illustrates how developmental contexts can shape a youth's opportunity to pursue certain sparks, which can then influence their ability to develop a certain skill or increase their knowledge of a particular content area (e.g. horse husbandry).

Belonging and Relationships as Health Outcomes

For belonging and relationships, having an inclusive environment is paramount. In contexts where there is racism, discrimination, or oppression can have detrimental effects on a youth person's ability to form positive relationships where they feel a sense of belonging. As Dr. Jones articulates in her article, "Levels of Racism," there can be institutionalized, personally mediated, and internalized racism (Jones, 2000). Institutionalized racism describe conditions where there is differential access to quality education, stable housing, gainful employment, quality health care, etc. Personally mediated racism describes when we form assumptions about the abilities, motives, and intentions of others based on their race or ethnic identities. Discrimination describes when we perform differential actions towards others according to their race or ethnic identities. 

Relation of Program Engagement and Health Outcomes

Participating in the 4-H youth development program provides many important opportunities. There are many facilitators (i.e. factors that increase program engagement) that positively influence a child's ability to engage with the 4-H program, such as access to reliable transportation, financial resources to pay fees, and caregiver support. Research has shown that there are many outcomes for California 4-H alumna, including a sense of responsibility, developing leadership skills, and public speaking confidence (Marshall-Wheeler, 2023).

Relation of Social Determinants of Health and Cooperative Extension

While we see that social determinants of health relate to the 4-H positive youth development program, what about other extension programming in the community? Do social determinants relate to extensionists who work with climate change, forestry education, invasive species, horticulture, and other important community programs and services? To answer this question, one may ask several questions:

• Does the program or service directly or indirectly involve the well being of people?
• Do environmental conditions play an important role in achieving programmatic success?
• Can policy or regulation influence the program?
• Does access to resources (material and/or immaterial) matter to the program's clientele?

The answers to these questions can reveal the relationship between social determinants of health and cooperative extension programming and services. As such, I believe it is important for us to remember that our work as extensionists can be enhanced by a deeper understanding of social determinants of health and their relation to our clientele. As we seek to address social determinants of health, our collective work in cooperative extension will ultimately achieve greater impact.

References

Arnold, M. E., & Gagnon, R. J. (2020). Positive youth development theory in practice: An update on the 4-H Thriving Model. Journal of youth development (Online), 15(6), 1-23. https://doi.org/https://doi.org/10.5195/jyd.2020.954 

Braveman, P., Egerter, S., & Williams, D. R. (2011). The social determinants of health: coming of age. Annual review of public health, 32, 381-398. https://doi.org/https://doi.org/10.1146/annurev-publhealth-031210-101218 

Castañeda, H., Holmes, S. M., Madrigal, D. S., Young, M.-E. D., Beyeler, N., & Quesada, J. (2015). Immigration as a social determinant of health. Annual review of public health, 36(1), 375-392. https://doi.org/https://doi.org/10.1146/annurev-publhealth-032013-182419 

Centers for Disease Control and Prevention. (2022). Social Determinants of Health at CDC. Centers for Disease Control and Prevention,. https://www.cdc.gov/about/sdoh/index.html

Healthy People 2020. (2023). Social Determinants of Health. https://health.gov/healthypeople/priority-areas/social-determinants-health

Jones, C. P. (2000). Levels of racism: a theoretic framework and a gardener's tale. American journal of public health, 90(8), 1212-1215. 

Marmot, M. (2005). Social determinants of health inequalities. Lancet(9464), 1099-1104. 

Marmot, M. (1999). Epidemiology of Socioeconomic Status and Health: Are Determinants Within Countries the Same as Between Countries? Annals of the New York Academy of Sciences, 896(1), 16-29. https://doi.org/https://doi.org/10.1111/j.1749-6632.1999.tb08102.x 

Marshall-Wheeler, N., Nayak, R., Iaccopucci, A., & Worker, S. (2023). Long-term outcomes of early adult 4-H alumni. Journal of Extension, 61(2). https://doi.org/https://doi.org/10.34068/joe.61.02.02