Throughout the early months of the pandemic, COVID-19 was widely referred to as “the great equalizer”—a novel global disease that no one was immune to, putting everyone at risk. Now in its wake, the disparities of this risk are becoming more apparent, as are the longstanding health inequalities that persist across the United States: that racial and ethnic minorities, low-income communities, and urban populations were all at a higher risk of infection, severity of illness, and mortality.1
These factors of race, income, and location are all examples of what are known as determinants of health: a wide range of personal, social, economic, and environmental factors that influence personal and communal wellbeing, impacting groups and individuals’ physical, mental, and social health. The latter two examples—income and location—are also included in the group of factors known as the social determinants of health, or the conditions of an individual of group’s environment, among which the pandemic revealed further disparities.
Mary Ellen Gornick, Senior Vice President of Global Services at Workplace Options (WPO), explains, “I think one of the things we found with COVID is that individuals at the lower-end of the economic scale—in neighborhoods who did not have ready access to quality healthcare, or in neighborhoods where people were less isolated—were all in communities where the rates were higher not only in terms of transmission but also in terms of the severity of the illness.”
In addition to disproportionate physical health outcomes, the pandemic has also exposed how social and economic factors impact mental health. Research from the Boston University School of Public Health found that while nearly 1 in 3 American adults reported symptoms of depression and anxiety as a result of the pandemic, low-income adults were seven times more likely to experience these symptoms due to factors including job loss, changes to childcare, and difficulties paying rent; another study of adults living in Massachusetts and North Carolina cited food and energy insecurity as additional contributors to this disparity—signifying a causation between negative social and economic conditions and negative health outcomes.2
Not only do these social determinants affect health and quality of life, but they also impact the workplace; job performance, attendance, retention, productivity, and profitability are all facets that can be significantly inhibited as a result of negative social determinants, making these factors something that employers need to pay attention to when examining organizational performance. By responding to social determinants of health, leaders can not only enhance the success of their organizations, but they can also foster a safer and more inclusive workplace, mitigating risks that jeopardize the health of their employees and in turn promoting better health and wellbeing. As Gornick explains, “that whole thing with COVID, if nothing else, nails down the fact that social determinants of health are really key to good health outcomes and overall wellness outcomes.”
Understanding Social Determinants of Health (SDOH)
In order for employers to enhance organizational performance, employee engagement, and employee wellness, they first need to have a communicable understanding of what social determinants of health are. “The causes of causes,” social determinants of health (SDOH) refer to a specific group of social and economic factors, or “conditions,” of the environments in which people live, learn, work, and age, that influence health and wellbeing, mortality, and quality of life.3 These factors can include education level, income, and employment, as well as access to quality educational, economic, and job opportunities; housing and neighborhood conditions, as well as access to adequate housing, energy, clean drinking water, and better air quality; quality of food, as well as access to supermarkets and food sources; health and access to quality health care; mode and reliability of transportation; interpersonal relationships and social support; and social integration and community context.
In short, SDOH indicate that a person’s ZIP code has just as much—if not more—of an impact on health and wellness outcomes than genetics or medical care, as research has shown that clinical care only accounts for about 20 percent of health outcomes, whereas social and economic factors account for approximately 40 percent.4-5 This is perhaps the most recognizable in the field of epidemiology, as infectious diseases have always disproportionately impacted poor and disadvantaged communities. But other common health conditions, including cancers, cardiovascular diseases, pulmonary disorders, diabetes, and neurodegenerative diseases like dementia, are also influenced by access or lack thereof to serviceable resources that promote positive health and health behaviors, as well as the conditions of one’s environment.6 Even mental disorders, including depression, anxiety, psychosis, PTSD, and substance abuse are all at least partly driven by social risk factors.7
The Five “Key” Domains of SDOH
What these findings ultimately suggest is that poor and disparate health outcomes are the results of material deprivation and social exclusion; the presence of negative SDOH typically indicating the lack of something else, whether a lack of access to resources, care, community, and support.8 But just as SDOH explain the causes for poor health outcomes, they also reveal ways to protect against them; that is, by restoring or creating access to resources and support. In response to this as well as growing research that places social and economic factors as the principal causes of persisting health inequities, both national and international public health agencies have shifted their focus away from the traditional solutions of medical care, and toward a multisectoral, community-integrated approach to achieving health equity “in all policies” by addressing social determinants of health holistically and simultaneously.
In order to design and implement organized strategies for approaching SDOH, the Office of Disease Prevention and Health Promotion (ODPHP) has categorized SDOH into five key domains:
- Economic Stability, which encompasses factors of employment, work conditions, housing, income level, and class status.
- Education, which encompasses factors including early childhood education and development, access and ability to enroll in higher education, graduation status, and language and literacy.
- Social and Community Context, which encompasses factors such as civic participation, social cohesion and support, discrimination and racism, and cultural norms and standards.
- Health and Health Care, which encompasses factors regarding access to medical care, primary care, and health literacy.
- Neighborhood and Built Environment, which encompasses factors including access to food, quality of food, environmental conditions, public safety, and quality of housing.
Similar to Maslow’s pyramid, these five domains of SDOH address the key needs that must be met in order for people to live and function to their full potential. According to Gornick, improving these key areas is essential for promoting better health and a better quality of life, saying that when these needs go unmet, people are merely “fighting for their existence”—surviving, rather than living—and therefore cannot reach their full potential.
To explain the relationship between the two models, Gornick says, “If you look at Maslow’s Hierarchy of Needs, it says that first you have to have those basic needs met, then you have to belong to something, be a part of a community, and then you can begin to move up the pyramid and actualize and meet your full potential. With the social determinants of health, these argue that there are five factors that influence that bottom part of the pyramid, and unless you are okay with those—unless you have your medical needs taken care of, know where your next meal is coming from, unless you’re economically stable—then you can reach your full potential.”
What this Means for Employers
“If it works in a community, it works in an organization, too,” Gornick testifies, adding, “If you want to invent the best products for the future; if you want your sales team to sell your products or services so that you can be successful; if you want your customer service representatives to be able to solve the problems that people have with their products or services; if you want your product manufactured in a way so that employees pay attention to quality control and safety, then you have to be intentioned to what people call the ‘wellness components.'”
While employers might not be able to solve global or even national health inequalities, they do play a crucial role in improving the health and quality of life of their surrounding communities, as the workplace serves as one of the key environments that influence SDOH. According to the Health Enhancement Research Organization (HERO), employers are responsible for promoting economic stability and social cohesion, as work inherently controls employees’ level of income, and therefore access to housing and education; the amount of time and money they can put towards satisfying other essential needs; their access to opportunities for social connectedness; and their sense of coherence and self-efficacy. Without these key needs fulfilled, both employees and their organizations suffer, as organizations lose an estimated $153 billion each year in lost productivity due to absenteeism, disability, and turnover caused by poor health outcomes.9
Responding to SDOH in the Workplace
Employers are in a unique position when it comes to addressing SDOH as the workplace serves as both an environment that influences the mental, physical, and social wellbeing of employees, and an arena that is impacted by these states of wellbeing, with the efficiency of an organization depending on the conditions, attitudes, behaviors, and abilities of its workers.10 Consequently, employers are not only responsible for improving the conditions of their workplace that impact the health of their employees, but they are also tasked with alleviating the negative health outcomes that are caused by other SDOH. To do this, employers should adopt workplace strategies that aim to reduce stress, material deprivation, and social isolation. These strategies include:
- Identifying what health risks need to be addressed. Employers will only be able to successfully promote better health and wellbeing so long as their strategies address the specific social needs of their employees and target the specific social determinants that are compromising their health. To do so, leaders can refer to the demographic data of their workforce as well as their surrounding community to evaluate income level, education level, quality of housing, race, gender, community context, and other factors that may be contributing to poor health outcomes. Tools that may help employers conduct an assessment of demographics include the Area Deprivation Index (ADI), which accounts for income, education, and housing quality at the neighborhood level, and the National Equity Atlas, which measures racial inclusion at the city, state, and national level.
From there, employers can design and implement employee health surveys to further assess which social risk factors pose the biggest threat to their health and wellbeing, as well as assess the current health conditions, behaviors, and attitudes of their employees. Tools that may help employers design their surveys include the Centers for Medicare and Medicaid Services’ AHC HRSN Screening Tool, which assesses health-related social needs including access to housing, food, transportation, utilities, interpersonal safety, education, and social support, in addition to assessing physical and mental health concerns. Additionally, employers can refer to the Center of Disease Control and Prevention’s workplace health assessment module designed to help employers identify current health concerns impacting their workplace, gather opinions and feedback directly from their employees, and determine what actions to take from there. In lieu of formal assessments, employers can also survey current problems by connecting one-on-one with employees through conversations and emails, or by hosting group or team meetings.
- Modifying benefits based on employee needs. After assessing their employees’ current barriers to good health, employers should then look at what they are offering in their benefits package to determine if they are adequately addressing social needs, or if there is room for improvement. For example, in a report released earlier this year, the National Alliance of Healthcare Purchaser Coalitions outlines ways that employers can improve service offerings, such as by creating benefit plans that address transportation challenges or by creating financial stability programs; the takeaway being that employers should look beyond traditional health care plans and consider adopting programs that will address specific social needs. Additional benefits to consider include paid sick leave, maternity leave, leave for all parents, family caregiving benefits, contributions to 401(k) plans, subsidized childcare services, mental health counseling, nutrition counseling, and meal delivery—all which have been shown to decrease unexpected medical costs, alleviate symptoms of anxiety, depression, and stress, and promote better health and protect against chronic illness.
Ultimately, the best way to modify current benefits to ensure that they are adequately meeting employee needs, is to model what the local, state, and national government is providing or prioritizing. For example, Congress has recently begun to expand supplemental benefits legislation for Medicare Advantage plans, allowing providers to offer non-primarily health-related benefits, targeting issues including food insecurity, transportation issues, and housing instability.
- Improving employee access to quality healthcare. According to the Northeast Business Group on Health, employees at the lower end of the economic scale tend to use the healthcare system as if they were not covered by health insurance at all; they are less likely to have a PCP, more likely to use emergency services, are admitted to the hospital almost two times more than other insured employees, and tend to avoid or delay in seeking care. This is due to a number of reasons, including perceived lack of affordability, transportation issues, lack of childcare, and lack of health literacy—all of which are factors that employers should address when modifying non-healthcare benefits.
Additional components, however, include linguistic barriers and a lack of trust in physicians and medical practitioners, for reasons of perceived mistreatment due to gender, income-level, race, or ethnicity.11 In order to promote better trust in, and therefore better use of healthcare plans, employers with group coverage plans should consider switching to providers who are culturally competent and whose physicians mirror their employees. A survey conducted by Deloitte Center for Health Solutions found that over 50 percent of Asian and Hispanic participants claimed that having a culturally competent provider is a top priority when choosing a provider; about 67 percent of Black or African American participants, and over 50 percent of Asian and Hispanic participants said they wanted a provider similar to them; and in general, younger participants between the ages of 18 and 44 were more likely to say that having a provider with a similar background to them is important. As Gornick explains, “When you think about healthcare, it’s not only coverage—coverage is important, but it’s also access to a healthcare provider who does not create challenges to get there; a provider who has both linguistic and cultural competency; and a provider who offers high quality of care.”
In terms of alleviating linguistic barriers, Gornick argues, “employers need to do a lot of communicating directly to their employees about how to utilize and take advantage of what they’re provided, and they need to watch utilization rates and look at the outcomes to ensure that people are taking advantage of what is available to them.” This can include hosting meetings or sharing digestible documents to go over what employees’ health plans cover, where they can go to for questions, and how they can find additional support. For more information on national health plans that have launched initiatives addressing SDOH and health inequities, employers can refer to the Northeast Business Group on Health’s 2022 guide for employers.
- Providing a livable wage. One reason why current healthcare plans are not adequately protecting the health of employees is because insured employees are avoiding or delaying care for the simple reason that they cannot afford it. A 2017 survey conducted by CareerBuilder found that 78 percent of Americans live paycheck to paycheck, and over 25 percent do not set aside savings each month. This makes healthcare plans like high deductible health plans (HDHP) insufficient, as lower-income employees avoid PCP care and preventive care, and delay diagnoses and treatment. Additionally, low wages also bar adequate access to childcare, which further inhibits employees utilizing healthcare resources.
On top of disrupting use of health and childcare, J. Paul Leigh, a University of California-Davis epidemiologist, found that low wages could also be linked to increased incidents of diabetes, heart disease, arthritis, obesity, hypertension, and premature mortality, particularly for women under the age of 40, primarily due to financial stress and the inability to make co-payments or pay deductibles to access blood pressure and cholesterol medicines.12 Leigh also noted that while obesity is estimated to cost $190 billion in medical bills each year, a 10 percent decrease in obesity would save over $19 billion—indicating that raising wages to promote better health behaviors could reduce costs of medical care and save organizations money.
In order to determine what wages would be considered livable for an organization’s employees, employers should refer to the demographics and social risk factors assessed through employee health surveys; current minimum wages, or even the proposed $15 minimum wage, are not inherently livable. Employers need to determine the level of income required for their employees to cover basic needs within their specific communities. According to Gornick, this is something that employers should be paying more attention to, arguing, “Once somebody is employed, we kind of go, ‘oh well, check the box, they’re employed.’ But you’ll find that with the minimum wage standard so low, even if someone is on public funding, public maintenance, they might still not be able to move into economic stability, maybe because their expenses are over their ability to provide, or they have debt, or they live in a really fragile system where something could go wrong with their car and somebody could become ill and just that one little thing can really throw the factor.”
- Collaborating with local programs on health initiatives. Even with improved healthcare, medical care is not enough to alleviate poor health and reduce inequities when individuals still face challenges including homelessness, food insecurity, health and nutritional illiteracy, and poor access to health facilities or opportunities for physical exercise. Therefore, in addition to modifying current gaps in healthcare accessibility and utilizations, employers should seek to model current public health strategies that aim to create community-level, cross-sector partnerships for health. Potential partnerships that employers should explore include partnerships with state and local government agencies, regional health systems, colleges and universities, and national nonprofit organizations as well as affiliated local chapters, such as the YMCA.13 Another benefit to corporate and nonprofit partnerships includes receiving government grants to help fund health initiatives; examples include partnering with the Boy Scouts of America for cleanup projects, food drives, and food delivery services; collaborating with the Salvation Army for clothing drives; and collaborating with local public health agencies and food pantries on projects targeting food insecurity, such as educational programs that teach employees how to adopt a healthier lifestyle, and services that improve employees’ access to healthy foods.
In addition to collaborations, employers should make the effort to educate themselves on additional health-related resources that they can refer their employees to in order to promote better health and safety. These include shelters, food pantries, counseling centers, churches, youth groups, social service agencies, and local chapters for national advocacy organizations such as the American Heart Association. For a more comprehensive explanation of how employers can further improve health initiatives through collaborative efforts, employers can refer to the Federal Emergency Management Agency’s 2021 guide on building private-public partnerships. Additionally, for more information on how to address SDOH through supplemental benefits, modified healthcare plans, and alternative program information, employers can review the ASPE Office of Health Policy’s 2022 report on addressing SDOH.
- Practicing diversity, equity, and inclusion (DEI) in the workplace. While compensation, benefits, and healthcare plans can have a positive effect on employee health and wellbeing, the impact that work conditions have on these health outcomes, and the role they play in current health disparities cannot be overlooked. According to the US Bureau of Labor Statistics, there are around 2.8 million nonfatal workplace injuries and illnesses reported each year.14 While reported injuries stem from the more corporal aspects of work—lifting, pulling, and pushing heavy loads, using poor-quality equipment, and being exposed to chemicals—work-related illnesses stem from employees’ exposure to psychosocial risk factors, or adverse work conditions that affect employees’ psychological response to the social environment of the workplace. High job demands, a lack of autonomy, a lack of recognition or reward, and interpersonal conflicts with supervisors and colleagues, are all examples of psychosocial risk factors that are predictive of a range of health problems including anxiety, depression, insomnia, heart disease, cardiovascular disease, diabetes, and premature morbidity—and these risks do not impact all employees equally.15 According to a 2013 study from the American Journal of Industrial Medicine, racial and ethnic minorities are at a higher risk of illness or injury due to unfair treatment in the workplace, including discrimination, harassment, social isolation, and exploitation.
In short, social support—or perceived social support—in the workplace has a substantial impact on health outcomes. While a lack of social support contributes to negative health outcomes, having a perceived abundance of social support has been associated with higher levels of self-efficacy, which strengthens employees’ ability to cope and manage stress, protecting them against illness and injury. With that said, it is on employers to promote and maintain an inclusive, equitable workplace culture. Potential DEI practices include hosting employee trainings on unconscious bias, workplace discrimination, and cultural competency; using more inclusive language in the workplace; and establishing employee resource groups (ERGs).
- Training employees to be wellbeing ambassadors. In addition to promoting social support through DEI practices, employers can train employees who are passionate about promoting better health and wellbeing to become wellbeing ambassadors for the organization. Wellbeing ambassadors, sometimes known as mental health champions, is a first point of contact for an employee who is experiencing distress to turn to before seeking professional support. While these employees are not mental health professionals, nor are they certified or expected to provide treatment, they can encourage employees to seek support for health-related concerns, refer employees to additional services and resources when requested, and empower employees to adopt healthy behaviors and attitudes.
Without breaching confidentiality, wellbeing ambassadors can also help leaders design and implement health-related programs by recording data from conversations that can be used to determine where support should be targeted to; whether they need to target food insecurity, financial instability, racism and discrimination, or barriers to childcare, for example. Wellbeing ambassadors can also ensure that these programs are effective by promoting them to employees and reducing the stigma on seeking and accessing care.
Ultimately, strategies that aim to address SDOH in the workplace will only be effective so long as employers make the effort to connect with their employees to determine what health-related resources and services they need access to, as well as to evaluate the current gaps and barriers that are preventing employees from accessing quality care and support. Strengthening pathways to care not only improves employee health and wellbeing, but it ultimately enhances an organization’s performance and longevity. As Gornick attests, “You can’t run a successful business unless you pay attention to the needs of your people, and figure out what’s going to make them perform the best and work the best in your organization.”