There’s an ongoing debate in health care and mental health care about the impact of various environmental factors on health, including the health of children. By environmental factors, we mean the external factors present in the communities in which we live, rather than nature in general. In recent years, researchers, social scientists, and health professionals introduced a new term to describe the environmental/community factors that impact our health: the social determinants of health (SDOH).
The U.S. Department of Health and Human Services (HHS) define the SDOH as follows:
“The social determinants of health are 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.”
Experts divide the SDOH into five categories:
- Economic Stability
- Education Access and Quality
- Health Care Access and Quality
- Neighborhood and Built Environment
- Social and Community Context
In their discussion of the SDOH, the World Health Organization (WHO) foregrounds the effect of the SDOH on health and wellbeing worldwide:
“Research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. For example, numerous studies suggest that SDOH account for between 30-55% of health outcomes. In addition, estimates show that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector.”
According to the WHO, the SDOH can have a positive effect on health and wellness, or a negative effect on health and wellness. Here’s what they mean:
- Components of SDOH that lead to positive outcomes:
- Safe communities
- Affordable transportation
- Affordable housing
- High quality education
- Access to good jobs
- Ample greenspace
- Access to social assistance and support program
- Components of SDOH that lead to negative outcomes:
- Community violence
- Presence of discrimination, bias, racism
- Low quality air and water, i.e. pollution
- Limited access to medical care
- Limited access to healthy food
The data on the SDOH are eye-opening. That’s why an article on the impact of the SDOH on mental health among children caught our attention.
Social Determinants of Health, Children, and Mental Health
Published in October 2023, the article “Patterns of Social Determinants of Health and Child Mental Health, Cognition, and Physical Health” posed this primary research question:
“What are the underlying patterns of the multidimensional social determinants of health (SDOH), and what are their associations with individual mental health, cognition, and physical health outcomes in children?”
To answer this question, the research team analyzed data on over 10,000 children with an average age of 9 years old, enrolled in the Adolescent Brain Cognitive Development (ABCD) Study, which was conducted between 2016 and 2021. They divided the participants into the following four categories, or patterns, based on the SDOH.
Pattern 1: Affluent Communities.
Children in these communities experience:
- High socio-economic status (SES)
- Low rates of stigma related to mental health/mental health treatment
- Healthy environment
- High academic performance
- Access to healthy food
- Moderate crime rates
This group made up 38.8% of the study sample.
Pattern 2: High Stigma Communities.
Children in these communities experience:
- High rates of stigma related to mental health/mental health treatment
- Bias toward/discrimination against women
- Bias toward/discrimination against sexual and gender minorities
- Unhealthy environment: industrial pollutants, poor air quality, high heat exposure
- Group living/mobile homes/military barracks
This group made up 10.6% of the study sample.
Pattern 3: Communities With High Socio-Economic Deprivation.
Children in these communities experience:
- Low family income
- High unemployment rates
- Low home value
- High poverty rates
- Absence of telephones/computers
- Low health insurance coverage
- Low reading and math proficiency
- Greater dependence on public assistance
- High lead exposure
- High levels of racism/discrimination toward immigrants
This group also made up 25.3% of the study sample.
Pattern 4: Communities With High crime, Low education, Dense Population.
Children in these communities experience:
- High rates of crime
- High rates of drug sales/drug activity
- School poverty
- High air pollution
- Crowded housing/high population density
- Low educational attainment
- Little/no access to greenspace
- Low home ownership rates
This group made up 10.6% of the study sample.
Once they divided the sample set into these four patterns, they analyzed exposure to the different patterns to mental health outcomes, cognitive outcomes, and physical health outcomes.
Let’s take a look at what they found.
SDOH Patterns and Child Mental, Cognitive, and Physical Health Outcomes
We’ll share the results by outcome category, below. For the raw data, follow the link to the study, above. We’ll start with mental health, and report the outcomes for each SDOH pattern, then do the same for the remaining three outcome categories.
Mental Health Outcomes
1: Affluent community
- Lowest levels of externalizing disorders
- Lowest levels of internalizing disorders
2: High-stigma environment
- Moderate levels of externalizing disorders:
- Showed rates similar to Patterns 3 and 4, higher than Pattern 1
- Moderate levels of internalizing disorders:
- Showed rates similar to Patterns 3 and 4, higher than Pattern 1
3: High socio-economic deprivation
- Highest levels of externalizing disorders
- Highest levels of internalizing disorders
4: High crime, low education, dense population
- Moderate levels of externalizing disorders:
- Showed rates similar to Patterns 2 and 4, higher than Pattern 1
- Moderate levels of internalizing disorders:
- Showed rates similar to Patterns 2 and 4, higher than Pattern 1
Cognitive Outcomes
1: Affluent community
- Highest levels of overall cognitive performance (combined crystallized and fluid intelligence scores)
- Highest levels of crystallized intelligence (word and image recognition)
- Highest levels of fluid intelligence (pattern recognition, memory, pattern comparison, sequence memory)
2: High-stigma environment
- Lower levels of overall cognitive performance than Patterns 1 and 4, higher levels than Pattern 3
- Lower crystallized intelligence than Pattern 1 and 3, higher than Pattern 4
- Lower levels of fluid intelligence compared to Pattern 1, higher than Pattern 3, lower than Pattern 4
3: High socio-economic deprivation
- Lowest levels of overall cognitive performance
- Lowest crystallized intelligence
- Lowest fluid intelligence
4: High crime, low education, dense population
- Higher overall cognitive performance than Patterns 2 and 3, lower than Pattern 1
- Higher crystallized intelligence than Patterns 2 and 3, lower than Pattern 1
- Higher fluid intelligence than Patterns 2 and 3, lower than Pattern 1
Physical Health Outcomes
1: Affluent community.
- Days of Over an Hour of Exercise Per Week: 3.8
- Higher than Patterns 2-4
- Lower Body Mass Index (BMI) than Patterns 2-4
- More sleep disorders than Pattern 4, fewer than Patterns 2 and 3
2: High-stigma environment
- Days of Over an Hour of Exercise Per Week: 3.6
- Lower than Pattern 1, higher than Patterns 3 and 4
- Higer Body Mass Index (BMI) than Pattern 1, lower than Patterns 3 and 4
- More sleep disorders than Patterns 1 and 4, fewer than Patterns 3
3: High socio-economic deprivation
- Days of Over an Hour of Exercise Per Week: 3.23
- Lower than Patterns 1-2, higher than Pattern 3
- Higher Body Mass Index (BMI) than Patterns 1-2, higher than Pattern 3
- Most sleep disturbance/disorders among the 4 Patterns
4: High crime, low education, dense population
- Days of Over an Hour of Exercise Per Week: 3.06
- Lowest among the 4 Patterns
- Highest Body Mass Index (BMI) among the 4 Patterns
- Lowest level of sleep disturbance/disorders among the 4 Patterns
Suicidality
1: Affluent community
- Higher percentage of suicidal ideation than Patterns 3 and 4.
- Lowest percentage of suicide attempts among all Patterns.
2: High-stigma environment
- Highest percentage of suicidal ideation among all Patterns
- Lower percentage of suicide attempts than Patterns 3 and 4, higher percentage than Pattern 1
3: High socio-economic deprivation
- Higher percentage of suicidal ideation than Pattern 4, lower percentage than Patterns 1 and 2
- Highest percentage of suicide attempts among all Patterns
4: High crime, low education, dense population
- Lowest percentage of suicidal ideation among all Patterns
- Higher percentage of suicide attempts than Patterns 1 and 2, lower percentage than Pattern 3
Here are the primary takeaways from this data:
- Children living in areas of high socioeconomic deprivation reported lowest scores on metrics related to mental, cognitive, and physical health outcomes
- Children living in affluent areas showed highest overall scores mental health, cognitive, and physical health outcomes
- In high-stigma environments with higher crime rates/drug activity, lower education attainment, and high-density population, children showed:
- Lower overall cognitive performance
- Higher BMI
- More sleep disturbance/disorders
Here’s how the research team summarizes their findings:
“Children living in areas characterized by high crime and drug sales, low education, and high population density were observed to exhibit both lower cognitive function and insufficient physical activity compared with the other SDOH patterns. The chronic stress in these communities, coupled with limited access to basic resources, can hinder cognitive development and discourage physical activity, deteriorating overall cognition and activity levels.”
The data are clear: the SDOH have a significant impact on mental and physical health. There are clear action steps we can take to mitigate these negative consequences, however.
What We Can Do to Create Change
In 2018, the Kaiser Family Foundation (KFF) published a report called “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity.” Their report defines the ADOH as “the conditions in which people are born, grow, live, work and age.” Since we see clear differences in health outcomes for children based largely on socioeconomic status, we look the KFF publication for their recommendations about how we can transform the social determinants of health from negative to positive for these demographic groups.
Here’s how we can improve the SDOH in six areas: economic, neighborhood/environment, education, education, food stability, community, and health care.
How to Improve the SDOH for Children
1. Enhance Economic Stability
When community members have access to employment and income, they can meet the financial needs for themselves and their children, including rent, health care, and recreational activities. This reduces chronic stress and improves overall health.
2. Improve Neighborhoods and the Physical Environment
Federal, state, and local governments can take steps to improve access to safe and affordable housing, increase access to effective public transportation, improve the quality and quantity of greenspace and recreational opportunities, and consider a community policing model for neighborhood safety.
3. Improve Education and Schools
Evidence shows that when we enhance and improve early education programs, allocate funding for safe K-12 schools, and improve access funding to ongoing education programs for adults, outcomes in all other life domains improve.
4. Work to Provide Adequate Food for All and End Hunger
With regards to children, this means bolstering breakfast, lunch, and snack programs in schools and expanding community food options for adults. Federal, state, and local policymakers can work to reduce food deserts by creating programs that increase the amount of healthy food options in low-income communities.
5. Expand Social Services in Communities
The nature of our community – including our relationships with friends and families – can help improve the mental and physical health of our children. In some cases, children don’t have the family and community support they need. Therefore, we can work to increase access to social support systems and services, and work to reduce the social and environmental stressors in traditionally underserved communities.
6. Expand and Improve Mental Health Care/General Health Care
For children’s mental health this means expanding insurance programs for uninsured children and their families and creating incentives for providers to offer care in traditionally underserved areas. It also means increasing funding for school-based mental health providers, school-based assessments, school-based social and emotional learning (SEL) programs, and improving the overall quality of and access to health care for children and families nationwide.
This is a tall order, but it’s not beyond our reach. When we work together toward a common goal we all agree on – improving the mental health of our children – we can create real change that has a real impact on the lives of the real people in our communities. When we take care of our children, what we’re really doing is taking care of our future – and that’s important.
