Addressing structural and social determinants/drivers of health and health disparities

Structural and social determinants of health influence health outcomes and contribute to health disparities. They are often called drivers of health because being in a disadvantaged situation doesn't guarantee or determine a bad outcome, but it does steer towards it, making it harder to achieve a good one. Many of these factors exist outside of the healthcare system. However, healthcare professionals can still play an important role in addressing them, which helps reduce health disparities and improve health outcomes for both individuals and populations.

Healthcare professionals can act at multiple levels. They can address structural and social determinants of health at the individual patient level, community level, and through advocacy for policies that promote health equity.

Before we get into details, let’s go over a case.

Kazim is a 43-year-old Afghan refugee who has lived in the United States for 10 years. He works long hours in construction, speaks limited English, has limited formal education, and has not routinely accessed healthcare since arriving in the United States. He shares housing with several other Afghan men who provide much of his social support. His wife and children remain in Afghanistan, and he works long hours in hopes of eventually bringing them to the United States.

Kazim was recently hospitalized with an infected foot ulcer and was found to have previously undiagnosed diabetes with complications including peripheral neuropathy and peripheral artery disease After discharge, he was referred to a community clinic for follow-up but has now missed two appointments.

The members of his healthcare team, which includes a primary care physician, endocrinology nurse practitioner, and a community health worker, message each other through the electronic medical record system in an attempt to better support him. It would be easy to label Kazim as not engaged in care and discharge him from the clinic, but that approach would only reinforce health inequities. A better approach is to consider the barriers affecting his ability to engage in care.

Several structural and social determinants of health may be influencing Kazim’s situation. His refugee status, education, income, available transportation, occupation, and language barriers may affect his ability to access healthcare and manage his diabetes.

He may have difficulty attending appointments because of work demands, costs, or limited understanding of his condition. He may also be experiencing stress related to separation from his family or trauma associated with his refugee experiences. At the same time, Kazim’s local Afghan community represents an important source of support and resilience.

Understanding both the barriers and strengths in Kazim's life can help guide a more effective and equitable approach to care.

To understand how we can help Kazim, let’s consider several strategies healthcare professionals can use to address structural and social determinants of health at the individual patient level. These include identifying social needs, helping patients navigate services and resources, providing culturally responsive and trauma-informed care, and supporting health literacy through appropriate patient education and shared decision-making. Together, these approaches can help reduce barriers to care and improve health outcomes.

First, healthcare professionals need to identify social needs. This begins with taking a thorough social history and using validated screening tools to identify barriers related to housing, food access, transportation, financial strain, health literacy, and social support. Recognizing these barriers helps clinicians connect patients with appropriate resources.

Another important strategy is the use of warm referrals, care navigation, and flexible access to care. Warm referrals involve directly connecting patients with needed services rather than simply providing information. Community health workers can also help build trust and improve engagement by serving as a bridge between patients and the healthcare team. Flexible scheduling, including evening or weekend appointments, may help reduce barriers related to work and transportation.

Another important strategy is culturally responsive care. This approach recognizes that patients bring unique cultural backgrounds, values, and experiences into healthcare encounters. Cultural Formulation Interviewing is a structured approach that helps clinicians understand how patients view their illness, its causes, available support, and potential treatments. By better understanding the patient’s perspective, clinicians can improve communication, engagement, and outcomes across cultural contexts.

A related approach is trauma-informed care. This recognizes that trauma, chronic stress, and structural discrimination may affect health behaviors, trust, and engagement with care. Clinicians should respond with empathy, create a sense of safety, and avoid actions that may re-traumatize patients.

Finally, healthcare professionals can promote shared decision-making and improve health literacy. Structural disadvantage may be associated with lower health literacy, but not lower intelligence or decision-making capacity. Clinicians should communicate using plain language, professional interpreters when needed, and the teach-back method to confirm understanding. In the teach-back method, patients are asked to explain the plan in their own words so that misunderstandings can be identified and corrected.

To improve Kazim’s engagement with care, the healthcare team could ask a community health worker with shared cultural or linguistic experience to reach out and help Kazim understand the diagnosis and importance of treatment.

Flexible appointment scheduling could help accommodate his work responsibilities.