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101.3 Upstream: The Social Determinants of Health
Where we live, learn, work and pray shapes how long and how well we live
Your materials
Slides (PowerPoint) Handout (Word)
For instructors
Facilitator guide Printable pre and post tests Quiz (LMS import)
What you will learn
- Define the social determinants of health in plain words
- Name the five Healthy People 2030 domains with local examples
- Use the river story to tell upstream from downstream
- Describe physical, mental, emotional and spiritual impacts on health
Start here
Two babies are born today, less than two miles apart in Cuyahoga County. Why might one live 23 years longer?
Lesson
The river story
Public health workers often tell this story:
- People in the river: We see people struggling in a river, and we pull them out one by one.
- More keep coming: We work harder, but more people float by every hour.
- Someone walks upstream: One of us goes up the river to see why people are falling in.
- Fix the bridge: Upstream, a broken bridge is the cause. Fixing it saves many people at once.
What are social determinants of health
Healthy People 2030 defines them as the conditions where people are:
- Born and live: Housing, safety, clean air and water, and the places we grow up.
- Learn and work: Schools, jobs, pay, and the skills and chances we get.
- Play and worship: Parks, rec centers, churches, mosques and the people we gather with.
- Age: Support, care and connection as we grow older.
The five domains, close to home
| Domain | What it looks like here |
|---|---|
| Economic stability | Steady pay, rent you can afford, food money |
| Education access and quality | Strong schools, reading skills, job training |
| Health care access and quality | Insurance, a nearby clinic, a doctor who listens |
| Neighborhood and built environment | Safe streets, bus lines, groceries, lead-safe homes |
| Social and community context | Family, church, block clubs, fair treatment |
Two miles apart in Cuyahoga County
- 65.4 Life expectancy in years, Buckeye-Woodhill and University Circle tract
- 88.6 Life expectancy in years, a Shaker Heights tract
- 23 yrs Gap between tracts less than two miles apart
Source: Center for Community Solutions, 2019
Health is more than the body
Ohio asks CHWs to understand four kinds of impact on health:
- Physical: The body: blood pressure, asthma from mold, injuries, hunger.
- Mental: Thinking, focus and mental illness, such as depression or anxiety.
- Emotional: Feelings like stress, fear, grief and hope, and how we cope.
- Spiritual: Meaning, faith, purpose and connection to something larger than ourselves.
Looking upstream with Ms. Lopez
- What we see: Ms. Lopez in Clark-Fulton keeps going to the emergency room for her son's asthma attacks.
- Why it happens (upstream): Their rental has mold and old carpet, rent is high, and she fears asking the landlord for repairs.
- What we can build on (assets): A tenant rights group, a home asthma program, a bilingual promotora and her parish, which knows a trusted contractor.
Situation: the missed appointments
Situation: Mr. Carter in Hough has missed three diabetes visits. His clinic calls him noncompliant. You learn he lost his job, his phone was cut off, and the bus to the clinic takes 90 minutes.
What do you do as a CHW?
- Listen without judgment and thank him for sharing
- Name the barriers together: money, phone, transportation
- Connect him to resources, such as 211 and Medicaid transportation if eligible
- Tell the care team about the barriers, with his consent
Talk it over
- Which of the five domains shapes health most on your block?
- Think of the river story. What is one broken bridge in your neighborhood?
- Which upstream condition do you think gets talked about least?
Study sheet
The big idea: Our health is shaped mostly by the conditions where we live, learn, work, play, worship and age.
Key points
- Social determinants of health are the conditions in the places where people live their lives.
- Healthy People 2030 groups them into five domains, from economic stability to social and community context.
- The river story reminds us to care for people today and fix causes upstream.
- In Cuyahoga County, life expectancy differs by about 23 years between tracts less than two miles apart.
- Upstream conditions affect physical, mental, emotional and spiritual health.
- Words like noncompliant can hide upstream barriers; CHWs bring those barriers to light.
Remember
- Five domains: economic stability, education, health care, neighborhood and built environment, social and community context
- Cuyahoga County tracts: 65.4 years vs 88.6 years, about 23 years apart (2019)
- Four impacts on health: physical, mental, emotional, spiritual
Ask yourself
- Which upstream conditions shaped my own health growing up?
- When I hear a label like noncompliant, what questions will I ask?
Vocabulary
| Word | What it means |
|---|---|
| Social determinants of health (SDOH) | The conditions where people are born, live, learn, work, play, worship and age that shape health. |
| Healthy People 2030 | The national set of ten-year health goals from the U.S. Department of Health and Human Services. |
| Upstream | The root causes of health problems, such as income, housing, schools and policy. |
| Downstream | The health problems we see in a person, such as illness, injury or an emergency visit. |
| Life expectancy | The average number of years a person born in a place can expect to live. |
| Census tract | A small area the Census Bureau uses to count people, often a few thousand residents. |
| Built environment | The human-made places around us: homes, streets, stores, parks and bus lines. |
| Economic stability | Having steady income and enough money for basic needs like food, rent and utilities. |
| Health equity | Everyone has a fair chance to be as healthy as possible. |
| Spiritual health | A sense of meaning, purpose, faith or connection that helps a person cope and hope. |
Real-life situations
The empty refrigerator
Ms. Watkins in Glenville is a grandmother raising two grandsons. At a visit you notice the refrigerator is nearly empty and she skips meals so the boys can eat.
What to do
- Ask gently, with respect, if food money is tight this month
- Help her check eligibility for SNAP and find a nearby food pantry through 211
- Ask about kinship caregiver supports she may qualify for
- Plan a follow-up call to see if the help came through
Why: Hunger is an economic stability issue, not a personal failing. Connecting her to resources treats the cause, not just the symptom.
The worker with the cough
Mr. Nguyen works long shifts at a warehouse in Lorain and has had a cough for a month. He says he cannot take time off to see a doctor.
What to do
- Do not guess what is causing the cough
- Help him find a clinic with evening or weekend hours
- If he has trouble breathing or chest pain, call 911
- Ask if he has health insurance and help him apply if not
Why: Work schedules and insurance are upstream barriers. The CHW removes barriers and connects him to care, without diagnosing.
The grieving teen
Jalen, 17, from East Cleveland, has stopped coming to youth group since his cousin died. His aunt says he barely sleeps or eats.
What to do
- Reach out gently and listen without pushing
- If he talks about hurting himself, stay with him and call or text 988 together
- Connect his aunt to youth grief and counseling services
- Invite him back to trusted groups, like his youth pastor or a coach
Why: Grief touches mental, emotional, spiritual and physical health. Trusted community ties are assets for healing.
Activity: My block, five domains
About 25 minutes.
- Draw a simple map of the blocks around your home, or of a neighborhood you serve.
- Mark one thing on your map for each of the five Healthy People 2030 domains.
- Circle one thing that harms health and star one thing that helps health.
- Write two sentences: what is one broken bridge upstream, and who could help fix it?
- Post your map in the course discussion or bring it to the live session.
Post-test
Ten questions. You need 75% to pass, with one retake. Your result is saved in this browser.