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Ebele Umeukeje @EbeleUmeukeje

Ebele Umeukeje is an Assistant Professor of Medicine at Vanderbilt University Medical Center. She is a nephrologist and an epidemiologist passionate about improving health outcomes in vulnerable patients with kidney disease. Her research aims to understand the influence of novel psychosocial factors on adherence in patients with kidney disease, and inform evidence-based, patient-centered innovative approaches to improve adherence and critical outcomes in this patient population. Dr Umeukeje also has a special interest in health disparities in these vulnerable patients, especially those mediated by race.

Competitors for the Inequities Region

Governmental Policies vs Institutional Initiatives

Environmental Determinants of Health vs Social Determinants of Health

Copyright: Iscotlanda Photography / Shutterstock

“We have to put reduction of health inequalities at the center of our public health strategy and that will require action on the social determinants of health.” – Michael Marmot

Kidney disease is a public health crisis that afflicts persons of all segments of society. Racial/ethnic disparities in advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are well-established, and differences in CKD incidence, prevalence, and progression across socioeconomic status and racial/ethnic strata are increasingly being recognized. Socioeconomic deprivation and environmental conditions, as well as chronic stress associated with these factors, play a strategic role in the causal pathway from CKD risk to the development and complications of CKD and ESKD. These factors, known as the ‘social determinants of health’, include low socioeconomic status, limited education, low health literacy, unemployment, lack of insurance, poor living conditions (neighborhood and physical environment), lack of social support, discrimination and segregation, limited access to health care, and more.

Copyright: James Mercier / Shutterstock

Social determinants of health exert a negative influence on the drivers of CKD development and/or progression including obesity, diabetes, hypertension and endothelial dysfunction, chronic inflammation, neurohormonal activation, and oxidative stress. For instance, numerous studies have shown a strong association between socioeconomic status and the incidence, prevalence, and complications of CKD. Within the context of kidney transplantation, social determinants of health play a key role in observed racial disparities. It has been shown that perceived racial discrimination, transplant knowledge, and lower income are associated with longer time to waitlist acceptance. Social determinants of health perpetuate kidney health inequity and addressing these determinants must be the main target of our public health efforts. To fully appreciate the impact of social determinants of health on kidney diseases it is imperative that we have a clear understanding of the concept and scope of social determinants of health, and its relationship with other key drivers of health outcomes.

“Health inequalities and the social determinants of health are not a footnote to the determinants of health. They are the main issue”. – Michael Marmot

The World Health Organization (WHO) describes health inequity as “systematic differences in the health status of different population groups, which have significant social and economic costs both to individuals and societies.” Health inequity is a product of the social, economic, environmental, and structural disparities that contribute to differences between groups in health outcomes both within and between societies.

In a comprehensive report published by a committee of the National Academies of Sciences, Engineering, and Medicine describing pathways to health equity, two main root clusters of causes were identified: The first is “structural inequities” which are produced on the basis of identity. They reflect the intra and interpersonal, institutional, and systemic barriers which drive the differential distribution of power and resources across lines of race, gender, class, sexual orientation, gender expression, ability, and other dimensions of individual and group identity e.g., sexism, classism, able-ism, xenophobia, and homophobia. These structural barriers include governmental policies and institutional initiatives. The second, and more fundamental root cause of health inequity, is this concept of the ‘social determinants of health’ which encompasses the unequal social, economic, and environmental conditions resulting from unequal allocation of power and resources including goods, services, and societal attention.

Graphic courtesy of First Nations Health Authority (reproduced with permission)

Social determinants of health have been elegantly described as “the terrain upon which the effects of structural inequities play out”. Stated differently, social determinants of health broadly describe the conditions in which people are born, grow, live, work, and age including not only socioeconomic status, education, employment, social support networks, and access to health care but also the neighborhood and physical environment a.k.a. environmental determinants of health. Socioeconomic constellations, which are a critical component of the social determinants of health, mediate the environmental determinants of health, and these environmental determinants of health are an integral component of social determinants of health. It goes without saying that social determinants of health are arguably the ‘biggest elephant in the room of health disparities’ because they encompass all the factors tied to the conditions in which people exist, and cut across the social, economic, physical, and service environment.

“If you’re going to live, leave a legacy. Make a mark on the world that can’t be erased.” -Maya Angelou

Why should we (as kidney health experts) focus on social determinants of health?

Social determinants of health drive kidney disease disparities as well as poor outcomes for all groups, and despite the inherent complexity of these factors, they are mostly mutable factors that can be intervened upon to mitigate CKD risk and minimize chances of developing CKD and ESKD. Compared to the more upstream drivers of kidney health inequity such as laws and policies, some of the social determinants of health are factors more easily within our control as providers, such changes we can make within our health care system and/or practice, and most likely to yield immediate health benefit to the patients we serve.

What can we really do about social determinants of health?

As health professionals, it is important that we recognize how social determinants of health are both shaped by our worldviews and in turn reinforce our views of the world, which in turn influence health outcomes and often escalate health care costs. As we strive to prioritize patient-centered care, it is also critical that we understand the diversity of the patient population we serve. Inspired by our knowledge of social determinants of health, we must strive to hone our skills in cultural competency/sensitivity and effective communication practices in the context of the patient’s home and community, to optimize the chances that our patients will adhere to our recommendations and prescribed therapies. Finally, consistent with the key tenets stipulated by the WHO for improving health at a global level, we must aspire to create a workforce trained in the social determinants of health and to be committed to raising awareness about these most influential and comprehensive determinants of health.

– Guest Post written by Ebele Umeukeje @EbeleUmeukeje

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

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