Why It Matters

Social determinants of health (SDOH) are the conditions in the places where people are born, live, learn, work, play, and age. They affect a wide range of health, functioning, and quality-of-life outcomes and risks.

 

Differences in disease rates at the population level are in large part due to structural forces that increase the risk of exposure to disease agents for segments of the population. These forces and elements include poverty, a lack of economic opportunities, substandard or unaffordable housing, residential segregation, criminal justice policies and incarceration, racism and other forms of discrimination, land and environmental use planning, and community food systems, among other factors. 

 

To stop HIV in Iowa, we must identify and develop strategies to address the structural factors (i.e., the social determinants of health) that contribute to health inequities, including disparities in rates of HIV, STD, and hepatitis.

 

Where We Stand Today

About Social Determinants of Health

Social determinants of health (SDOH) refers to the overlapping conditions, social structures and economic systems (e.g., social environment, physical environment, political systems, and structural and societal factors) that are responsible for most health inequities.

 

The study of social determinants of health goes beyond individual-level risk factors and health outcomes to build an understanding that individual health and lifestyle choices are strongly influenced by the characteristics of the environments in which individuals live, work,  grow, and age.

 

SDOH are connected to PLACE and offer an important missing link in the study and understanding of health disparities and poor health outcomes.

Social Determinants of Health Priority Areas

U.S. Department of Health and Human Services, through the Healthy People 2030 national objectives, developed a place-based framework that identifies five main SDOH priority areas that we will use in our planning work this year:

Social Determinants of Health

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Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved 11 March 2022, from https://health.gov/healthypeople/objectives-and-data/social-determinants-health. Colors updated.

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Economic Stability

Reducing the proportion of people living in poverty; increasing employment in working-age people

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Education Access and Quality

Increasing the proportion of high school students who graduate in four years; increasing the proportion of grade 4 students with reading and math skills at or above the proficient level

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Healthcare Access & Quality

Increasing the proportion of people with health insurance; increasing the proportion of adults who get recommended evidence-based preventive health care

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Neighborhood and Built Environment

Reducing the rate of minors and young adults committing violent crimes

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Social and Community Context

Reducing the proportion of children with a parent or guardian who has served time in jail, reducing bullying of transgender students, low food security in children

What We're Doing Now

Current efforts addressing social determinants of health for people living with HIV in Iowa

The following programs are available throughout the state of Iowa to address social determinants of health (SDOH) for people living with HIV (PLWH):

  • Ryan White Housing Service—provides housing services for people living with HIV/AIDS who are in Ryan White Part B medical case management.
     

  • Housing Opportunities for Persons with AIDS (HOPWA)—a federal program by the U.S. Department of Housing and Urban Development designed to assist people who have been diagnosed with HIV/AIDS and their families who are homeless or at-risk of homelessness.
     

  • AIDS Drug Assistance Program (ADAP)—a state- and territory-administered program authorized under Ryan White Part B that provides FDA-approved medications to low-income people living with HIV who have limited or no health coverage from private insurance, Medicaid, or Medicare. ADAP is a payer of last resort. 

Overview of efforts to address SDOH in Iowa

Efforts to address health care access

  • Medicaid Expansion in 2016
     

    • Iowa Health and Wellness Plan (IHAWP)—Iowa’s version of the 2016 Medicaid Expansion allowed under the Affordable Care Act. IHAWP seeks to  provide comprehensive health care coverage to low income adults who were not previously eligible for Medicaid (e.g., single, low income adults).
       

    • Since Iowa’s Medicaid Expansion in 2016, we have seen an increase in participation in health care, specifically among low income adults who were not previously eligible for Medicaid.
       

  • Pre-Release Medicaid Enrollment Program—through this program, incarcerated individuals are able to enroll in Medicaid in anticipation of rejoining their home communities.
     

  • COVID Child Tax Credit

 
Efforts to reduce homelessness

  • Homeward (formerly Polk County Continuum of Care) coordinated by Mid-Iowa Health Foundation
     

    • Youth Homelessness Demonstration Project (YHDP)—in 2019, the U.S. Department of Housing and Urban Development (HUD) awarded $1.86M to Polk County for a two year period as part of YHDP. 

      YHDP projects are designed to provide housing options and supportive services for people under the age of 25 who are experiencing homelessness or are at risk of homelessness. Crucially, the projects also focus on racial equity and addressing the disproportionate number of black youth who experience homelessness.
       

  • Youth and adult homeless shelters

Other current efforts to address SDOH

  • ProjectIowa—a non-profit organization that offers support and training services to Iowans seeking better careers

  • Community Action Agencies

  • Human and Civil Rights Commissions

  • DMARC

  • Eat Greater Des Moines—a non-profit organization that gathers extra food and distributes it throughout the community

  • SURJ

  • Director’s Council

  • NAACP

  • Central Iowa Returning Citizens Achieve (CENTRA)—a project of United Way of Central Iowa, CENTRA supports central Iowans returning from prison by helping them connect with employment, housing, and other services in the community.

  • AMOS

Opportunities

Using data to identify SDOH most closely associated with HIV and STI transmission at the geographic level

One routine function of HIV surveillance programs is to geocode HIV data and link them with socio-economic, demographic, and geographic variables from the U.S Census American Community Survey (ACS).

 

ACS data allows us to assess the social, economic and demographic characteristics of place, and enables surveillance programs to assess the specific social determinants of health (SDOH) associated with HIV, the relationship of HIV to other diseases, and health care resources in a defined area. HIV surveillance data are geocoded to the census tract level by address of residence at the time of diagnosis and linked at the census tract.

 

The Centers for Disease Control and Prevention (CDC) performed these analyses using 2018 HIV diagnoses among U.S. adults and ACS data for 2014-2018. They analyzed the relationships between HIV diagnoses and 5 SDOH measures:
 

  • federal poverty status,

  • education level,

  • median household income,

  • health insurance coverage, and

  • Gini index (a summary measure of income inequality).

 

HIV diagnosis data included age, race/ethnicity, sex at birth, mode of exposure where included, linkage to care, and viral suppression as outcome variables.

Gaps, Barriers, & Challenges

Housing

​Insufficient and unstable housing:

The role of housing as a social determinant of health is well-established. The lack of housing, or poor quality housing, have been found to negatively affect health and wellbeing. Additionally, structural, social and environmental conditions, as well as neighborhood aspects, are all demonstrated to be significantly correlated with measures of health and wellbeing.

Homelessness:

People who experience lack of housing have higher rates of illness than the general population. The social determinants of health focus area will work on developing recommendations that will:

  • Reduce homelessness among people living with HIV, and among people who are most vulnerable to acquiring HIV
     

  • Address policies that impose restrictions for eligibility to housing vouchers
     

  • Reduce eviction rates among vulnerable populations, and address policies that lead to unsafe and inadequate housing for people at risk of transmission of HIV

In progress: Identifying policies that prioritize investments in affordable, adequate housing, boost affordable housing supply, and meet the needs of families of different socio-economic statuses.

Incarceration

People who have been incarcerated face limitations in access to:

 

  • Affordable housing
     

  • Employment
     

  • Federal programs such as SNAP and TANF (depending on type of conviction)

 

For people who are currently incarcerated, certain convictions also limit access to programs designed specifically for people who are currently incarcerated.

 

The Medicaid Inmate Exclusion Policy also blocks incarcerated people from receiving Medicaid coverage. This can result in disruption in coordination of HIV care.

In progress: Identifying policies that prioritize investments in effective, non-carceral systems of community-based safety and accountability, including transformative and restorative justice, decarceration, and decriminalization.

Education 

​Barriers in education systems include:

  • Policies that foster the school-to-prison pipeline
     

  • Policies that are homophobic and/or transphobic
     

  • Lack of policies and practices that support LGBTQ students.

In progress: Identifying policies that address discrimination against individuals based on race, ethnicity, sexual orientation, or gender identity.

Healthcare
  • Some existing healthcare policies impede access to HIV treatment and health care services and exacerbate HIV-related disparities
     

  • Health care practices and members of the workforce may perpetuate institutional bias in medical care

In progress: Identifying policies that engender a culture of holistic health, emphasizing access to prevention and ease of treatment.

 
 
 
 
A young mixed race lesbian couple hold hands while walking on a sidewalk through an urban

To stop HIV in Iowa by 2030, this focus area must:

  • Address social and structural determinants of health and co-occurring conditions that impede access to HIV services and exacerbate HIV-related disparities.
     

  • Reduce homelessness among people with diagnosed HIV and people vulnerable to HIV transmission.
     

 
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Process for Community Engagement 

Engagement Focus

The goal of the social determinants of health (SDOH) focus area is to increase understanding of the impacts of socio-economic, political, and structural forces on population health, beyond individual behavior or biology.

 

The focus of the work is to identify and strengthen the evidence that addressing and improving social determinants of health will reduce transmission of HIV in Iowa; and identify strategies and partners to address SDOH in a meaningful way.

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Gathering Feedback

  • Interview experts in Iowa on work they have done to identify and address SDOH
     

  • Identify research that the Iowa Department of Public Health and/or the Bureau of HIV, STD, and Hepatitis still needs to do to demonstrate to policy makers the connection between improving transportation, jobs, housing, etc. and improving health. 
     

  • Review county health needs assessments and health improvement plans to see which counties have identified SDOH in plans and how they plan to address them
     

  • Identify other organizations or programs that could be supported or partnered with to address the SDOH affecting people with or at risk for HIV
     

  • Identify model programs or strategies to address SDOH that could be tried in Iowa

 
 

Resources

Centers for Disease Control and Prevention

U.S. Department of Health and Human Services

Slightly run down older homes in an urban neighborhood