Social Determinants of Health: Considerations for Athletic Health Care

Health Systems and Services

Health systems and services is a broad category of factors that are defined as the access or lack of access to effective and affordable care.²⁰ Health systems and services should strive for culturally proficient health care, which denotes that health care will also be equitable. Health systems and services can be considered from a variety of perspectives, including how to navigate the health care system as well as a person's capacity to obtain, process, and understand health information.²⁰ The breadth of the category highlights the many factors that contribute to access to health care. Health care access can depend on health insurance, and employers are often the providers of that insurance in the United States. Healthy People 2020¹⁵ reported that 1 in 5 Americans under age 65 years lacked health insurance, and 1 in 4 lacked a primary care physician, which limits health care access. Although lack of access can negatively influence health, the issue is not as simple as having or not having health insurance. Institutional perspectives are needed to assist in determining and addressing access as an area of improvement and a critical factor for becoming culturally proficient and reducing health disparities. Gulliford et al³⁷ defined access to health care using 4 dimensions: service availability, barriers to service utilization, relevance and effectiveness of access, and equity of care. When evaluating access to care in a population, considering these dimensions, responding appropriately, and asking culturally proficient questions are essential.

In athletic health care, appropriate questions related to the dimension of service availability are whether enough ATs are accessible to all secondary schools and athletes in a district; whether employment models for ATs are full time, part time, or per diem; and whether ATs provide services only during competitions. Currently, access to AT services across the United States is limited, despite efforts to have an AT in all secondary school settings. In 2015, Pryor et al³⁸ found that 70% of secondary schools employed an AT, but only 37% employed one on a full-time basis. An AT may be the first and only health care provider a child participating in sport has access to, which highlights the value of athletic health care in promoting the health of people and populations.

Another appropriate question related to the 4 dimensions presented by Gulliford et al³⁷ is, “What is the health literacy of my patient?” Health literacy is “the capacity to obtain, process, and understand the basic information needed to make appropriate health decisions.”^39,40(p278) Athletic trainers can influence the health literacy of patients. Understanding the health literacy of patients is a potential opportunity to reduce this barrier to health care. Using cognitive interviewing techniques, lay terms, and associative examples can improve patient understanding and trust.⁴¹ In efforts to improve patient health literacy, ATs often make appointments, navigate the insurance process, and educate patients on health topics. Athletic trainers not only provide health services that reduce the negative influence of social determinants but, in many cases, also guide patients through the health care system. Athletic trainers seeking additional information on patient health literacy should explore the World Health Organization “Healthy Literacy Toolkit,” which aims to promote understanding of patients' limitations and strengths.¹⁸

Transportation

Transportation is often considered a physical environment social determinant. However, similar to the World Health Organization,²⁶ we discuss transportation separate from the physical environment because it is multifaceted and consists of the infrastructure and services necessary for individuals to move around their communities.⁴² In a 2013 review,⁴³ numerous study authors reported a positive relationship between access to transportation and health care, with greater access to transportation related to better access to health care. When transportation is limited or designed inadequately, patients may be unable to attend health care appointments, thereby delaying care. Transportation can have a negative effect on health through pollution, the ability to get to and from work, and access to health care.⁴⁴ For example, those without access to a vehicle cited transportation as a primary factor for missing health care appointments.^45,46 Transportation can also have a positive effect on health through increased access to education, job opportunities, exercise, and social contact.⁴⁴ Access to an AT alone can reduce the negative effect of the lack of transportation on a patient's health by reducing the need to seek health care outside of a school environment. Another example, often observed in collegiate or university athletics, is how ATs have mitigated the lack of transportation for their patients by coordinating transportation to and from appointments with an offsite physician. In some instances, the AT may accompany the athlete to the appointment, reducing the lack-of-transportation barrier to the health care experience.

Education

Education has been defined as “the access or lack of access to learning opportunities and literacy development for all ages.”^20(p118) Education occurs in schools, the community, the workplace, and the home and leads to accumulation of knowledge.²⁰ Educational attainment influences health in a variety of ways. Evidence from early childhood education suggests that children from lower-income communities have a drastically reduced vocabulary compared with children in higher-income communities,⁴⁷ which negatively affects literacy, academic achievement, and health.^20,48,49 Conversely, increased educational attainment leads to better employment opportunities, healthy behaviors, and longevity and a lower risk of injury.^20,50,51 In 2019, Franz and Cook⁵² examined the Dominican Republic's traditional baseball academies, which focus primarily on athletic ability. Because these academies maximized the athletes' ability to earn a major league contract, 97% of players lacked the education to pursue a different career and often ended up in poverty.^53–55 A community-based research project was launched to determine whether an increased emphasis on academic success could change the outcomes for these athletes.⁵² Focusing on academic success presented an alternative to homelessness, promoted educational opportunities, and stimulated equity for players and their communities.⁵² In the United States, many athletes attend colleges and universities to play sports and desire to play professionally, yet only a small percentage of the population makes it to professional sports.⁵⁶ In a 2004 review,⁵⁷ authors examined barriers to African American athletes' persistence in intercollegiate athletics and learned that, despite being academically capable, once the athletes' sport eligibility ended, some left the institution and did not earn their degree. Efforts to overcome these barriers have been put into place to improve opportunities in education and promote overall well-being.

In athletic health care, education cannot be ignored. For example, parental educational attainment influences children's involvement in sports. Parents reporting higher levels of education were more likely to have children who participated in sports year-round and specialized in 1 sport.⁵⁸

The negative effects of educational attainment on health may be observed when a student-athlete is put on academic probation because of poor grades. Perhaps the grades slipped because the student-athlete needed to support the family with a job or by caring for younger siblings while maintaining the commitment to the team. In that scenario, the student-athlete may feel increased pressure to do well in school or lose his or her role on the team. When home life, school, and sport interact, conflicts can take an immediate mental and physical toll on the student-athlete. The longer-term effect of poor grades in high school and the intersecting pressures of home life, school, and sport may limit collegiate options and job opportunities later in life.

An example of a positive effect of educational attainment is the student-athlete who graduates with honors and is awarded a scholarship for excellent performance in the classroom, which subsequently expands future education and job opportunities. Thus, whether a person achieves a high level of educational attainment may lead to long-term positive or negative health outcomes.

Employment

Employment, or lack thereof, is another social determinant strongly connected with others and influences one's health.²⁰ Whether related to housing, health care services, or education, employment can drive these other social determinants because it is often the primary source of income and health insurance for adults in the United States.²⁰ As strong as the association is between employment and health insurance, researchers⁵⁹ have also found strong associations between the type of insurance provided through employment and individuals' physical activity levels. Specifically, children with government or no insurance participate in less physical activity than children with private health insurance.⁵⁹

Employment affects health outcomes through use of workplace resources and opportunities (eg, health education or exercise classes, vending machines or cafeterias), psychosocial burdens, and the physical environment of the workspace.^20,60,61 In athletic health care, employment may contribute to health in a variety of ways. For example, an athlete working a job to support a family may need to do so after school hours and practice sessions, leaving less time for sleep, studying, and social activities. Less sleep and less time for studying and social activities can negatively influence academic performance⁶² and ultimately health and well-being. Parental employment is another consideration for minors. Parental employment may positively influence an athlete's ability to participate in sport, but it may also restrict participation if the family has barriers related to the costs of play,⁵⁸ access to health care through insurance, or work-related transportation challenges. Whether in reference to the athlete or parent, employment can weigh heavily on our patients, especially in terms of their ability to engage in sport and access health care services when needed.

Income and Wealth

Income primarily results from employment, and employment drives income inequalities.⁴² Income fluctuates throughout one's lifespan, but wealth accumulates over time and can be measured by the assets and debts that provide a snapshot of personal finances and economical resources.²⁰ Income and wealth affect health in many ways. Primarily, they are a safeguard for health care expenses and increase the ability to seek preventive health care and better housing and education, which are important for health.²⁰ Researchers^63–65 have indicated that those with higher incomes experience less illness and disease and live longer, healthier lives than those with lower incomes. Children of lower-income families are more susceptible to obesity, asthma, digestive and heart conditions, elevated blood lead levels, and hearing problems.^63,66,67

Generational wealth has been the impetus to access to health care in the United States. Wealth is the dominant source of disparities in the United States for people of color.⁶⁸ United States history has been rich with policies subverting constitutional rights, such as life, liberty, and the pursuit of happiness, for historically underrepresented groups. The most egregious of these policies were racially motivated and positioned people of color at the bottom of a wealth gap that has increased over the last 400 years, perpetuating second-class citizenship beyond slavery that kept Black and Brown people from the benefits of generational wealth.⁶⁸ Though many poor White people suffer from the economic divide, a more disparate relationship between access to health and poor health outcomes exists for populations of color.

In addition, income and wealth often dictate children's opportunities to participate in sports,^58,69 potentially depriving them of the health benefits and access to health care sports provide. In one study,⁷⁰ secondary schools in Wisconsin that did not employ an AT were more likely to be in counties with lower median household incomes and have students who were eligible for a free or reduced-cost lunch. Schools in California reported similar results, in addition to having almost 30% of athletes in secondary schools participating in sports at a school without an AT.⁷¹ These findings suggest a link between lower income areas and access to athletic health care. When treating patients, including minors, ATs should be aware of the effect of income and wealth on health. For example, if a high school freshman track athlete experiences respiratory distress but lacks a history of asthma on the preparticipation physical examination, the AT should consider that the health condition may be undiagnosed because the family cannot afford regular visits to a doctor. Athletic trainers working with athletes from low-income areas may benefit from the awareness that they may be one of the most frequent or the only health care provider(s) accessed by these athletes. Athletic trainers can guide patients to school-based or free community health centers and serve as advocates for these services if none exist.⁷² Continued efforts are necessary to proactively address the unmet health needs and services of this community.

Housing

As a social determinant, housing accounts for the availability, density, diversity, and segregation within a neighborhood and is the infrastructure in which one lives.^20,26 Health effects related to housing are compounded by other social determinants, such as income and the physical environment. Quality and safety, stability, affordability, and neighborhood are 4 pathways that describe the connection between housing and health,^73–75 and each affects the ability of residents to make healthy choices. Environmental factors in the home, such as exposure to lead, water leaks, or pests, are safety concerns and have been associated with the onset of asthma.^73,74,76 In 2017, 37.8 million families spent 30% or more of their income on housing, affecting the ability to purchase healthy foods, pay for prescription medication, and cover other essential expenses.^73,77 The US Department of Housing and Urban Development considers families who spend 30% of their income on housing to be cost burdened.^73,77 Conversely, those with more affordable housing may be able to use up to 77% of their income for education, health care costs, and food.⁷⁸ Investigators^79,80 have suggested that people with housing insecurity or those living in unstable housing environments may be less likely to seek preventive health care and more likely to access emergency services, delay the filling of prescriptions, and not adhere to treatment plans. As such, people in unstable living situations tend to have higher health care costs and poorer health outcomes.

Because the physical conditions of homes, the environment of neighborhoods, and affordability of housing affect health, ATs should think beyond patient-clinician interactions and consider the homes patients return to at the end of the day. A survey⁸¹ of more than 3000 student-athletes indicated that 14% of National Collegiate Athletic Association Division I athletes experienced homelessness, and this rate was even higher for student-athletes in Division II and at 2-year colleges. Even when ATs provide an optimal healing environment, if patients return to housing environments that do not promote health, optimal health outcomes may be unattainable. Given the reality of athlete homelessness, it may be helpful for ATs to be prepared with a list of local community resources for athletes in need.

Public Safety

Public safety, or the lack thereof, affects individual and community health. Exposure to violence, such as hate crimes, child abuse, homicides, or suicides, increases the risk of obesity, injury, poor mental health, and early death.^20,82–85 Children who live in unsafe communities and are witnesses to or victims of violence may be more likely to report poor health⁸⁶ and decreased academic achievement⁸⁷ than children in safer communities. Further, the stress of living in hazardous environments tends to decrease the physical activity of residents in that community and compromise mental health and well-being.^88–90 The safer the neighborhood in which one resides, the greater the likelihood people will be physically active and take advantage of parks and green space. Athletes who live in unsafe communities may suffer academically, live in fear, and lack positive role models.^87,90

Physical Environment

The physical environment represents the natural and built environments that people occupy. Housing; transportation systems; access to food and parks; climate change; and the air, water, and soil quality of the environment are examples of the physical environment.^20,42 The physical environment negatively influences health through pollution, lead exposure, unsafe transportation, or water contamination and may increase the risks for birth defects, cancer, and respiratory conditions.^91,92 Access to food sources, such as grocery stores, is important for making healthy decisions about diet. Consuming healthy foods consisting of whole grains, fruits, and vegetables and limiting sodium and sugar intake reduces illness and disease.⁹³ When healthy food options are limited, too expensive, or nonexistent, individual and population health declines.²⁰ For example, a school located in a community where small convenience stores outnumber larger grocery stores will have more unhealthy food options. Green space and parks are features of the physical environment associated with improved mental health, reduced mortality, and increased physical activity.^20,94–96 Ensuring that sports fields are safe for play is also crucial for injury prevention. In athletic health care, considering the physical environments in which athletes live and play is necessary to ensure that these spaces are safe and resources are available in order to prevent injury and illness.

Social Environment

The social environment includes aspects of an individual's social life, such as relationships, culture, neighborhood cohesion, and social norms, and is often measured in relation to mental health.²⁰ In 2006, McNeill et al⁹⁷ described the most common ways in which the social environment affects health and well-being. One avenue involves community social norms, which facilitate (eg, participation in physical activity) or prevent (eg, drug use) healthy habits forming.⁹⁷ Limitations in the physical environment, such as a lack of parks or green space, can restrict social interactions and networks in a community, eventually affecting health-related behaviors.²⁰ Another avenue is through social cohesion and social capital within the community.⁹⁷ Communities with more social capital and supportive neighbors positively affect health by reducing crime, increasing the sense of safety, and providing social support.⁹⁷ Along with social norms, the cultural environment also affects health. In athletic health care, sport teams tend to have their own culture. For instance, sports that uphold a certain body image, such as gymnastics, wrestling, track, and dance, were associated with higher incidences of anorexia and bulimia.^98–101 Further, ATs play a crucial role in providing social support to their patients. Clement et al¹⁰² studied injured athletes' perceptions of social support from peers, coaches, and ATs and found that social support from ATs had a significant effect on overall health and well-being. Therefore, building positive, supportive relationships with patients may help ATs promote health in their patients.

Relationships Among the Social Determinants

Collectively, the social determinants of health are conditions that affect patients and contribute to their immediate and long-term health outcomes. Although we have described the social determinants individually, they are often interrelated, increasing the complexity of their effects on health outcomes.^20,103 Further, structural inequalities related to race and poverty can compound the negative effects of social determinants of health. A first step is for ATs to acknowledge that social determinants may be contributing to their patients' outcomes and work to better understand the complexity of their interactions in order to provide culturally proficient support for each athlete.