Framing Theoretically Informed Social Determinants of Health Research Questions

Background

Advances in medicine have revolutionized patient care over the past decades, with improved patient outcomes and life expectancy. This is particularly true for surgery where the advent of minimally invasive and robotic techniques along with enhanced recovery pathways has led to significant reductions in surgery-related morbidity and mortality across the spectrum of surgical conditions. ^, The primary focus of these advancements has been on optimizing surgical care and management of diseases to improve patient outcomes. However, accumulating literature now demonstrates that medical care alone in itself cannot adequately improve overall health or limit healthcare disparities. Instead, health is more directly influenced by a complex interplay of social, psychological, and structural factors rooted in environments and systems that fundamentally shape downstream health indicators and determinants. It emphasizes the compelling role of certain social and dynamic factors (other than traditional “medical care”) that directly influence patient outcomes and shape health across larger settings and populations. This is evidenced by widening mortality among social groups despite national health coverage programs permitting universal access to medical care suggesting prominent inequalities in health according to social class and economic status. Moreover, literature suggests that only 10%–15% of preventable mortality can be accredited to the medical management of diseases. Instead, health outcomes and health-related behaviors are more significantly shaped by certain social, economic, and behavioral factors including income, race, education, and occupational hierarchy. Now widely recognized as social determinants of health (SDH), these dynamic characteristics have increasingly gained popularity as individual to systemic-level factors directly interacting with (and contributing to) adverse health outcomes and disparities in care. These disparities have been shown to penetrate throughout the continuum of surgical care and range of health-related outcomes.

With the increasing understanding of the overwhelming influence of SDH in shaping health outcomes, the medical community has called into question the appropriateness and importance of traditional health indicators. This has resulted in a growing emphasis on measuring impact of interventions to improve health through outcomes of populations at large. The importance of addressing SDH has been widely recognized in public health policy and practice in its crucial role in promoting health equity and reducing health disparities as a means to improving overall population health. In the context of surgery, a growing emphasis is being placed to understand the complex relation of these factors with healthcare, health seeking behavior, attitudes, and practices. Literature on SDH is replete with the impact of social, economic, and psychosocial factors on accessing surgical care, operative outcomes, and adherence to postoperative care. It is now widely recognized that a considerable proportion of adverse surgical outcomes tends to cluster among individuals from underprivileged backgrounds, exhibiting interdependence between the two. Those who experience greater disadvantage from multiple SDH-related factors in multiple dimensions are more likely to experience poorer surgical outcomes including delayed access, low quality of care, more invasive operations, higher complications, and lower survival. However, much of the research in this area has focused on describing the relationship between SDH and surgical outcomes, rather than developing cost-effective interventions aimed at mitigating them. To address the latter, targeted interventions to optimize their success requires a multidisciplinary approach and should be grounded in evidence-based research. These can then be leveraged to identify prevalence and distribution of health disparities, populations at the highest risk of these disparities, and shape evidence guided interventions to limit them. As such, ongoing research in this area is crucial to developing effective interventions aimed at improving outcomes. However, such efforts require an extensive understanding of the complex interplay of social determinants on daily life to ensure relevance and applicability of the findings and interventions developed in real-world settings. Therefore, in this chapter, we explore theoretical frameworks governing the relationship between social determinants and health outcomes with the aim to create a conceptual basis for identifying theoretically informed and relevant research questions.

Theoretical Frameworks

Theoretical frameworks have been widely used and implemented in public health research. Their primary purpose is to serve as a means to group interrelated concepts to understand the relationship between constructs and form hypotheses to understand behaviors and outcomes related to the theory or concept being studied. Utility of such frameworks becomes imperative in exploratory work to understand abstract concepts, which are not very well understood. While conceptual models are more structured and explore a more specific topic, theoretical frameworks cast a wider net and explore broader ideas and theories. A significant advantage of theoretical over conceptual frameworks is their ability to allow public health experts to link related concepts to understand temporality and associations of a complex phenomenon. Since such phenomenon operate at various levels of systems and populations, these frameworks also allow the opportunity to understand associated factors at all levels, stages, and magnitudes of their effect.

Theoretical frameworks are not causal pathways. Instead, they serve as a conceptual lens through which the problem of interest can be viewed from multiple angles, each with the potential of forming a separate theory on its own. Each angle (theory) is then explored for its ability to explain a certain aspect of the complex, multifaceted problem, with each lens providing a different perspective. This allows all facets of the problem to be explored. Thereby, theories with a sound basis are then explored in the context of similar theories to understand their interaction with each other and combined association with outcomes. Theories found to be interrelated are then grouped into concepts, which are categorized based on their theme, structured and organized into models to understand temporal relations with the outcome. This results in the formation of theoretical frameworks, bringing together various abstract concepts related to an idea and organizing them into structured pathways, which can then be further explored to form hypothesis and propositions.

Theoretical frameworks also serve as guides for selection of appropriate research methodologies and techniques. Through laying a groundwork for selection of measures and outcome indicators most relevant to the theoretical constructs of interest, these frameworks ensure that the methods and data analysis techniques being used are consistent with the research questions being answered, facilitating real-world applicability of the research findings. Ultimately, theoretical frameworks serve as powerful tools that can aid in framing complex problems, understanding correlations, developing interventions, and guiding research to translate these hypotheses into evidence-based concepts.

Role of Theoretical Frameworks in Understanding Social Determinants of Health in Surgery

Social determinants impact surgical outcomes through complex causal pathways mediated by a multitude of dynamic factors. Broad and multifaceted, these factors range from individual (genetics, lifestyle, health behaviors) to systemic levels (including infrastructure, hospital quality, and policies regulating access) and affect the entire continuum of surgical trajectory—from access to surgical care, intra- and postoperative outcomes to rehabilitation. In the context of surgery, theoretical frameworks accomplish two major purposes. Firstly, they serve as powerful tools providing a unique conceptual lens through which the complex interplay between (and influence of) nonmedical factors on surgical outcomes can be viewed from multiple levels (from individual to systemic). For example, racial and ethnic minorities are known to have lower access to surgical care and hence, postoperative outcomes and recovery. While the larger association has been established between race and surgical outcomes, there are a multitude of intermediary factors that mediate this effect. A large proportion of Black and Latino populations reside in economically disadvantaged neighborhoods with poor access to both healthcare and education. Accumulating literature demonstrates that patients with low health literacy have difficulty understanding postoperative care instructions and poor follow-up retention, hence increasing their risk of complications and negative outcomes. Additionally, neighborhoods with high crime and suicide rates also impact the residents' psychological well-being, with the resulting mental stress directly influencing their disease course and recovery. Through providing a structured and systematic model to conceptualize these various determinants, theoretical frameworks can help cluster related factors into meaningful categories, allowing the study of interaction between these determinants and their influence on surgical outcomes.

Secondly, the temporal relationships defined in these frameworks can help identify critical junctures in the causal pathways that are crucial to achieving the desired health outcomes. When leveraged appropriately, these standpoints can be targeted to optimize effectiveness of such interventions and shape policies governing the determinants of health. Examining the temporal relationship from a broader perspective also allows public health experts to identify critical gaps in current health policies and interventions, providing windows of opportunities to refine and/or renew policies to improve health equity and outcomes. Continuing the aforementioned example, incorporating the social and economic disadvantage of racial and ethnic minorities into urban housing, income, and employment policy development can target the root cause of poor surgical outcomes in these populations. Thus, identifying key standpoints in causal pathways can also help maximize the success of such interventions, while simultaneously boosting their cost-effectiveness. However, developing such interventions to mitigate surgical disparities first requires a thorough understanding of the mechanisms that cause them. Hence, understanding SDH through evidence-based research rooted in conceptual grounds is crucial to improving surgical outcomes and reducing health disparities on a systemic level.

Research on Social Determinants of Health

Over the past three decades, there has been a growing realization that the dramatically rising health problems across the entire spectrum of healthcare conditions cannot be treated with medical care alone. Hence, awareness around social determinants and their overwhelming influence on surgical outcomes has led to various efforts grounded in evidence-based research to establish an understanding of their causal pathways, mechanisms of action, and interplay with health. Since most of the research has been exploratory, various theoretical frameworks (including the ones discussed above) have been employed by public health experts to gain a comprehensive understanding of this broad and complex topic, with a focus on social justice and health equity. In the following, we discuss types of research surrounding SDH across the globe.

Types of Research

Epidemiological research

Epidemiological research is focused around understanding the prevalence and distribution of health disparities across populations. In doing so, it helps identify populations at the highest risk of worsened outcomes from systemic inequalities. This area of research explores the patterns of diseases and their outcomes in different populations. Epidemiological research has been gaining traction across the globe for identifying health disparities across socioeconomic, racial, and ethnic groups. Focusing efforts on vulnerable populations through population-level interventions can allow effective and equitable distribution of resources. Another area of focus in epidemiological research is to identify risk factors among these populations that make them vulnerable to adverse health outcomes. Thereby, health differences observed between populations and reasons accounting for these differences can be studied, allowing opportunities for improvement both within and between populations across the globe. Over the years, a robust body of evidence has accumulated aimed at understanding the impact of various social determinants on specific health outcomes such as cardiovascular health, diabetes, trauma, etc. among individuals, citizens, and nations. Table 13.1 illustrates examples of epidemiologic studies exploring SDH and their relation to patterns of diseases, differences in behaviors, and outcomes.

Table 13.1

Epidemiological Studies on SDH

Name	Study Details	Outcome Measures	Findings
Shields et al.	National study to assess sociodemographic and behavioral factors influencing health.	Predictors of life expectancy, disability-free life expectancy, and the presence of fair or poor health among residents.	Percentage of minority population, unemployment rate, older populations, average income, and education were stronger predictors of health compared with behavioral factors such as smoking, obesity, infrequent exercise, and heavy drinking.
Paro et al.	National study of 853,449 medicare-insured patients on impact of social vulnerability on surgical outcomes.	Perioperative complications, 30-day readmission, mortality, and length of stay.	Despite insurance coverage, patients with higher social vulnerability had higher risk of complications, extended length of stay, readmission, and mortality rates from commonly performed surgeries.
Son et al.	National study of 3142 US counties.	Trends and disparities in cardiovascular disease (CVD) mortality.	Rural counties with higher proportion of Black residents had higher CVD mortality accounted for by differences in income, food, and housing.
Haider et al.	National study of 429,751 trauma patients on impact of race and insurance status.	Mortality from trauma.	African America, hispanic, and uninsured patients had the highest mortality from trauma.
Diaz et al.	National study of 299,583 patients from high social vulnerability US counties.	Postoperative outcomes.	Black and minority patients residing in high socially vulnerable counties had up to 68% higher odds of serious complications from surgery.
Dhillon et al.	Data analytical study to assess disparities and quantify disease burden in Southeast Asia Region (SEAR).	Trends of morbidity, mortality, risk factors, social determinants, research capacity, health education, workforce, and systems.	SEAR countries had the highest proportion of global mortality. Disparities within these countries and when compared globally were linked to inequalities in education, poverty, political conditions, and other social determinants.

Sociological research

An important field in studying SDH, this discipline explores the interplay of social and economic factors in influencing health outcomes. Understanding social and economic inequalities allows health advocates and public health experts to identify mechanisms, leading to inequalities between individuals and across population to address and mitigate health disparities. Research in these areas targets individualistic factors (such as poverty, education, and social support) along with broader, systemic constructs including structural racism, discriminatory behaviors toward population subsets, and societal segregations. The compounding effect of racial/ethnic identity and socioeconomic status has taken center stage in medicine over recent years, with wider and extensive implications across the spectrum of healthcare conditions. Literature is replete with evidence stressing on the inverse relation of both with health outcomes—where racial/ethnic minorities and individuals from underprivileged backgrounds face worsened health outcomes despite controlling for other important factors. Table 13.2 highlights a few examples of sociological research exploring the effect of social and economic factors on health outcomes. By understanding and linking these structural factors and social mechanisms through which social determinants affect health outcomes, this crucial area of research enables experts to develop policies and interventions targeting the root causes of health disparities while promoting health equity.

Table 13.2

Sociological Studies on SDH

Name	Study Details	Outcome Measures	Findings
Avendano et al.	Longitudinal study on the effect of wealth, income, and education on stroke.	Incidence and mortality from stroke.	Low wealth and income were important risk factors for socioeconomic and social disparities in stroke identifying inequalities in access for economically disadvantaged groups.
Dedman et al.	Cohort study of 4973 children on impact of childhood housing conditions on health outcomes.	Adult all-cause mortality.	Children with poorer household conditions reflecting low socioeconomic background had significantly increased risk of later adult mortality from common diseases.
Reyes et al.	Cohort study of 80,312 patients on racial and ethnic differences in access to surgical care.	Delayed diagnosis of appendicitis.	Non-hispanic Black patients had higher rates of delayed appendicitis diagnosis.
Kim et al.	National large database study on influence of socioeconomic factors on health outcomes.	Poor health and obesity.	Higher rates of poor health in low-income and education populations signifying a steep socioeconomic gradient.
de Jager et al.	National large database study on impact of income on emergency General surgery outcomes.	Incidence of adverse events in rural and urban populations.	Patients from low-income quartiles in urban areas had higher adverse events from disparities in access to high-quality care.
Lamm et al.	Cohort study of 96,990 patients on influence of socioeconomic status on gastric cancer outcomes.	Mortality and unplanned readmissions after gastric cancer surgery.	Patients with low income and low education had 57% and 48% higher mortality, respectively. Privately insured patients had lower mortality rates.

Health economics research

Disparities in healthcare result in higher costs of care and a preventable burden on already fragile healthcare structures. As interventions are being implemented and tested to reduce health disparities in the context of social determinants, there is a need to understand the cost-effectiveness of these interventions to estimate the social and economic benefits of reducing health disparities. Economic research explores the costs of health disparities and their effect of individuals, communities, populations, and healthcare systems. Another area of focus in economic research is to investigate the impact of healthcare interventions addressing social determinants such as healthcare programs for improving access, interventions to protect income, improving poverty, living conditions or educational interventions on improving individual to population health. However, the field is not solely limited to monetary benefits but also extends to the broader social and economic impact of such interventions. Examples include improved welfare, economic growth, and productivity. Another crucial arm of this disciple is policy implementation and assessing their success with the aim to inform strategies that are both effective and affordable. Such studies are crucial in shaping future policies and identifying priorities for further interventions to optimize their impact and utility. Table 13.3 describes some notable examples of economic research on SDH in surgery.

Table 13.3

Health-Economic Studies on SDH

Name	Study Details	Outcome Measures	Findings
Mohan et al.	Systematic review on SDH guided interventions on breast, cervical, and colorectal cancer screening.	Intervention cost, incremental cost per additional person screened, and/or quality-adjusted life-year (QALY).	Interventions were found to be cost-effective, resulted in increased screening rates, and were associated with earlier diagnosis resulting in improved outcomes and significant gains in QALYs.
Zafari et al.	Cost-effectiveness analysis of housing policy for low-income populations.	Long-term health and economic benefits.	Restricted housing vouchers resulted in lower overall cost, improved health, and increments on QALYs compared with traditional vouchers.
LaVeist et al.	Cost–benefit analysis of eliminating health disparities for minority populations.	Direct medical costs, indirect costs (number of lost workdays due to an illness or disability), and cost of premature deaths.	Reducing health disparities for minority populations would save $230 billion from direct medical costs and $1 trillion from indirect loss, illness, and premature death.
Chaudhary et al.	Data analytical study on incidence of racial disparities in universally insured patients.	Outcomes and healthcare utilization after trauma.	Universal insurance and equal access to care resulted in mitigation of disparities in outcomes of Black patients with overall lower odds of mortality and readmissions.
McGowan et al.	Umbrella review on the effectiveness of place-based interventions in improving public health.	Health behaviors, personal and community well-being, living conditions, and access to resources.	Interventions aimed at improving physical environments had positive impact on health outcomes and were cost-effective. Patients living in proximity to the interventions had greater improvements than those living at a distance.
Brilliant et al.	Field trial to assess the effectiveness of health education and economic incentive interventions on cataract surgery acceptance in rural India.	Awareness and acceptance of cataract surgery.	Interventions covering total cost of surgery and house to house visits had the highest acceptance rates.

Knowledge Gaps in Current Literature and Priorities for Further Research

Despite ongoing efforts to understand the wider implications, impact, and applicability of SDH in influencing health outcomes, several challenges and knowledge gaps continue to exist in the field. While causal pathways and upstream fundamental factors have been extensively identified along with potential interventions to address them, these concepts have yet to proportionally penetrate governmental policies and national surgical care planning. This can largely be attributed to the continuous individualistic approach of public health endeavors rather than shifting toward a structural approach to incorporate broader implications of such determinants on surgical outcomes. While health disparities research is now more widely recognized than ever in the surgical community, understanding of the source and perpetrators of these inequalities, along with factors enabling, sustaining, or removing them, remains limited. These issues can partly be traced back to the complex, dynamic, and interconnected nature of health determinants. Because these factors can take several decades or even generations to effect health and generate measurable outcomes, assessing their effects or designing interventions to address them necessitates longitudinal studies backed by vast financial and material resources, which are difficult to sustain. Additionally, these pathways pan out over long periods of time, and doing so becomes vulnerable to effect modification by various individualistic and environmental characteristics along causal pathways, adding to their complexity. This is further limited by lack of social, psychological, and other important nonmedical variables in large publicly available databases, making study of longitudinal relationships, patterns of disease, and outcomes difficult. Public health research is also often victim to political barriers in translating knowledge into outcomes, making implementation of designed interventions cumbersome. When compounded by the inverse graded relationship between socioeconomic status and health of both individuals and populations at large, implementing and assessing the effectiveness of such interventions in low resource setting becomes considerably difficult. Some aspects of these determinants also remain unexplored. As an example, while the effect of health determinants on illnesses and disease course has become apparent, their effect on recovery and rehabilitation remains limited.

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