INTRODUCTIONSocioeconomic factors are powerful determinants of health. Current discourse abounds with references to addressing social determinants of health to improve the health and well-being of people and populations. Certainly, from a worksite health promotion perspective, social determinants of health play an important part in the health, well-being, and functional status of employees. In fact, in early 2010, we wrote a column in ACSM’s Health & Fitness Journal® on exactly this topic (1). We considered a “causal chain” of determinants of premature deaths and highlighted how social determinants of health relate to health behaviors, biological markers, diagnosed disease, and premature death (see Figure 1). Biological markers included the early indicators (or signal events) for subsequent disease diagnoses, the topic of our earlier column on the 2018 Physical Activity Guidelines for Americans (2). This time, we consider the relationship between physical activity and the upstream social determinants of health themselves among members of the workforce.Figure 1: A causal chain of determinants of premature death and its agents. Reprinted with permission from Pronk and Kottke (1).Social Determinants of Health In the 1970s, British epidemiologist Sir Michael Marmot studied British civil servants and found that people in high-status jobs tended to be healthier than those in low-status jobs (3). Since then, awareness has been heightened regarding the notion that socioeconomic factors are powerful determinants of health. Furthermore, Marmot and colleagues (4) continued their research and uncovered a “Top 10” most important group of social determinants of health: low social status, relentless stress, social exclusion, work, unemployment, social support, addiction, food, and transport (see Table 1).TABLE 1: Top 10 Social Determinants of HealthSome of these Top 10 factors are more closely linked to the workplace than others. In addition, measurement of the social determinants is a complex endeavor. Clearly, the metrics need to be related to topics that reflect both an organizational (company) context as well as an individual (worker) context. As such, measurement strategies need to be of appropriate interest for both of these stakeholders while also actionable. In Table 2, we have outlined a set of 10 metrics that reflect social determinants of health (2,4,5). The metrics we have outlined include life satisfaction, happiness, happiness of friends and relatives, social support, financial management, savings, donation practices, job satisfaction, neighborhood safety, and volunteerism. Although these factors may not be fully or wholly representative of each of the Top 10 social determinants as outlined by Marmot and colleagues (4), they are considered to be directionally aligned.TABLE 2: Scoring of Social Determinants of Health MetricsPhysical Activity Physical activity benefits the health and well-being of individuals of all ages and has been associated with many health factors and reduced risk of illness. These include improvements in quality of life, sleep, bone health, physical and emotional function, blood pressure, cancer risk, dementia risk, weight loss and risk of weight regain, among others (1,6,7). It also affects outcomes of importance and related to the workplace setting, including work performance and family income. Furthermore, these benefits are applicable to virtually everyone, from men and women to younger children, older adults, pregnant women, people with chronic disease, people with disabilities, those who wish to prevent disease, employees, and many other categories, regardless of race or ethnicity (1,6,7). Is Physical Activity Linked to Social Determinants of Health? It may be that higher levels of physical activity behavior represent a surrogate measure for higher levels of individual attention to and engagement in taking care of oneself. It also may be true that lower levels of physical activity behavior are linked to more challenges related to socioeconomic barriers to health. Regardless, if a relationship exists, it may provide an opportunity to create innovative solutions that support employees in achieving higher levels of health and well-being that subsequently may be tested for their effectiveness. It may be that higher levels of physical activity behavior represent a surrogate measure for higher levels of individual attention to and engagement in taking care of oneself. It also may be true that lower levels of physical activity behavior are linked to more challenges related to socioeconomic barriers to health. A CASE STUDY We considered data from 7342 HealthPartners employees, including 1998 spouses, who completed a health assessment (HA). The HealthPartners “Be Well” program is offered to health plan members, covered spouses of health plan members, and nonmembers who are HealthPartners employees. All three categories of HA completers are included. Assessments were completed between 1/15/2018 and 12/31/2018 with an overall HA response rate of 72%. The level of physical activity in which respondents engaged was defined as the total number of reported minutes of physical activity in a week. This is a sum of reported moderate and vigorous minutes without any adjustment for vigorous activity, i.e., the amount of vigorous minutes is not doubled to total minutes as is the case when assessing physical activity risk. When we considered the criteria for determining physical activity risk as a function of meeting guidelines, we did account for vigorous physical activity levels by multiplying those minutes by 2 to determine overall activity levels. The absence of risk levels for the social determinants metrics used in this analysis was based on a 0 to 10 score (rating of 9 or 10) or according to two or more categories (see Table 2). Table 3 presents the general population demographics. On average, this population may be characterized as mostly female, middle-aged, white, and well-educated. Also included in the table is the percent not “at risk” for each of the 10 social determinants, as well as the average number of social determinants risk factors reported for the population studied. Figure 2 shows the number of participants assigned a category of risk between 0 and 10 corresponding with the number of reported social determinant risks. This graph is overlaid with the number of physical activity minutes for the participants in each category. Figure 2 visualizes the aggregated data.TABLE 3: Descriptive Characteristics of the Population (N = 7,342)Figure 2: Social determinants of health aggregate score and physical activity levels.Major differences in weekly minutes of physical activity were noted between those workers at risk for each social determinant and those not at risk. In Figure 3, these data are presented according to presence or absence of risk among the 10 social determinants and weekly activity levels. All “no risk” social determinants, except for the financial savings determinant, are associated with significantly higher levels of physical activity.Figure 3: Physical activity (minutes/week) by social determinants of health risks.The magnitude of the differences should be noted. There are major differences between physical activity levels within each single social determinant risk factor groups. However, the magnitude of physical activity difference among those who have or do not have the social determinant risk factor is relatively small, although statistically significant (except for financial savings). For example, the difference between life satisfaction risk and no risk is 7 minutes of physical activity per week among those who do not meet the PA guideline. For every 10-minute increment of physical activity, the likelihood of not having the life satisfaction risk is reduced by 0.6% (at a P < 0.000). This observation holds true for all social determinants studied. However, it also is important to note that we observed increasingly lower levels of physical activity with the accumulation of social determinant risk factors (or socioeconomic risk) (see Figure 2). This observation is consistent with the studies of Marmot mentioned earlier. Those who are exposed to more socioeconomic challenges tend to engage in less healthy behaviors, experience more biological risk factors (or “signal events”), and, as a result, more disease diagnoses and premature deaths (2,3). Indeed, employees in this population were experiencing more than one social determinant risk factor at the time of the HA. As noted in Table 2, employees reported, on average, 4.2 of the 10 social determinants. INSIGHTS AND CONCLUSIONS Physical activity appears to be related to various social determinants of health. However, at the level of each single, individual socioeconomic risk factor we looked at, the magnitude of the differences in physical activity levels alone may not persuade worksite health practitioners to prioritize programs aimed at improving social determinants. This case study does not provide clarity regarding the precise nature of the relationship between social determinants and physical activity. Pathways other than those represented by the factors considered in this case study should be considered. Physical activity appears to be related to various social determinants of health. However, at the level of each single, individual socioeconomic risk factor we looked at, the magnitude of the differences in physical activity levels alone may not persuade worksite health practitioners to prioritize programs aimed at improving social determinants. On the other hand, those who experience higher numbers of socioeconomic risks simultaneously may benefit greatly from additional support to overcome such challenges to be able to engage in healthy behaviors such as physical activity. At the practitioner level, knowledge of the cumulative effect of multiple socioeconomic risk factors on physical activity may help in working one-on-one with employees to help address social and economic barriers to living a healthier lifestyle. Employers too may want to think about the potential to engage the workforce in beneficial socioeconomic programs through company policy approaches to support employees in coping with social and economic challenges. For example, using opt-out strategies to increase engagement in a company-sponsored 401K program instead of relying on opt-in approaches will inevitably engage more workers and prepare them for retirement financially. Similarly, employers may consider promoting community programs aimed at increasing social support and decreasing loneliness. As a result, stress may be reduced over time and job satisfaction increased. Perhaps this may even lead to enjoyment of physically active breaks at the workplace and family bike rides on the weekends.
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