Social Determinants of Health: Grand Challenges in Social Work’s Future

Addressing social determinants of health (SDOH) has a long history in social work, which from its inception has recognized the interplay between social context and the welfare of individuals, groups, communities, and the larger society. The profession has been, and will continue to be, well aligned with an SDOH perspective; this was addressed in a Viewpoint piece in this very journal in 2010 wherein social work was characterized as “a good fit” with this framework (Moniz, 2010). However, it is less clear as to what the future holds for countless well-established social work roles as well as those that are newly emerging as attention to collaborative SDOH initiatives expand and related partnerships, policies, and programs develop. Clearly, social workers will continue to “enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty” (National Association of Social Workers [NASW], 2015, p. 1). However, the manner in which social workers practice and the basis of their efforts will likely be increasingly interdisciplinary in nature and more closely and formally associated with an SDOH perspective in the near future.

As per the World Health Organization (WHO), SDOH are defined as “the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels” (WHO, n.d.). Furthermore, these conditions and circumstances heavily influence a variety of health risks and outcomes (Centers for Disease Control and Prevention, 2015), showing that consequences are inequitable and quite disparate. From this description, it is clear that understanding SDOH involves multifaceted exchanges between social and economic factors, the physical environment, and behavior. Consequently, one can look to the mission of social work with its focus on social and environmental contexts that affect well-being on all levels (NASW, 2015) and clearly recognize connections to a person-in-environment practice orientation and the biopsychosocial assessment model. Additional substantiation for upholding and expanding the integration of an SDOH perspective within the discipline is evident in the manner in which social conditions and the “distribution of money, power, and resources” (WHO, n.d.) is framed. Herein, language around inequity, disparity, and advocacy aimed at oppressed, vulnerable, and disenfranchised populations prominently frames SDOH as a social justice issue (Healthy People 2020, 2016). It is therefore important for our profession to focus change efforts on macro practice levels. By numbers alone, it is clear that social workers are well represented within the health professions; nationally, they provide the majority of mental health services, while medical settings are ranked as the third most common among practice areas (NASW, 2009). Therefore, it is incumbent on the profession to adapt and evolve within current practice arenas while actively seeking new spheres of proficiency in the future landscape of policies, initiatives, programs, and interventions that are built on an SDOH perspective.

Increased attention to SDOH across health professions has been seen within academic literature, demonstration projects, the development and application of evidence-based practices, and among various initiatives in the public and private sectors for quite some time (Braveman & Gottlieb, 2014). Moreover, an understanding of the cost-effectiveness of primordial prevention efforts that focus change where and when risk factors first develop is becoming more widely accepted (Braveman & Gottlieb, 2014). Perhaps the most influential reason for increased attention to SDOH is the Patient Protection and Affordable Care Act (ACA) of 2010 (P.L. 111-148). Though this reform legislation seeks to improve the quality, accessibility, and affordability of health insurance while reducing health care costs, it has also ushered in a new vernacular that supports an SDOH framework. For instance, the term “essential health benefits” is described as a collection of service categories required within health insurance plans; what is distinct about these classifications is that the ACA not only includes substance use, mental, behavioral, and rehabilitative care, but also clearly identifies preventive and wellness services. Prevention and wellness strategies herein are supported on two levels: through individual responsibility for one’s behavior fostered by public awareness and education that promotes good choices and through community-level efforts funded by grants to local organizations (Leong & Roberts, 2013). Specifically, Subtitle C of the ACA provides grant funding to the state Departments of Health and Human Services and local organizations to provide large-scale interventions that promote well-being in localities that are characterized as having “racial and ethnic disparities, including social, economic, and geographic determinants of health.” The use of SDOH language in the ACA not only demonstrates a national commitment to this perspective, but also informs the profession of social work about potential roles within this framework. Accompanying this paradigm shift is the opportunity for the development of innovative methods for delivering services, which was also expanded upon in this legislation. For instance, telehealth, or the electronic delivery of medical, behavioral, and educational wellness services (American Telemedicine Association, n.d.), is specifically referred to in the ACA in relation to care coordination, remote monitoring, collaborative community efforts, and in the development of new models for best practice. Forecasting potential innovative social work practice areas and reflecting an SDOH perspective, non–medical service provider utilization of telehealth methods for treating behavioral health problems in underserved areas is explicitly recommended (ACA, 2010). This particular example illustrates one of many ways in which social work practice may need to change and evolve in the near future; in this context, the profession must appreciate the current and growing market, interest and investment in novel approaches, and client outcomes to successfully adapt. To illustrate, it is predicted that the mobile health application market, or mHealth, is projected to grow 33 percent, reaching 59 billion dollars by 2020 (Maheu, 2016). Currently, thousands of mobile applications specifically designed for managing mental and behavioral health problems are available for download at your app store. Furthermore, many of these applications charge a monthly fee that covers electronic interaction with health professionals (East & Havard, 2015; Maheu, 2016); however, it is unclear whether social workers are prepared to fulfill these roles. This one case in point is among many anticipated changes indicating that it is imperative for social workers to be well represented among professionals of varying fields as we look to the future. The ever-changing landscape of health professional designations, specialties, certifications, and the like has the potential to subsume areas of practice traditionally fulfilled by social workers if we are not prepared to meet the challenge (Maheu, 2016). At the same time, an SDOH perspective seeks to address chronic social and environmental contributors to health from a collaborative and holistic approach; taken together, the potential for competition among professionals and the expectation of cooperative efforts lead one to consider how social work can best position itself as a leader within emerging approaches and shifting areas of practice.

The Social Work Grand Challenges introduced by the American Academy of Social Work and Social Welfare (AASWSW) in January of 2015 not only draw attention to the profession’s connections to the SDOH perspective, but also provide a roadmap outlining prospective practice areas and settings in which to apply discipline-specific expertise. NASW (2009) has provided some direction about preparing for the future of the profession, but the introduction of the Social Work Grand Challenges furthers this path by plotting a distinct course of action with clarity of purpose. These high-level aims are described as “ambitious yet achievable goals for society that mobilize the profession, capture the public’s imagination, and require innovation and breakthroughs in science and practice” (Kalil, 2012). These 12 challenges are indeed grand, yet the manner in which the AASWSW presents them, accompanied by supporting research, working papers, and ancillary materials, provides a clear and usable framework for the profession to “champion social progress powered by science” (AASWSW, n.d.). This initiative is a call to action for all in the discipline to make and use connections between scholarship, knowledge, and practice expertise by fostering collaboration across levels and disciplines to address our most persistent and impactful social problems.

The Social Work Grand Challenges reflect well-defined large-scale goals that, although separate, connote connections in their social impact and the reciprocal manner in which they are depicted. The content of these challenges indicates an SDOH perspective suggesting that all forms of health and well-being are social in nature, not only in their etiology, but also by virtue of how they are disparately managed. This broad, holistic, collective, and interdependent understanding of health, well-being, and social problems is evident across these 12 challenges. At the same time, each of these aims is forward-looking, suggesting innovation and progressive thinking to prepare for the future. For instance, among the challenges is “harness technology for social good,” which brings to mind the telehealth example. The description of this particular call to action tackles professional applications of digital technology targeted at social problems with the aim of having a larger influence among a greater number of individuals. Some advantages outlined by using innovative applications are cost-effectiveness, the provision of a greater breadth of services, easy access, and rapid program development. Referring directly to mHealth, a related working paper notes that “technology integration can create practice that includes flexible, on-demand, personal, and individually paced services” (Berzin, Singer, & Chan, 2015, p. 1). The discipline must prepare by developing commensurate proficiency as technology will continue to produce social work practice innovations. Unmistakably, the Social Work Grand Challenges are future oriented and innovative while building on historical accomplishments of the profession and evidence-based knowledge. The combination of these attributes yields a model for practitioners to discern what may be needed for social work to position itself as a leader within emerging approaches and shifting areas of practice.