Social determinants of health in multiple sclerosis

Abstract

Social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are the non-medical factors that influence health outcomes. Evidence indicates that health behaviours, comorbidities and disease-modifying therapies all contribute to multiple sclerosis (MS) outcomes; however, our knowledge of the effects of social determinants - that is, the 'risks of risks' - on health has not yet changed our approach to MS. Assessing and addressing social determinants of health could fundamentally improve health and health care in MS; this approach has already been successful in improving outcomes in other chronic diseases. In this narrative Review, we identify and discuss the body of evidence supporting an effect of many social determinants of health, including racial background, employment and social support, on MS outcomes. It must be noted that many of the published studies were subject to bias, and screening tools and/or practical interventions that address these social determinants are, for the most part, lacking. The existing work does not fully explore the potential bidirectional and complex relationships between social determinants of health and MS, and the interpretation of findings is complicated by the interactions and intersections among many of the identified determinants. On the basis of the reviewed literature, we consider that, if effective interventions targeting social determinants of health were available, they could have substantial effects on MS outcomes. Therefore, funding for and focused design of studies to evaluate and address social determinants of health are urgently needed.

Fig. 1. WHO social determinants of health.

Social determinants of health are the conditions in which people are born, grow, live, work and age. They are non-medical factors that influence health outcomes through a wide-reaching influence on all aspects of life. Social determinants of health can be divided into two categories: individual factors and structural determinants. Individual factors (for example, gender, race and ethnicity) have an effect via societal inequalities and structural determinants (such as health-care access and social support), which in turn affect health through their influence on the individual.

Fig. 2. Potential interactions between selected social determinants of health and multiple sclerosis outcomes.

Many social determinants of health interact and intersect with each other, leading to poorer outcomes, in either an additive or even a multiplicative manner. There are potential further interactions between living with chronic multiple sclerosis symptoms such as cognitive impairment and bladder or bowel impairment, and social determinants of health. Multiple sclerosis and its symptoms might reduce an individual’s social determinants of health, particularly those related to employment and social isolation, which might then amplify the effect of multiple sclerosis. Studying this vicious cycle is complex owing to the multiple and varying influences that exist at both the individual and group level.