Voting Is One of The Social Determinants Of Health

Voting is increasingly recognized as a social determinant of health (SDOH) by the medical community. Voting has also become a public health issue [Ref 1]. There is a connection between voting and health. This connection between voting and health works both ways: health influences the ability to vote, but surprisingly, voting also influences health. As such, physicians need to get involved in voting advocacy.

What are Social Determinants of Health (SDOH)?

SDOH are social needs and environments that contribute to health. Healthy People 2030 describes it as “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks”. [Ref 2]. Many significant healthcare outcomes are determined by these non-medical factors such as: income, access to healthy food, transportation, affordable and safe housing etc.

SDOH can be grouped in 5 domains that influence health [Ref 2]:

1. Economic Stability, including:
   1. Income
   1. Job stability
2. Education Access and Quality
3. Health Care Access and Quality
   1. Access to healthy food
      1. E.G. poor access to healthy food can lead to diabetes.
   1. Access to clean water
   1. Access to health care
4. Neighborhood and Built Environment:
   1. Safe housing
      1. For example: poor housing can lead to respiratory problems.
   1. Access to transportation
5. Social and Community Context
   1. Social connections
   1. Discrimination
   1. Violence

According to World Health Organization (WHO), SDOH may account for 30% to 50% of health outcomes [Ref 3]. As such, social determinants of health have a major impact on people’s health and physical and mental well-being. Overall, SDOH play a huge role in shaping a person’s health trajectory.

In 2022, the American Medical Association passed a resolution declaring voting a social determinant of health [Ref 4, 5, 6].

What is the connection between the health and voting?

Recent research shows a consistent association between voting and health [Ref 7]. People who vote tend to report better health than those who do not vote. Voters show better future mental and physical health than nonvoters, even after adjustment for a range of other factors including age [Ref 8].

Voting can influence health policies, fosters community empowerment, improves civic engagement and social capital.

1. HEALTH POLICIES:
   1. Elected officials make decisions about policies and budgets that directly affect health.
      1. Local Officials like Governors have broad powers over state expenditure including healthcare, Medicaid coverage, prescription drug policies, efforts to fight chronic and infectious diseases and mental health [Ref 9].
   1. Voting allows individuals to influence who makes these decisions and prioritize issues like healthcare access, education, and environmental quality, all of which impact health outcomes.
      1. Here was the ranking of top issue in In 2020 U.S. Presidential Election [Ref 10]:
         1. Economy and jobs ranked first (38% of voters)National security and terrorism ranked second (28% of voters)
         1. Health care ranked third (11%), followed by immigration (7%)
2. COMMUNITY EMPOWERMENT
   1. Voting can empower communities to advocate for their needs and hold elected officials accountable for addressing health disparities.
3. CIVIC ENGAGEMENT and SOCIAL CAPITAL:
   1. The act of voting and participating in the democratic process can foster a sense of civic engagement and social connection within communities.
   1. Strong social capital is associated with better health outcomes.

Studies have shown that voting and health outcomes are connected on several different levels:

1. VOTER TURNOUT:
   1. Higher voter turnout is correlated with better health outcomes in the communities (such as lower infant mortality rates) and improved access to healthcare.
   1. Lower voter participation is often linked to marginalized/socioeconomically disadvantaged communities and patients with chronic diseases.
2. ACCESS TO VOTING:
   1. Decreased access to voting leads to worse health outcomes.Patients with chronic diseases have decreased access to voting.
   1. Marginalized communities have decreased access to voting too.

Connection between voting and health is clear:

1. Cycle of poor health, leads to
2. Decreased access to voting, resulting in
3. Worse health outcomes.
4. That in turn decreases political capital and leads to health policies that de-prioritize the needs of subset of patients who are sick or marginalized.

By addressing SDOH, we can create a more equitable and healthier society. This requires collaboration between public health, government sectors like education and housing, and community organizations.

One way to improve access to voting to marginalized communities as well as patients who have no access or limited access to voting is to increase access to voting in health care spaces.

There are efforts in healthcare systems to increase voter registration and education in clinical environments.

There are efforts under way to increase to integrate voter registration and education into processes of healthcare delivery [Ref 11].

When we empower patients to vote, they engage in the process that ultimately has effect on health policies and outcomes. Here are some of the organizations involved in these efforts:

Vot-ER [Ref 12]: works on integrating civic engagement into healthcare system. That includes increasing voter registration and participation among patients, especially those who might face barriers to voting.

Civic Health Alliance [Ref 13] is a coalition of health and civic leaders working to improve America’s health through civic engagement in healthcare settings and communities. They curate resources, build partnerships, and raise awareness about the connection between civic engagement and health.

Patient Voting [Ref 14] is a program of Vot-ER that aims to “increase voter turnaround among registered voters who are unexpectedly hospitalized in the days and weeks prior to elections”.

Healthy Democracy Healthy People [Ref 15]is a nonpartisan coalition that works to strengthen civic engagement and public health. Some of these efforts include advocating for policies that make voting more accessible (like same-day registration and mail-in voting options). They also encourage civic participation (for example: attending public meetings, contacting elected officials, and volunteering).

Indelible Learning aims to increase education about electoral process and decrease cognitive bias in how we really elect U.S. President.  I am Principal Investigator on a project funded by U.S. Department of Education, Institute of Education Sciences to create Election Lab Games. The main goal of this project is to enhance overall Electoral College education.

Election Lab is a collection of authentic games that combine actual history with data science. These games place voters in the role of a campaign strategist. Moreover, with multidisciplinary approach (i.e. combining Math + Statistics + Civics) these Election Lab games increase data literacy [Ref 16]. Election Lab Games beautifully elucidate a complex process of winning the highest office in the United States. Through immersive hands-on experience these games turn U.S. Presidential Elections into fun, engaging, motivating and easier to understand process.

After playing 2016 Election Game, one Superintendent exclaimed: “This Game is INSANELY BRILLIANT! It takes a highly charged emotional issues, and it takes the emotion right out of it. Great visuals! Easy to understand. Beautiful!”

And who does not want to replace highly charged emotions with increased critical thinking, acceptance, negotiation, and tolerance?

It is only with multi-prong approach of increasing civic education and voting participation that we can make a dent in increasing engagement of voters in electoral process.

Through building innovative educational technology (i.e. Election Lab video games) we aim to increase critical thinking and data literacy. We also aim to increase voting engagement in particularly: youth voting. We believe that voting is a habit. The more educated population is about voting, the more durable voting habit they will develop as adults.

At the end of the day, all these skills: increased critical thinking, decreased cognitive bias, increased data literacy, increased civics participation and increased voting habit, will ultimately result in improved health, improved health outcomes and improved overall quality of life.

REFERENCES:

1. Advancing Health Equity through Protecting and Promoting Access to Voting. APHA (American Public Health Association). https://www.apha.org/Policies-and-Advocacy/Public-Health-Policy-Statements/Policy-Database/2023/01/18/Access-to-Voting Accessed May 27th, 2024. 
2. Healthy People 2030: Social Determinants of Health.  https://health.gov/healthypeople/priority-areas/social-determinants-health Accessed May 27th, 2024. 
3. World Health Organization. Social determinants of health. Available at: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1. Accessed May 27th, 2024.
4. AMA Acknowledges Voting Is a Social Determinant of Health — Gerrymandering has disenfranchised already vulnerable communities, delegates argue. https://www.medpagetoday.com/meetingcoverage/ama/99223 Last accessed May 27th, 2024. 
5. Support for Safe and Equitable Access to Voting H-440.805. AMA Public Health Policy https://policysearch.ama-assn.org/policyfinder/detail/voting%20as%20social%20determinant%20of%20health?uri=%2FAMADoc%2FHOD.xml-h-440.805.xml Last accessed May 27th, 2024. 
6. Health Plan Initiatives Addressing Social Determinants of Health H-165.822 https://policysearch.ama-assn.org/policyfinder/detail/social%20determinants%20of%20health?uri=%2FAMADoc%2FHOD.xml-H-165.822.xml Last accessed May 27th, 2024. 
7. Nelson C, Sloan J, Chandra A. Examining Civic Engagement Links to Health Findings from the Literature and Implications for a Culture of Health. Santa Monica, CA: RAND Corporation; 2019. https://www.rand.org/pubs/research_reports/RR3163.html
8. Ballard PJ, Hoyt LT, Pachucki MC. Impacts of adolescent and young adult civic engagement on health and socioeconomic status in adulthood. Child Dev. 2018;90(4):1138–1154. https://srcd.onlinelibrary.wiley.com/doi/10.1111/cdev.12998
9. Local Officials Often Make Health Care Decisions with Little Input from Citizens. Milken Institute School of Public Health https://onlinepublichealth.gwu.edu/resources/local-politics-and-healthcare/ Last accessed May 27^th 2024
10. Robert J. Blendon, John M. Benson Implications of the 2020 Election for U.S. Health Policy NEJM 2020/10/28 doi: 10.1056/NEJMsr2031592 https://www.nejm.org/doi/pdf/10.1056/NEJMsr2031592
11. Anisha Ganguly, Danielle Morelli, Kavita P. Bhavan. Voting As a Social Determinant of Health: Leveraging Health Systems to Increase Access to Voting: https://catalyst.nejm.org/doi/abs/10.1056/CAT.22.0368
12. Vot-ER Home – Vot-ER Last accessed May 27^th 2024
13. Civic Health Alliance https://www.civichealthalliance.org/ Last accessed May 27^th 2024
14. Patient Voting https://www.patientvoting.com/ Last accessed May 27^th 2024
15. Healthy Democracy Healthy People https://www.healthydemocracyhealthypeople.org/  Last accessed May 27^th 2024.
16. Election Lab: A Computer Board Game Where STEM Meets Civics by Stuart Criley and Jasminka Criley. Published in 2019 Connected Learning Summit Proceedings Pg 22-30.

Jasminka Criley, MD

Jasminka Vukanovic-Criley MD, FACP, FHM is a multiple award-winning physician, from cancer researcher, internal medicine physician, and Medical School Associate Clinical Professor to entrepreneur. She has mentored many undergraduate, graduate, and postgraduate students and faculty. She is the Principal Investigator on studies from the National Institutes of Health and the U.S. Department of Education creating research-driven #edtech games and digital media to improve health, civics, science education, and healthy habits. Dr Criley is also a founding Board member of Physician’s Weekly. She can be reached on X at @criley_md and at www.linkedin.com/in/jasminka-criley-md