# data[].attributes.body
Case study summary:

Ana, a second-year internal medicine resident recently elected as chief resident, has been feeling burned out for months. Her mood is low, energy depleted, and she struggles with her demanding ICU rotation, where she's on call every third night. Her stress is compounded by her mother's recent breast cancer diagnosis, and Ana feels overwhelmed and unable to focus on work.

Her performance has declined, leading to mistakes in patient care, and she worries her symptoms resemble the depression she experienced as a teenager. Afraid of being seen as weak, Ana feels trapped, unable to take time off, and isolated in her struggles.

# data[].attributes.body
-Low energy

-Difficulty waking up

-Sleep deprived

-Feeling overwhelmed

-Feeling hopeless

-Difficulty focusing

-Decreased performance

-Lack of motivation

-Isolation

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Social Determinants of Health (SDOH) in Ana’s Case

# data[].attributes.subject
Social Determinants of Health (SDOH) in Ana’s Case

# data[].attributes.body
Work Environment and Demanding Schedule: Ana is working an intense ICU rotation with shifts every third night, which impacts her sleep, physical stamina, and mental focus.

# data[].attributes.body
Family Support and Geographic Distance: Her mother’s recent breast cancer diagnosis introduces stress, compounded by the distance, which limits Ana's ability to be physically present.

# data[].attributes.body
Economic Stability and Access to Mental Health Resources: The lack of vacation time and her previous history of depression make it challenging for her to seek mental health treatment or take time off to recover without impacting her career progression.

# data[].attributes.body
Ana’s mother was diagnosed with cancer.

Ana’s is stressed and worried she is not able to be with her mother.

# data[].attributes.body
Professional Pressure and Social Stigma: There is a strong culture of endurance and resilience in Ana’s residency program, where expressing struggle may be viewed as a weakness.

# data[].attributes.body
These SDOH factors play a significant role in Ana’s health, impacting her mental well-being and leading to burnout and emotional fatigue. The demanding work environment restricts her access to sleep and recovery, while family illness and geographical separation create additional emotional burdens. Social stigma within her profession discourages her from seeking help, potentially exacerbating her symptoms of burnout and depression. The cumulative effects of these factors highlight how Ana’s socio-professional conditions impede her ability to prioritize mental health and recovery.

# data[].attributes.attachment_link.readable_text
. Author manuscript; available in PMC: 2024 Jan 9.

Abstract

Introduction:

This research evaluated existing health equity frameworks as they relate to social determinants of health (SDOHs) and individual factors that may impact injury outcomes and identify gaps in coverage using the Healthy People (HP) 2030 key domains.

Methods:

The study used a list of health equity frameworks sourced from previous literature. SDOHs and individual factors from each framework were identified and categorized into the Healthy People 2030 domains. Five injury topic areas were used as examples for how SDOHs and individual factors can be compared to injury topic-specific health disparities to identify health equity frameworks to apply to injury research.

Results:

The study identified 59 SDOHs and individual factors from the list of 33 health equity frameworks. The number of SDOHs and individual factors identified varied by Healthy People 2030 domain: Neighborhood and Built Environment contained 16 (27.1%) SDOHs and individual actors, Social and Community Context contained 22 (37.3%), Economic Stability contained 10 (16.9%), Healthcare Access and Quality contained 10 (16.9%), and Education Access and Quality contained one (1.7%). Twenty-three (39.0%) SDOHs/individual factors related to traumatic brain injury, thirteen (22.0%) related to motor vehicle crashes and suicide, 11 (18.6%) related to drowning and older adult falls. Eight frameworks (24.2%) covered all HP 2030 key domains and may be applicable to injury topics.

Conclusions:

Incorporating health equity into research is critical. Health equity frameworks can provide a way to systematically incorporate health equity into research. The findings from this study may be useful to health equity research by providing a resource to injury and other public health fields.

Practical Applications:

Health equity frameworks are a practical tool to guide injury research, translation, evaluation, and program implementation. The findings from this study can be used to guide the application of health equity frameworks in injury research for specific topic areas.

Keywords: Injury, Framework, Health equity, Social determinants of health, Healthy People 2030

1. Introduction

The prevention of injuries, both intentional and unintentional, is a significant public health challenge. In 2021, unintentional injury, suicide, and homicide were the first, second, and fourth leading causes of death, respectively, among all decedents aged 1-44 ( CDC NCIPC, 2021). The burden of intentional and unintentional injuries varies across the lifespan and recent publications have illustrated the disproportionate distribution of injuries among people from racial and ethnic minority groups, and by geography, urbanicity, and other social determinants of health (SDOHs) such as economic stability and health care access, and individual factors such as age ( Kegler et al., 2022; Miller et al., 2021; Moreland et al., 2022; Shaw et al., 2022; Stone et al., 2022; Wulz et al., 2022). SDOHs are defined as "the 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"( Department of Health and Human Services, 2022). SDOHs are factors that impact health equity, which is defined by the Centers for Disease Control and Prevention (CDC) as the fair and just opportunity for all persons to attain their highest level of health ( CDC NCCDPHP, 2022). SDOHs along with individual factors, or a person's behaviors or individual characteristics (e.g., biology, age), ( WHO, 2017) can impact health inequities ( Pirkis et al., 2023; CDC OMHHE, 2022) and may affect outcomes differently in various injury topic areas-for example, suicide, traumatic brain injury (TBI), older adult falls, drowning, and motor vehicle crashes. These individual factors and SDOHs can influence health outcomes. For example, although race/ethnicity is not considered an SDOH according to the HHS definition, the way society uses race or ethnicity in systems, policies, actions, and attitudes can influence health outcomes.

Achieving health equity across populations requires making the connection between identified health disparities and their root causes. Underlying these health disparities may be inequities in economic, social, or environmental factors that serve as barriers or opportunities for people to achieve their highest level of health ( CDC OMHHE, 2022). Addressing these underlying inequities may help inform the public health field regarding resource allocation, particularly for culturally sensitive, tailored interventions, and advancing health equity. Health equity frameworks may inform metrics for measuring changes in the key determinants of and barriers to achieving better health. These metrics may provide measures for the reductions in health disparities between populations to help gauge progress towards health equity ( Braveman et al., 2017).

The use of health equity frameworks in disparities-focused research may be one potential avenue for assessing how disease, injury, and violence prevent some populations from achieving optimal health. Healthy People 2030 (HP 2030) framework uses data-driven objectives to measure health equity progress on a national level by addressing the upstream factors that impact health disparities ( Department of Health and Human Services, 2022). The HP 2030 framework consists of measurable objectives grouped into five key domains which emphasize the importance of addressing upstream factors to improve health and eliminate health disparities. The five key domains include:

Economic Stability (e.g., affordable housing and homes)

Education Access and Quality (e.g., education among people with disabilities)

Health Care Access and Quality (e.g., availability of health insurance)

Neighborhood and Built Environment (e.g., transportation safety), and

Social and Community Context (e.g., positive relationships at home) ( Department of Health and Human Services, 2022).

The SDOHs and individual factors that apply to the five key domains of the HP 2030 framework may have differing levels of relevancy depending on the injury topic area. Reporting health disparities between groups is common in injury literature and is an essential part of surveilling and monitoring injury within populations. A recent literature review of injury-related meta-analyses and systematic reviews highlighted a variety of health equity frameworks and indices that have been used in research to measure and characterize health equity within populations ( Lennon et al., 2022). However, only three of the meta-analyses and reviews identified in the literature search applied health equity frameworks to injury topics. While some of these tools for measuring health equity may not be universally applicable to all injury topic areas, relatively few studies to date have explored the utility of well-referenced health equity frameworks for injury research ( Lennon et al., 2022).

Health equity frameworks have been used in the literature to conceptualize health equity. There remain areas of opportunity for exploring the applicability of health equity frameworks to injury topic areas to aid in conceptualizing health equity in injury and understand what factors may be most at play in causing inequities in injury outcomes. Conceptualizing health equity in a framework can help researchers understand relationships between different SDOHs and individual factors and help instill a health equity lens during research, translation, evaluation, and program implementation. Health equity frameworks are also a practical tool that can be used to translate research into public health action by informing the development of equitable interventions that address the complex, interrelated factors that influence health equity ( Peterson et al., 2021; Woodward et al., 2021). The CDC National Center for Injury Prevention and Control (NCIPC) commonly utilizes the Social-Ecological Model-which is a four-level model to understand the interplay of risk and protective factors between the individual, relationship, community, and societal levels-to conceptualize SDOHs and health equity ( CDC NCIPC, 2022a). Other recent research has created a blended injury equity framework using the Social-Ecological Model, Three Levels of Racism, and the Haddon matrix ( Kendi & Macy, 2023). The purpose of this research is to evaluate existing health equity frameworks as they relate to SDOHs and individual factors that may impact injury outcomes, to characterize frameworks that may be considered to apply to injury topic areas, and to identify gaps in coverage of frameworks by using the HP 2030 key domains.

2. Methods

For the purposes of this research, a health equity guiding framework was defined as a theoretical construct that assesses key domains and concepts associated with health equity. This study assessed 33 health equity frameworks from a previous literature review ( Table 1) ( Lennon et al., 2022). Additional information regarding these frameworks are noted elsewhere. Due to the effect of both SDOHs and individual factors on injury health outcomes, both were included in this study.

Table 1.

Framework

Description

Citation(s)

Dahlgren and Whitehead Model

Maps the influence of individual (e.g., lifestyle factors) and environmental factors (e.g., community influences, living and working conditions, etc.) on health.

de Lima Silva et al., 2014; Driscoll et al., 2013

Equity-Effectiveness
Model

The effectiveness of community-level interventions decreases along a set of parameters which measures access to, and quality of, care.

Nooh et al., 2019

Fundamental Cause Model

Examines the relationship between socioeconomic inequalities and health; the ability to control disease/death is influenced by access to fundamental resources (e.g., knowledge, money, power, prestige, and beneficial social connections).

Tulier et al., 2019; Diez Roux, 2012

Healthy People (2020 and 2030)

Provides science-based, national objectives each decade dedicated to improving the health of all Americans. Healthy People 2020 developed a framework that organized the social determinants of health into five key domains: (1) Economic Stability, (2) Education, (3) Health and Health Care, (4) Neighborhood and Built Environment, and (5) Social and Community Context. Healthy People 2030 established a framework to describe the initiative's rationale and approach, including its vision, mission, foundational principles, plan of action, and overarching goals (new objectives are underway).

Welch et al., 2022; Chen et al., 2020; Mohan and Chattopadhyay, 2020; Sokol et al., 2019; Min et al., 2022; Yelton et al., 2022, Maness & Buhi, 2016; Abbott and Williams, 2015

PROGRESS/PROGRESS Plus

Acronym used to identify dimensions across which health inequities may occur, specifically, place of residence; race/ethnicity /culture/language; occupation; gender/sex; religion; education; socioeconomic status; and social capital.

Turnbull et al., 2020; Chhibber et al., 2021; Schröders et al., 2015; Lehne & Bolte, 2017; Schüz et al., 2021; Campos-Matos et al., 2016; Aves et al., 2017; Welch et al., 2022; Morton et al., 2016; Buttazzoni et al., 2020; Brown et al., 2017a; Brown et al., 2017b; Ahmed et al., 2022; Cohn & Harrison; 2022

Social-Ecological Model

Theory-based framework for understanding how social and structural determinants influence health and wellbeing.

Habbab & Bhutta, 2020, Yiga et al., 2020, Pereira et al., 2019, Reno & Hyder, 2018, Greenbaum et al., 2018, Christidis et al., 2021, Allen et al., 2020, Karger et al., 2022, Taylor & Lamaro Haintz, 2018

Stress-Exposure Disease Framework

Conceptual framework that outlines the relationships between race, environmental conditions, and health.

Gee & Payne-Sturges, 2004; Payne-Sturges et al., 2006b

World Health Organization (WHO) Conceptual Social Determinants of Health (SDOH) Framework

Outlines how social, economic, and political factors (e.g., income, education, occupation, gender, race, and ethnicity) impact an individual's socioeconomic position, which, in turn, influences their vulnerability and exposure to health conditions.

Chen et al., 2020, Bhojani et al., 2019; Dover & Belon, 2019; Wang et al., 2020; Allen et al., 2020; Armstead et al., 2021; Batista et al., 2018; Owusu-Addo et al., 2016; National Academies of Sciences, Engineering, and Medicine, 2016; Min et al., 2022

This study used the HP 2030 Framework to categorize SDOHs and individual factors into five key domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context ( Department of Health and Human Services, 2022). Each health equity framework was analyzed by two independent reviewers to assess which SDOHs and individual factors the frameworks addressed. Then, the SDOHs and individual factors were categorized by the key domains of the HP 2030 Framework using a best fit model, based on alignment with the objectives outlined in the HP 2030 Framework, to identify and understand gaps in coverage in the five key domains ( Department of Health and Human Services, 2022). The authors identified SDOHs and individual factors from the full list that most related to injury, including drowning, older adult falls, motor vehicle crashes, suicide, and traumatic brain injury ( CDC NCIPC, 2022b; CDC NCIPC, 2023a; CDC NCIPC, 2023b; CDC NCIPC 2023c; CDC NCIPC 2023d). The authors used the list of health disparities from the referenced CDC NCIPC webpages to compare to the SDOHs and individual factors from the frameworks. If the two reviewers did not agree on key domain categorization, all authors were engaged in a discussion to reach consensus. The HP 2030 Framework domains which encompassed the SDOHs and individual factors specifically related to injury topic areas were compared with the health equity frameworks to understand potential alignment of health equity frameworks with injury topic areas.

3. Results

There were 33 health equity frameworks included in this study ( Table 2). Of the 33 health equity frameworks, eight frameworks were found to cover all five of the HP 2030 key domains: Dahlgren and Whitehead Model; Environmental determinants of health; Life Course Approach; Policy-Oriented Approach; Social and Cultural Determinants of Mental Disorders; Social-Ecological Model; the Frieden Framework; and the World Health Organization's (WHO) Conceptual SDOH Framework. Most of the health equity frameworks contained SDOHs and individual factors that addressed at least one domain (n =29; 87.9%). The most common domain was Social and Community Context (n =30; 90.9%), followed by Neighborhood and Built Environment (n =26; 78.8%), Economic Stability (n =26; 78.8%), Healthcare Access and Quality (n =23; 69.7%), and lastly Education Access and Quality (n =10; 30.3%) ( Table 2).

Table 2.

Healthy People 2030 Key Domains

Health Equity Framework (N = 33)

Economic Stability

Education Access and Quality

Health Care Access and Quality

Social and Community Context

Neighborhood and Built Environment

World Health Organization (WHO) International
Classification of Functioning, Disability and Health (ICF) model

X

X

X

X

TOTAL (%)

26 (78.8)

10 (30.3)

23 (69.7)

30 (90.9)

26 (78.8)

A total of 59 SDOHs/individual factors ( Table 3) were identified from the 33 health equity frameworks included in this study ( Lennon et al., 2022). The SDOHs and individual factors identified by the health equity frameworks varied by HP 2030 domain: 22 (37.3%) SDOHs/individual factors fit under Social and Community Context, 16 (27.1%) under the Neighborhood and Built Environment domain, 10 (16.9%) under Economic Stability, 10 (16.9%) under Healthcare Access and Quality, and one (1.7%) under Education Access and Quality ( Table 3).

Table 3.

Healthy People 2030 Key Domains

Social Determinants of Health (SDOHs) and Individual Factorsb Identified (N = 59)

Economic Stability

Education Access and Quality

Health Care Access and Quality

Social and Community Context

Neighborhood and Built Environment

TOTAL (%)

10 (16.9)

1 (1.7)

10 (16.9)

22 (37.3)

16 (27.1)

The most frequently identified SDOHs and individual factors in the list of health equity frameworks (N =33) within each respective domain were social context/environment (n = 19; Social and Community Context HP 2030 key domain), socioeconomic status (n = 17; Economic Stability), residential location/neighborhood (n = 17; Neighborhood and Built Environment), education (n = 12; Education Access and Quality), and health status/conditions (n = 14; Healthcare Access and Quality) ( Fig. 1).

Fig. 1. Top Three Social Determinants of Healtha and Individual Factors Most Frequently Identified in Health Equity Guiding Frameworks Categorized by Healthy People 2030 Key Domainsb-d (N =33).

a Social determinants of health (SDOHs) are broader in scope and include the social, economic, and environmental factors that influence the health and well-being of communities. SDOHs and individual factors can be categorized in the five different domains in the Healthy People 2030 model: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment, and Social and Community Context.

b Includes health equity frameworks found in Table 1.

c Only one SDOH was categorized in the Education Access and Quality domain, therefore only one is shown.

d Definitions for select terms:

Agriculture/food production and access addresses "supply side" of food security at the national or international level and is determined by economic and physical access factors such as the level of food production, stock levels, and net trade (this includes food access, which refers to household level food security and whether individuals can obtain food, food stability, food availability, food deserts, rurality, agriculture and food production).

Healthcare system factors/characteristics refers to access to quality, affordable, and timely preventive and curative health care that recognizes individual patient needs, including their health history and personal preferences.

Power/Prestige refers to an imbalance in status and opportunities between populations based on factors such as race and ethnicity, gender, income, or sexual orientation.

Social context/environment are factors and circumstances in the broader social setting (such as exposure to community stressors or personal/life experiences) that shape behaviors, beliefs, and/or perceptions of individuals and groups of people.

When comparing to injury topic areas, 23 (39.0%) SDOHs/individual factors related to TBI, thirteen (22.0%) were related to motor vehicle crashes and suicide, and 11 (18.6%) were related to drowning and older adult falls ( Table 4) ( CDC NCIPC, 2021). Four domains were most relevant to suicide and TBI (Economic Stability, Health Care Access and Quality, Social and Community Context, and Neighborhood and Built Environment), three for falls (Economic Stability, Social and Community Context, and Neighborhood and Built Environment) and two were found most relevant for both motor vehicle and drowning (Social and Community Context and Neighborhood and Built Environment).

Table 4.

HP 2030 Key Domain

Social Determinants of Health (SDOHs) and Individual Factorsd (n =29)

Drowning

Motor vehicle crashes

Older adult falls

Suicide

Traumatic brain injury

TOTAL (%) (N = 59)

11 (18.6)

13 (22.0)

11 (18.6)

13 (22.0)

23 (39.0)

4. Discussion

To our knowledge, this is the first study of its kind to assess SDOH and individual factor coverage within existing health equity frameworks and assess applicability of these frameworks to injury topic areas. SDOHs and individual factors by injury topic area were analyzed to demonstrate how health equity frameworks that incorporate these factors may align with injury outcomes through comparison with topic-specific health disparities. To understand commonalities between SDOHs and individual factors abstracted from the health equity frameworks, this study used the HP 2030 key domains. The HP 2030 key domains have ties to injury-related outcomes. For example, one of the HP 2030 Neighborhood and Built Environment objectives is to reduce the rate of minors and young adults committing violent crimes ( Department of Health and Human Services, 2022). Frameworks reviewed in this study addressed different types of SDOHs and individual factors, which may make them more or less suitable for application to injury topic areas ( Department of Health and Human Services, 2022).

The SDOHs and individual factors identified in the health equity frameworks varied across the HP 2030 key domains. As shown in Fig. 1, the Social and Community Context and Neighborhood and Built Environment key domains had more coverage compared to the Economic Stability, Health Care Access and Quality, and Education Access and Quality key domains. One potential reason for this may be because this study used a best fit model, meaning that each SDOH and individual factor was categorized into one of the five HP 2030 key domains and overlap between domains was not assessed. Another potential reason may be that some SDOHs and individual factors such as age, genetic predictors, and environmental factors, which are part of the Neighborhood and Built Environment and Social and Community Context key domains, are more commonly included in health equity frameworks compared to SDOHs and individual factors found in other domains. Eight frameworks in the study covered all five of the HP 2030 key domains. These frameworks appear to be most universally applicable for conceptualizing health equity broadly based on alignment with the HP 2030 key domains. However, the SDOHs and individual factors found to be relevant to the suicide and TBI topic areas appeared in all but the Education Access and Quality domain, so additional frameworks that did not cover the Education Access and Quality key domain could be considered, such as A Public Health Framework for Reducing Health Inequities, the health equity measurement framework, World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) model, the Multi-level Systems Approach, Pathways Model, PROGRESS/PROGRESS Plus, Rural Community Health and Well-Being Framework, social determinants of child health, and the WHO Social Political, Economic and Cultural Conceptual Model. For falls, the Weathering Hypothesis and social and demographic determinants of health-related quality of life could be considered as well, since these frameworks cover the three key domains identified for falls. Additionally, the Community Stress Theory and the framework for understanding racial/ethnic disparities in environmental health could be considered for motor vehicle and drowning.

The health equity field is constantly evolving and expanding, making relationships between terms difficult to comprehend and apply to research. However, incorporating health equity frameworks into research is important for understanding and contextualizing the underlying drivers of health disparities. The application of health equity frameworks in research may be an effective strategy to help researchers evaluate and conceptualize why health outcomes may differ between populations, which can lead to more tailored upstream prevention strategies and progress towards health equity ( Braveman et al., 2017). The findings from this study may serve as a useful tool for researchers in injury and other public health fields to reference and utilize when considering health equity frameworks to include in their disparities-focused research.

5. Limitations

There are a few limitations to this study. This study utilized a compilation of health equity frameworks that were identified from a limited number of sources (e.g., PubMed, CINAHL) ( Lennon et al., 2022). Therefore, additional health equity frameworks found in other citation databases or resources may have been excluded. The authors added the SDOHs and individual factors into the five key domains recommended by HP 2030 using a best fit model; therefore, some SDOHs and individual factors may have overlapped into other key domains, and instances of potential overlap were not reported in the study. Given that the health equity frameworks used in this study were developed and used at different points in time in the past decades, terminology for describing the same SDOHs and individual factors may have varied over time, which could have caused an increase in number of SDOHs and individual factors reported. Additionally, the CDC webpages that were used to determine health disparities for injury topic areas to compare to underlying SDOHs and individual factors did not necessarily mention all health disparities that are present within the topic areas, which could have led to the exclusion of other SDOHS and individual factors when determining applicability of health equity frameworks to injury topic areas.

6. Conclusions

The importance of incorporating health equity into the public health field, including injury, is critical. Health equity frameworks can provide a way for those in the fields of research, implementation, translation, and program development to incorporate health equity into their research. During this process, it is important to note which SDOHs and individual factors are covered by the frameworks and how these apply to specific fields of research. This study adds to the existing literature by identifying SDOHs and individual factors addressed by 33 health equity frameworks used in the literature and providing a tool for researchers to begin identifying health equity frameworks that can be applied to their work. The findings from this study could be used to develop a health equity framework for specific injury topic areas or other public health areas. Further research may observe how frameworks can be applied to new and existing injury research, using SDOHs and individual factors as a guide to select the most fitting framework based on the populations most disproportionately affected by injury outcomes.

7. Practical Applications

Health equity frameworks are a practical tool to guide injury research, translation, evaluation, and program implementation. The findings from this study can be used to guide the application of health equity frameworks in injury research for specific topic areas. Moving forward, researchers may use these findings to develop and apply health equity frameworks that address the specific SDOHs and individual factors most relevant to framing and understanding health equity in injury prevention.

Acknowledgments

The Journal of Safety Research has partnered with the Office of the Associate Director for Science, Division of Injury Prevention, National Center for Injury Prevention and Control at the CDC in Atlanta, Georgia, USA, to briefly report on some of the latest findings in the research community. This report is the 75 th in a series of "Special Report from the CDC" articles on injury prevention.

Disclaimer

The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Biography

Andrea Carmichael, MPH graduated from George Mason University in 2018 with her MPH in Epidemiology and completed her practicum at the EPA's Office of Children's Health protection. She is currently a Health Scientist for the Division of Injury Prevention in the CDC's Injury Center, where she has presented and published on various injury topics including health equity, suicide prevention, drug overdose, and nonfatal injury data. She completed two COVID-19 response deployments, which involved monitoring and reporting cases among the general population and among people experiencing homelessness.

Natalie Lennon, MPH graduated from Emory University in 2021 with her MPH in Behavioral, Social, and Health Education Sciences. She currently works on the Suicide Prevention Team in the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC). In her current role, Natalie serves as a suicide subject matter expert for CDC's Comprehensive Suicide Prevention Program and conducts research focused on suicide and suicidal behaviors among disproportionally affected groups.

Judy Qualters, PhD, MPH is the director of the Division of Injury Prevention (DIP) in the National Center for Injury Prevention and Control (NCIPC) at CDC. In this role, Dr. Qualters provides leadership to bridge science and practice in an effort to move the field of violence and injury prevention forward. She also leads a diverse portfolio of work that includes surveillance, data and economic analysis, information technology, policy research, evaluation, and technical assistance to state health departments.

Footnotes

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

References

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2. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion (2022). Health Equity. Accessed May 16, 2023. [Available from: https://www.cdc.gov/chronicdisease/healthequity/index.htm].

3. Centers for Disease Control and Prevention, National Center for Injury Prevention Control (2022b). Drowning Facts. Accessed May 16, 2023. [Available from: https://www.cdc.gov/drowning/facts/index.html.

4. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (2023a). Disparities in Suicide. Accessed May 16, 2023. [Available from: https://www.cdc.gov/suicide/facts/disparities-in-suicide.html].

5. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (2023b). Facts About Falls. Accessed May 16, 2023. [Available from: https://www.cdc.gov/falls/facts.html].

6. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (2023c). Health Disparities and TBI. Accessed May 16, 2023. [Available from: https://www.cdc.gov/traumaticbraininjury/health-disparities-tbi.html].

7. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (2023d). Transportation Safety. Accessed May 16, 2023. [Available from: https://www.cdc.gov/transportationsafety/].

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# data[].attributes.attachment_link.title
Analysis of social determinants of health and individual factors found in health equity frameworks: Applications to injury research

# data[].attributes.attachment_link.description
This research evaluated existing health equity frameworks as they relate to social determinants of health (SDOHs) and individual factors that may impact injury outcomes and identify gaps in coverage using the Healthy People (HP) 2030 key domains. ...

# data[].attributes.body
The Patient Health Questionnaire-9 (PHQ-9) is a widely used tool for screening, diagnosing, and measuring the severity of depression. It consists of nine questions that assess the frequency of depressive symptoms experienced over the past two weeks. Each item is scored from 0 to 3, with higher scores indicating greater severity of depression.

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PHQ-9 and Hypothetical Scoring

The PHQ-9’s sections include evaluating the frequency of symptoms like "little interest or pleasure in doing things" and "feeling down, depressed, or hopeless," which help identify major depressive symptoms.

In Ana’s case, she likely scores high on indicators like “trouble falling or staying asleep, or sleeping too much” and “feeling tired or having little energy.” Given her struggles with motivation, low energy, and feeling hopeless, Ana would likely score within the moderate to severe range on the PHQ-9, which suggests that intervention and support are necessary.

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Score: ~20

Severe depression

little motivation

Low energy

- lead to mistakes: patient harm

# data[].attributes.body
Based in Ana's hypothetical results

# data[].attributes.attachment_link.title
PHQ-9 Depression Scale Questionnaire - AIMS Center

# data[].attributes.attachment_link.description
The PHQ-9 is a concise nine-item health questionnaire that functions as a screening tool, aids in diagnosis, and measures treatment response.

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Little interest or pleasure in doing things: Ana no longer enjoys reading medical literature or engaging in her usual activities.

# data[].attributes.body
Trouble falling or staying asleep, or sleeping too much: Though Ana attributes her issues to sleep deprivation from her ICU rotation, her ongoing fatigue and struggle to get out of bed suggest sleep disturbances.

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Difficulty concentrating: Individuals may struggle to focus on tasks, leading to decreased productivity and performance at work.

Ana’s feelings of hopelessness and questioning of her career choice reflect cognitive symptoms. These are influenced by professional pressures in a high-stress environment, leading to self-doubt and negative self-perception.

Indecisiveness: This may manifest as an inability to make decisions, often stemming from feelings of worthlessness or hopelessness.

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Persistent sadness or low mood: Affected individuals may feel a pervasive sense of sadness or emptiness that colors their daily experiences.

Loss of interest or pleasure in activities: This symptom can lead to withdrawal from social interactions and previously enjoyed hobbies.

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Work depression: Symptoms, causes, treatment, and more

# data[].attributes.attachment_link.description
A person may use the term “work depression” to refer to major depressive disorder or other forms of depression that present at work or because of work.

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Fatigue and low energy: Chronic fatigue can result from depression, impacting an individual's ability to engage in daily activities.

Physical aches and pains: Depression often manifests with unexplained physical symptoms that do not have a clear medical cause.

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Partner has somatic symptom disorder: how to help your partner.

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Found on Google from barendspsychology.com

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How Ana's Symptoms Relate to Self-Determination Theory (SDT)

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How Ana's Symptoms Relate to Self-Determination Theory (SDT)

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Ana's case can be analyzed through the lens of Self-Determination Theory (SDT), which focuses on human motivation, well-being, and the fulfillment of three basic psychological needs: autonomy, competence, and relatedness. These needs must be met for individuals to function optimally and maintain psychological health. Ana’s depression and burnout can be understood as a response to the frustration of these core needs in her work and personal life.

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The result in Ana’s burnout resulted in her missing signs from patients which can be dangerous for patients life and stressful for Ana’s as well as her career

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Ana feels she can’t speak about how she feels without being perceived as being “weak”, which can result in allowing others to help her and helping herself. This would lead into support system, not allowing others to be there for her in need. Feeling:

-isolated

-stressed

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Ana’s burnout with work may lead to dissatisfaction in her career. She regrets goin into the medical field.

She could feel helpless as she helps many but can’t help her mother.

She will slowly loose interest in her work and feel depressed.

work ethic would go down

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Job Demands

Financial Stress

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training environment

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Healthcare professionals burnout frequently.

Leading to: poor quality of care

Tawfik, D. S., Scheid, A., Profit, J., Shanafelt, T., Trockel, M., Adair, K. C., Sexton, J. B., & Ioannidis, J. P. A. (2019). Evidence Relating Health Care Provider Burnout and Quality of Care: A Systematic Review and Meta-analysis. Annals of internal medicine, 171(8), 555–567. https://doi.org/10.7326/M19-1152

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An effective intervention to improve Ana's physical and mental health outcomes would be the implementation of Mindfulness-Based Stress Reduction (MBSR). This intervention, rooted in mindfulness practices such as meditation and breathing exercises, has been shown to alleviate burnout, reduce symptoms of depression, and improve overall well-being in healthcare professionals like Ana.

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Evidence-Based Support for Mindfulness Based Stress Reduction

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Evidence-Based Support for Mindfulness Based Stress Reduction

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Research shows that MBSR can significantly improve both mental and physical health by reducing stress, enhancing emotional regulation, and improving sleep, all of which are relevant to Ana's case. A meta-analysis of 29 studies found that mindfulness interventions, including MBSR, resulted in a moderate reduction of psychological distress, anxiety, and depressive symptoms in healthcare professionals (Spinelli et al., 2019). Similarly, an 8-week MBSR program for residents in internal medicine demonstrated a marked decrease in burnout and increased well-being (Verweij et al., 2018). These findings suggest that integrating MBSR into Ana’s routine could help her manage the emotional exhaustion, negative mood, and physical fatigue associated with her burnout.

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Spinelli, C., Wisener, M., & Khoury, B. (2019). Mindfulness training for healthcare professionals and trainees: A meta-analysis of randomized controlled trials. Journal of Psychosomatic Research, 120, 29-38. https://doi.org/10.1016/j.jpsychores.2019.03.003

Verweij, H., van der Heijden, F. M. M. A., van Hooff, M. L. M., & Prins, J. T. (2018). The contribution of work characteristics, home characteristics, and gender to burnout in medical residents. Advances in Health Sciences Education, 23(4), 643-657. https://doi.org/10.1007/s10459-018-9834-0

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