Political Determinants of Health: New Data Reveals How Policy Impacts Sexual and Reproductive Wellbeing
A groundbreaking analysis reveals the profound impact of political and social factors on sexual and reproductive health (SRH) outcomes across the United States, underscoring the critical need to consider “Health in All Policies” approaches. Researchers have long understood that health is shaped by the conditions in which people live, work, and play – the social drivers of health. This latest work demonstrates how politics and policy are key determinants within that broader landscape.
Sexual and reproductive health encompasses a wide range of outcomes, including rates of sexually transmitted infections like HIV, birth outcomes such as infant mortality, and access to reproductive choices like long-acting reversible contraception (LARC). A recent machine-learning analysis of these social drivers, with interactive national scores available at RTIRarity.io, has quantified the risk of adverse SRH outcomes across the country. These scores, presented as percentile ranks from 0-100 (lower indicating better outcomes), reveal a complex relationship between state-level policies and public health.
The analysis shows the mean risk of adverse SRH outcomes – a composite of adolescent pregnancies, adolescent births, low birthweight infants, and rates of chlamydia and gonorrhea – varies significantly by state, as predicted by neighborhood social determinants. These percentile-ranked scores are referred to as Local Social Index (LSI) scores. While political leaning isn’t the sole predictor of SRH outcomes, the data reveals intriguing patterns. For example, some relatively liberal states, like New Mexico, exhibit worse-than-average SRH outcomes, while some conservative states, such as Kansas, demonstrate better-than-average results. This highlights the nuance of the issue and the importance of looking beyond simple political categorizations.
Researchers have previously examined policies like abortion bans and restricted sex education as factors influencing SRH. Now, they are expanding their modeling to the Census tract level in California and sub-county areas within Los Angeles County to provide even more granular insights.
California, generally a liberal state, presents a compelling case study. Despite its overall progressive stance, conservative pockets exist, such as the 48th Congressional District, represented by Republican Darrell Issa. Access to publicly funded reproductive healthcare also varies considerably within the state. However, California’s overall LSI score for SRH is comparatively low – indicating better outcomes – when compared to the national average. When analyzing data within a single state, researchers emphasize the need for within-state scores to account for regional variations.
. A map illustrating tertiles of SRH risk scores in California shows darker shading indicating higher risk areas. The California model identified ten key predictors of SRH within the state:
- Food insecurity, % of residents (2019)
- Violent crimes per 100k residents (2018)
- 4-year HS graduation rate, % of students (2010–13, 2015, 2017–18)
- Hospital readmission rate, % (2013–18)
- Students who are economically disadvantaged, % (2013–18)
- Emergency department visit rate, per 1k (2013–18)
- Unemployment rate, % (2015–19)
- Low social support, % (2018)
- Voting-age citizens who voted in the presidential election, % (2016)
- Students receiving free/reduced-price lunch, % (2013–18)
Notably, several of these predictors – food insecurity, HS graduation rate, economically disadvantaged students, and free/reduced-price lunch – were also identified as top variables in the national model. This underscores the pervasive impact of socioeconomic factors on SRH. “Food insecurity is the most important predictor,” researchers found, driven by poverty, food prices, and access to assistance programs like SNAP and school lunch programs. Policies aimed at reducing poverty and increasing food access could have a significant positive impact on birth outcomes.
The importance of voter turnout in the 2016 presidential election was also highlighted, with lower turnout rates observed in poorer communities facing barriers to participation. These barriers include apathy, lack of time, and limited access to information.
A more detailed analysis of Los Angeles County reveals further granularity. The map of deciles of LSI-SRH scores within the county shows the highest risk areas concentrated in reds and oranges, allowing public health practitioners to strategically allocate resources. The top ten predictors in Los Angeles County differ from those in the statewide model:
- Obesity prevalence rate, % (2018, 2019)
- Asthma prevalence rate, % (2018, 2019)
- Index of Concentration at the Extremes (ICE), non-Hispanic White & Hispanic (2010-2014)
- Children who grew up and lived as adults in a tract with low poverty, % (1978-2015)
- Chance of reaching top 20% income bracket among children born the same year, % (1978-2015)
- Tooth loss prevalence rate, % (2018)
- Sleep insufficiency rate, % (2018)
- Children claimed by two people in the year they were linked to parents, % (1978-82)
- Smoking prevalence rate, % (2018, 2019)
- Renter-occupied household size (2015-19)
The Index of Concentration at the Extremes (ICE), measuring spatial polarization in terms of income and ethnicity, is a particularly compelling indicator in Los Angeles. Furthermore, predictors utilizing data from the Opportunity Atlas highlight the long-term impact of childhood circumstances on adult health outcomes, including intergenerational poverty and historical divorce rates. These longitudinal measures provide a multi-generational perspective on the causes of health disparities.
Researchers are continuing to refine their methods and will publish peer-reviewed articles with more detailed findings. They encourage feedback and widespread dissemination of their work, emphasizing that now is a critical time to address the political drivers of health in the United States.
Lisa M. Lines, PhD, MPH is an independent consultant, senior health services researcher, and Assistant Professor in Population and Quantitative Health Sciences at the University of Massachusetts Chan Medical School. Her research focuses on drivers of health, quality of care, care experiences, and health outcomes, particularly among people with chronic or serious illnesses. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She served as chair of the APHA Medical Care Section’s Health Equity Committee from 2014 to 2023. Views expressed are the author’s and do not necessarily reflect those of UMass Chan Medical School.
Christina Fowler, PhD, MPH, is a health services researcher formerly with RTI International. Her research focuses on federal health policies and healthcare safety net programs that provide sexual and reproductive health (SRH) services, equitable access to SRH services, and contraceptive decision making. All opinions are those of the author.
