By Radhika Agarwal
Social determinants of health are the non-medical factors which influence health and quality of life.  They are conditions which are present within a patient’s everyday life and environment. Education access and health literacy are key social determinants of health recognized by Healthy People 2030.   There are specific goals to “increase the proportion of high school students who graduate in four years” and “increase the proportion of adults whose health care provider checked their understanding” by 2030.  
Definition: Individual Health Literacy is defined as “the degree to which individuals have the ability to find, understand and use information and services to inform health-related decisions and actions for themselves and others”. 
Why is this relevant? Health outcomes differ by education level. Individuals who do not graduate high school are more likely to suffer from 1 or more chronic health conditions.  Adults with a bachelor’s degree or higher are significantly more likely to understand their provider than those without a high school degree.  As of 2019, 12.1 percent of Georgians aged 25 years and older lacked a high school diploma. This rate of high school non-completion was highest among Hispanics (35.7 percent) within our state. 
Screening: Start by asking adult patients for highest grade completed. For children and teenagers, assess school performance and grade level. Poor school performance would warrant further investigation for health (physical or mental) or social concerns.
Recommendations and resources: To improve health understanding among adults with low-health literacy, the teach back method can be used to assess patient comprehension. Having easy-to-read handouts and educational material in clinic to provide for patients can serve as a reference after the appointment.
Adults without a high school degree can also be provided with information on programs to complete secondary education. The Technical College System of Georgia (TCSG) offers high school equivalency preparation and ESL classes with online and in-person options.  There are 23 main TCSG locations throughout Georgia with additional satellite locations.
For adolescent students at risk of not finishing high school (including for reasons specific to pregnancy and having children), high school completion programs are recommended, including “vocational training, alternative schools, social-emotional skills training, mentoring and counseling, supplemental academic services, attendance monitoring, and case management.” . For expelled students, Georgia requires districts to operate alternative high schools or provide alternative education. .  There are also community organizations we can refer parents to, such as local affiliates of Communities in Schools of Georgia – a non-profit organization with presence in 32 counties dedicated to providing social support, case management services, and emotional support to students. 
Dr. Agarwal is a GAFP Resident Member. She is board-certified in family medicine and currently completing a Preventive Medicine residency.
 World Health Organization (WHO), “Social determinants of health,” [Online]. Available: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1. [Accessed 19 October 2022].
 Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, “Health Literacy in Healthy People 2030,” [Online]. Available: https://health.gov/healthypeople/priority-areas/health-literacy-healthy-people-2030. [Accessed 19 October 2022].
 Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, “High School Graduation,” [Online]. Available: https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/high-school-graduation#cit18. [Accessed 19 October 2022].
 CDC, “QuickStats: Percentage of Adults Aged ≥25 Years Who Had Seen a Health Care Professional in the Past 12 Months and Who Easily Understood Information from Their Health Care Providers Most or All of the Time, by Sex and Education Level— National Health Inter,” MMWR Morb Mortal Wkly, 15 November 2019. [Online]. Available: https://www.cdc.gov/mmwr/volumes/68/wr/mm6845a6.htm. [Accessed 19 October 2022].
 America’s Health Rankings, United Health Foundation, “Education – Less Than High School, Georgia, United States,” [Online]. Available: https://www.americashealthrankings.org/explore/annual/measure/education_LT_HS/state/GA. [Accessed 19 October 2022].
 Technical College System of Georgia, “Georgia High School Equivalency (GED & HiSET) Program,” [Online]. Available: https://www.tcsg.edu/adult-education/adult-education-high-school-equivalency-hse/. [Accessed 19 October 2022].
 Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, “Health Equity: High School Completion Programs,” [Online]. Available: https://health.gov/healthypeople/tools-action/browse-evidence-based-resources/health-equity-high-school-completion-programs. [Accessed 19 October 2022].
 State Policy Database, National Association of State Boards of Education, “Alternative Education for Expelled Students – Georgia,” [Online]. Available: https://statepolicies.nasbe.org/health/categories/social-emotional-climate/alternative-education-for-expelled-students/georgia. [Accessed 19 October 2022].
 Georgia Department of Education, “CSI/TSI/Promise Alternative/Non-Traditional Education Alternative Education Team District Assignments,” [Online]. Available: https://www.gadoe.org/School-Improvement/Documents/AEP/Alternative%20and%20Non-Traditional%20Education%20Districts,%20Schools,%20and%20Assignments.pdf. [Accessed 19 October 2022].