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  • Review Article
  • Published:

Social determinants of health in multiple sclerosis

Nature Reviews Neurology volume 18, pages 723–734 (2022)Cite this article

Subjects

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.

Key points

  • Addressing an individual’s social determinants of health — that is, the conditions under which they are born, grow, live, work and age — could provide opportunities to reduce the burden of living with multiple sclerosis (MS).

  • Individual factors that may influence MS-related outcomes include sex, gender and sexuality, race and ethnicity, education and employment, socioeconomic status, and domestic abuse.

  • Societal infrastructures, including access to food, health care and social support, can also affect MS-related outcomes.

  • Awareness of the specific circumstances of a patient with MS might help neurologists deliver better care.

  • Social determinants of health are not static and can change according to wider sociopolitical contexts, as highlighted by the COVID-19 pandemic.

  • Rigorous studies of interventions to ameliorate the effects of poor social determinants on people with MS are urgently needed.

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Fig. 1: WHO social determinants of health.
Fig. 2: Potential interactions between selected social determinants of health and multiple sclerosis outcomes.

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Acknowledgements

This work received no specific funding. R.D. works within the Preventive Neurology Unit, which is part funded by Barts Charity. Y.L. and C.H.M. are funded by MS Australia fellowships.

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Authors and Affiliations

  1. Preventive Neurology Unit, Wolfson Institute of Population Health, Queen Mary University of London, London, UK

    Ruth Dobson, Rachel Horne & Gavin Giovannoni

  2. Department of Neurology, Royal London Hospital, London, UK

    Ruth Dobson & Gavin Giovannoni

  3. Department of Neurology, Massachusetts General Hospital, Boston, MA, USA

    Dylan R. Rice & Farrah J. Mateen

  4. Department of Neurology, National MS Center, Melsbroek, Belgium

    Marie D’hooghe

  5. Center for Neurosciences, Vrije Universiteit Brussel, Brussels, Belgium

    Marie D’hooghe

  6. Discipline of Exercise Science, Murdoch University, Perth, WA, Australia

    Yvonne Learmonth

  7. Centre for Molecular Medicine and Innovative Therapeutics, Murdoch University, Perth, WA, Australia

    Yvonne Learmonth

  8. Centre for Healthy Ageing, Murdoch University, Perth, WA, Australia

    Yvonne Learmonth

  9. Perron Institute for Neurological and Translational Science, University of Western Australia, Perth, WA, Australia

    Yvonne Learmonth

  10. Disability and Health Unit, Melbourne School of Population and Global Health, University of Melbourne, VIC, Australia

    Claudia H. Marck

  11. Department of Neurology, Fundación Santa Fe de Bogotá, Bogotá, Colombia

    Saúl Reyes

  12. School of Medicine, Universidad de los Andes, Bogotá, Colombia

    Saúl Reyes

  13. Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK

    Saúl Reyes & Gavin Giovannoni

  14. Joi Life Wellness MS Center, Smyrna, GA, USA

    Mitzi Joi Williams

  15. Department of Neurology, Centre for Neurosciences, Leeds Teaching Hospitals, Leeds, UK

    Helen L. Ford

  16. Faculty of Medicine and Health, University of Leeds, Leeds, UK

    Helen L. Ford

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  1. Ruth Dobson
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Contributions

R.D., D.R.R., M.D., R.H., Y.L., F.J.M., S.R., M.J.W., G.G. and H.L.F. researched data for the article. All authors contributed substantially to discussion of the content. R.D., D.R.R., M.D., R.H., Y.L., F.J.M., S.R., M.J.W., G.G. and H.L.F wrote the article. All authors reviewed and/or edited the manuscript before submission.

Corresponding author

Correspondence to Ruth Dobson.

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The authors declare no competing interests.

Peer review

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Nature Reviews Neurology thanks A. He, who co-reviewed with J. Hillert; E. Vasileiou, who co-reviewed with K. Fitzgerald; and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Review criteria To ensure an inclusive overview, we searched PubMed, Scopus, CINAHL through EBSCOhost, MEDLINE through OVID, all other Web of Science (BCI OR SciELO OR WoS OR CABI OR RSCI OR CCC) core collection, PsychINFO and Emcare (OVID) using a search strategy based on the WHO social and immediate determinants of health and a wide range of MS terms on 17 January 2022. We considered any original studies examining social determinants of health and MS outcomes from 2004 onwards, and did not restrict based on language, given the wide-reaching effects of social determinants of health. Out of 2,453 papers screened, a total of 194 papers were considered for inclusion, and the final decision was based on relevance to social determinants of health and MS, along with novelty and current relevance.

Related links

Social determinants of health: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

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Dobson, R., Rice, D.R., D’hooghe, M. et al. Social determinants of health in multiple sclerosis. Nat Rev Neurol 18, 723–734 (2022). https://doi.org/10.1038/s41582-022-00735-5

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