By Elaine Marshall, Isabel Geisler, L. Virginia Martinez, Krystal Abbott, and Katherine Hazen
Social drivers of health (SDOH), sometimes known as the social determinants of health, are factors in the social environment that shape individual and population health, including poverty, racism, housing, education, and employment. When judges decide cases that impact these social factors, their rulings can have important health implications. While cases impacting the SDOH can be landmark Supreme Court cases, such as the ruling on the CDC’s eviction moratorium during the COVID-19 pandemic, judges also make decisions on a daily basis that can affect the SDOH and thereby health. Take, for example, a child welfare case out of New York, In re Brittany T, 852 N.Y.S.2d 475 (N.Y. App. Div. 2008), where the issue before the judge was whether a family willfully and without just cause violated orders meant to support their child’s health through diet and exercise. The order required the family to use all resources available to ensure the well-being of the child, enroll the child at their own cost in a local gym and attend it at least 2-3 times a week, and actively and honestly participate in a nutrition program.
Cases like these turn on judges’ interpretation of the facts and the law. Given the social environment of this illustrative case, that interpretation might have included considering the impact of the SDOH on the parents’ ability to comply with the court order and ultimately support their child’s health. Consideration of the SDOH may have included attention to poverty and whether the family had sufficient funds to pay for healthy foods or a gym for diet and exercise; the role of the parents’ employment, a key SDOH, in allowing them to take time to attend the nutritionist program and closely monitor their child’s adherence to the program; or the feasibility of the 2-hour driving distance to the nutritionist appointments, reflecting the socially patterned access to health care and needed services. Deciding questions like these makes the judiciary a key player impacting people’s health and so, judges should be adequately educated about the SDOH.
Fulfilling this call, Salus Populi trainings aim to equip judicial attendees with the information they need to make more informed decisions when social factors that affect health are implicated in the cases that come before them. SP is a partnership between Northeastern University’s Center for Health Law and Policy, and Institute for Health Equity and Social Justice Research, led respectively by co-Principal Investigators Wendy E. Parmet and Alisa K. Lincoln. Since its inception in Fall 2021, and through June 2023, Salus Populi has conducted ten judicial training courses for approximately 556 attendees from 21 states. Attendees were from Massachusetts, Ohio, Virginia, the District of Columbia (DC), Rhode Island, Ohio, Washington, North Dakota, and other jurisdictions. Most attendees worked in state, tribal, or DC courts and at the trial or municipal-trial court level.
To begin assessing this public health intervention and ascertain if Salus Populi is meeting its aim of educating judges on the SDOH and their relationship to law, the project partnered with the Northeastern University Public Evaluation Lab and their program evaluation researchers to build an evaluation strategy. The strategy includes a pre- and post-training survey so that we can see if attendees’ knowledge, attitudes, and beliefs change or due to the training. Overall, responses to our pre-post surveys indicate that, on average, there were statistically significant increases in attendees’ perceptions of their knowledge of the SDOH and understanding of the relationship between the SDOH and judicial decision making after the training.
Not only did respondents’ understanding increase, but respondents agreed more strongly on the posttest than on the pretest that they could and would use their understanding of the SDOH in their judicial decision making or legal work. To expand on more specific areas of application, the Salus Populi Evaluation Team also asked attendees how they are most likely to use their knowledge of the SDOH in open-ended questions. Through these open-ended questions attendees told us that they will use their knowledge of the SDOH in areas such as discovery motions, sentencing, orders for substance use disorder evaluations and treatment, written opinions, and as presented by the parties or the record. They’ve also said that they will use their understanding of the SDOH on a case-by-case basis, in understanding litigants’ behavior, and when interpreting the facts. So, based on these examples, a SP trained judge might better assess, as well as communicate, the social factors that promote or impede access to drug treatment when writing orders for substance use disorder evaluation and treatment.
On average, respondents were also pleased with the delivery and structure of the program, as they indicated on the survey that the training was well organized, effective, and that they would recommend it to other judges. When asked through open-ended questions what attendees liked about the training, respondents mentioned the discussions, diverse perspectives from judges of different jurisdictions, training content, and the presenters. We also asked survey respondents how the training could be improved. Responses included feedback on the practical logistics of the training, and requests for more opportunities for discussion and to apply the course material.
Additional and rigorous evaluation methods are needed to further assess the impact of such an upstream public health intervention on judicial decision making and the community’s health. As such, in 2023, we also started in-depth interviews with program alumni to find out more about how they use the training concepts in their work and how the Salus Populi training can be improved. Furthermore, to determine impact beyond self-reporting, over the next year we will begin developing our methodology to assess the impact of the training on judicial decision making by exploring ways to access administrative court data and the judicial orders, memoranda, and opinions of our attendees. Overall, however, our emerging results indicate the usefulness of this judicial education program on the SDOH.
Elaine Marshall, MPH, JD, is a Postdoctoral Research Fellow for Salus Populi, and the Institute of Health Equity and Social Justice Research at Northeastern University.
Isabel Geisler, PhD, is a research assistant for Salus Populi and a recent sociology PhD graduate of Northeastern University.
L. Virginia Martinez was a Graduate Student Assistant for Salus Populi and is a sociology PhD student at Northeastern University.
Krystal Abbott is a Health Equity Intern with Salus Populi.
Katherine Hazen, JD, PhD, is the Director of Evaluation for Salus Populi and a Research Assistant Professor of Criminal Justice and Health Sciences at Northeastern University.
