What Are the Top Common Social Determinants of Health?

Housing Security

Housing security is a deeper issue than whether an individual has someplace to live. According to Healthy People 2030, an initiative out of the HHS Office of Disease Prevention and Health Promotion, housing instability “encompasses a number of challenges, such as having trouble paying rent, overcrowding, moving frequently, or spending the bulk of household income on housing.”

Healthy People 2030 said households that are cost-burdened are those that spend more than 30 percent of their income on housing; those that spend 50 percent of their income on housing are considered severely cost-burdened. Although these families or individuals have someplace to live, the high cost of housing leaves them with little money left to pay for other necessities like food, utilities, healthcare, and transportation, each of which is a key SDOH.

Homelessness, or being unhoused, is also a key issue under the housing security umbrella. Being unhoused means an individual does not have a nighttime residence or private residence that is not a shelter or other place not designed for sleeping. Folks who are unhoused have higher occurrence of chronic illness and also have more trouble accessing healthcare and managing their care.

Healthcare access may also be difficult for individuals who move around frequently, which can be a byproduct of unaffordable housing or unhealthy housing. Those who move residences frequently may not be reachable by their healthcare providers or may not be able to create a longitudinal relationship with their providers, if they build any relationship at all.

Finally, housing security can refer to the quality of housing an individual has. While one may not be cost-burdened or unhoused, homes without access to utilities, including broadband, or that are ridden with vermin are not conducive to good health and well-being.

Transportation

Transportation is a critical SDOH because it impacts individuals’ abilities to access other social services as well as healthcare. According to the Center for Population Health, transportation can fall under a few domains, such as

• Lack of vehicle access
• Inadequate infrastructure
• Transportation costs
• Adverse policies
• Long distances and lengthy travel times

Each of those factors can conflate into serious issues. Someone who doesn’t have a car and nobody to give them a ride to a doctor’s appointment might try to use public transportation. But that public transportation may be too far of a walk or too expensive to access. And even if that person does have a car, if the doctor’s appointment is too far away, they may not show up.

This could leave care unmanaged and leave an individual vulnerable to poor health outcomes.

Notably, transportation access impacts other social determinants of health. The above scenario could easily play out when going to the grocery store or another social service designed to address a different SDOH.

Food Security

Currently, 13.8 households are food insecure, meaning that they have limited or uncertain access to food, Healthy People 2030 said on its webpage about food security.

Per the US Department of Agriculture (USDA), food insecurity can be low, meaning individuals have to compromise food quality or desirability, or high, meaning individuals have to change their eating patterns or reduce food intake to make a grocery haul last longer.

Food security is essential to maintaining good health, regardless of the existence of chronic illness. However, food security is particularly vital for those with a diet-related illness, like diabetes or heart disease. Having access to certain foods that can aid in chronic disease management is key for patients with a diet-related illness.

Nutritional value is of utmost importance, too. While some may live in a food desert—an area in which they have limited access to food or grocery stores—others may live in a food swamp, or an area with a higher proportion of vendors that sell food with lower nutritional value.

Both are issues in terms of food security.

Income & Employment Conditions

Income is a social determinant of health that can affect others. For example, having a low income can cause food insecurity if one cannot afford groceries.

According to Healthy People 2030, economic stability and income are largely influenced by employment opportunities.

“People with steady employment are less likely to live in poverty and more likely to be healthy, but many people have trouble finding and keeping a job,” Healthy People 2030 says on the subject. “People with disabilities, injuries, or conditions like arthritis may be especially limited in their ability to work. In addition, many people with steady work still don’t earn enough to afford the things they need to stay healthy.”

And even people with well-paying, steady jobs can see their employment status as a social determinant of health. Certain jobs have adverse working conditions that can impact an individual’s health. Hazardous jobs or those in offices or factories with issues like poor air quality may lead to poor health outcomes.

Race, Ethnicity & Preferred Language

Race and ethnicity are key social determinants of health that have come to the forefront of the population health conversation in recent years. As more data about racial health disparities has come to light, it has become clear that race and ethnicity can influence one’s ability to achieve well-being.

Data has shown inequities across numerous disease states. Other studies have indicated differences in patient experience and patient safety based on race. These trends are also true for individuals for whom English is not their preferred language.

There is no conclusive data as to why race and ethnicity can impact health and well-being, but many have demonstrated that implicit bias and structural racism have a negative impact. The concept of weathering—the chronic stress incurred by experiencing everyday implicit and explicit racism—can have health impacts, too.

Notably, race, ethnicity, and preferred language can also drive certain social determinants of health. Individuals who are part of traditionally marginalized racial and ethnic groups are more likely to experience many of the SDOH listed in this article, which can further drive the steep health disparities seen in the US.

Gender Identity & Sexual Orientation

Like race and ethnicity, gender identity and sexual orientation are personal characteristics that can serve as social determinants of health. Being a part of the LGBTQ+ community can shape one’s ability to achieve health and wellness. Data has shown some health disparities impacting the LGBTQ+ community.

Those disparities can stem from a few areas. For one thing, members of the LGBTQ+ community may find it more difficult to find a healthcare provider who is able to deliver compassionate care free from discrimination. In 2021, KFF published data showing that members of the LGBTQ+ community face higher rates of chronic disease plus report more mistreatment from providers and poor healthcare experiences.

This is particularly searing for trans individuals, who have reported that it’s hard to find a provider who knows about trans healthcare needs.

These trends are particularly salient when looking at mental healthcare access for LGBTQ+ individuals, especially youth. Figures from a 2022 Trevor Project analysis showed that half of LGBTQ+ youth needed mental healthcare access but could not obtain it. Separate data from June 2023 showed that very few pediatric mental healthcare providers specialize in LGBTQ+ youth.

This has led to steep mental health disparities affecting members of the LGBTQ+ community. The National Alliance on Mental Illness says that LGB (lesbian, gay, bisexual) adults are over twice as likely to have a mental health condition than their heterosexual counterparts. For transgender people, the odds of having a mental health condition are four times as big as cisgender people.

Environment & Neighborhood

Environment as a social determinant of health has numerous factors.

First, one might consider neighborhood. Neighborhood can influence public safety, the schools an individual attends, access to green space, and the quality of other social goods, including public transportation.

Neighborhood is a key component of built environment, or the human-built structures that fill a physical space. Built environment refers to the green space, public parks, sidewalks, walkability, and playgrounds that might be in a space, all of which can influence well-being.

But environment as a social determinant of health can also refer to the non-built environment, like air and water quality. These factors have direct impacts on individual health; contaminated water can cause illness.

Moreover, climate change can impact health and well-being. Climate change has led to more drastic weather and climate events, as well as poorer water and air quality.

“Climate change is the single biggest health threat facing humanity, and health professionals worldwide are already responding to the health harms caused by this unfolding crisis,” the World Health Organization writes on its website.

WHO said the health risks associated with climate change can be wide-ranging and include:

• Injury and mortality from extreme weather events
• Heat-related illness
• Respiratory illness
• Water-born illness and other water-related health impacts
• Zoonoses, diseases that can be transmitted from animals to humans
• Vector-borne diseases
• Malnutrition or food-borne diseases
• Noncommunicable diseases
• Mental and psychosocial health

Educational Attainment

Educational attainment refers to the degree to which individuals complete their education, ranging from some college all the way up to doctoral degrees. There’s some clear-cut evidence underscoring the impact education has on overall health and well-being.

In 2021, researchers published in PNAS that folks with higher educational attainment tend to live longer. Adults with a bachelor’s degree are expected to live around 48.2 years out of a possible 50, compared to just 45.1 years for those without a college degree.

That’s likely a mixed result of the other social determinants of health that their education helped them circumvent and the good clinical outcomes apparent in those with higher education.

After all, educational attainment can influence some SDOH, like employment. It can also impact healthcare access and patient experience. Although there are exceptions, individuals with higher educational attainment may have higher health literacy, allowing them to more meaningfully engage in their own care management.

Healthy People 2030 has set its sights on education as a social determinant of health, crafting goals to create more educational equity among kids that will ideally endure into adulthood and positively impact well-being.

Adverse Childhood Experiences

Adverse childhood experiences, or ACEs, are “potentially traumatic events that occur in childhood,” according to the Centers for Disease Control and Prevention. Key ACEs may include

• Experiencing violence, abuse, or neglect
• Witnessing violence in the home or community
• Having a family member attempt or die by suicide
• Growing up in a household with substance use problems
• Growing up in a household with mental health problems
• Instability due to parental separation or household members being in jail or prison

Data has begun to show that ACEs can have a health impact. In 2023, researchers from McLean Hospital found that Black kids are more likely than White kids to have different brain structure that might lead to a higher predisposition to certain mental health conditions like post-traumatic stress disorder (PTSD). The team said this is likely the result of weathering and adverse childhood experiences.

Particularly, the disproportionate amount of childhood adversity Black kids face—mostly racism and socioeconomic burden—was linked to changes in the parts of the brain associated with PTSD. ACEs like racism can work as a “toxic stressor” to the brain, the researchers said.

A separate study from the National Institutes of Health and Eunice Kennedy Shriver National Institute of Child Health and Human Development uncovered certain ACEs that have an outsized impact on kids. Living in poverty, separation from a parent, and parental harshness or neglect are all key adverse childhood experiences (ACEs) that lead to an increased risk for premature death in adulthood, the team found.