- What makes some people healthy and others unhealthy?
- How can we create a society in which everyone has a chance to live a long, healthy life?
Healthy People 2020 is exploring these questions by:
- Developing objectives that address the relationship between health status and biology, individual behavior, health services, social factors, and policies.
- Emphasizing an ecological approach to disease prevention and health promotion. An ecological approach focuses on both individual-level and population-level determinants of health and interventions.
The range of personal, social, economic, and environmental factors that influence health status are known as determinants of health.
Determinants of health fall under several broad categories:
It is the interrelationships among these factors that determine individual and population health. Because of this, interventions that target multiple determinants of health are most likely to be effective. Determinants of health reach beyond the boundaries of traditional health care and public health sectors; sectors such as education, housing, transportation, agriculture, and environment can be important allies in improving population health.
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Policymaking
Policies at the local, state, and federal level affect individual and population health. Increasing taxes on tobacco sales, for example, can improve population health by reducing the number of people using tobacco products.
Some policies affect entire populations over extended periods of time while simultaneously helping to change individual behavior. For example, the 1966 Highway Safety Act and the National Traffic and Motor Vehicle Safety Act authorized the Federal Government to set and regulate standards for motor vehicles and highways. This led to an increase in safety standards for cars, including seat belts, which in turn reduced rates of injuries and deaths from motor vehicle accidents.1
Social Factors
Social determinants of health reflect the social factors and physical conditions of the environment in which people are born, live, learn, play, work, and age. Also known as social and physical determinants of health, they impact a wide range of health, functioning, and quality-of-life outcomes.
Don’t miss the Social Determinants of Health topic area and objectives.
Examples of social determinants include:
- Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods
- Social norms and attitudes, such as discrimination
- Exposure to crime, violence, and social disorder, such as the presence of trash
- Social support and social interactions
- Exposure to mass media and emerging technologies, such as the Internet or cell phones
- Socioeconomic conditions, such as concentrated poverty
- Quality schools
- Transportation options
- Public safety
- Residential segregation
Examples of physical determinants include:
- Natural environment, such as plants, weather, or climate change
- Built environment, such as buildings or transportation
- Worksites, schools, and recreational settings
- Housing, homes, and neighborhoods
- Exposure to toxic substances and other physical hazards
- Physical barriers, especially for people with disabilities
- Aesthetic elements, such as good lighting, trees, or benches
Poor health outcomes are often made worse by the interaction between individuals and their social and physical environment.
For example, millions of people in the United States live in places that have unhealthy levels of ozone or other air pollutants. In counties where ozone pollution is high, there is often a higher prevalence of asthma in both adults and children compared with state and national averages. Poor air quality can worsen asthma symptoms, especially in children.2
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Health Services
Both access to health services and the quality of health services can impact health. Healthy People 2020 directly addresses access to health services as a topic area and incorporates quality of health services throughout a number of topic areas.
Lack of access, or limited access, to health services greatly impacts an individual’s health status. For example, when individuals do not have health insurance, they are less likely to participate in preventive care and are more likely to delay medical treatment.3
Don’t miss the Access to Health Services topic area and objectives.
Barriers to accessing health services include:
- Lack of availability
- High cost
- Lack of insurance coverage
- Limited language access
These barriers to accessing health services lead to:
- Unmet health needs
- Delays in receiving appropriate care
- Inability to get preventive services
- Hospitalizations that could have been prevented
Individual Behavior
Individual behavior also plays a role in health outcomes. For example, if an individual quits smoking, his or her risk of developing heart disease is greatly reduced.
Many public health and health care interventions focus on changing individual behaviors such as substance abuse, diet, and physical activity. Positive changes in individual behavior can reduce the rates of chronic disease in this country.
Examples of individual behavior determinants of health include:
- Diet
- Physical activity
- Alcohol, cigarette, and other drug use
- Hand washing
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Biology and Genetics
Some biological and genetic factors affect specific populations more than others. For example, older adults are biologically prone to being in poorer health than adolescents due to the physical and cognitive effects of aging.
Sickle cell disease is a common example of a genetic determinant of health. Sickle cell is a condition that people inherit when both parents carry the gene for sickle cell. The gene is most common in people with ancestors from West African countries, Mediterranean countries, South or Central American countries, Caribbean islands, India, and Saudi Arabia.
Examples of biological and genetic social determinants of health include:
- Age
- Sex
- HIV status
- Inherited conditions, such as sickle-cell anemia, hemophilia, and cystic fibrosis
- Carrying the BRCA1 or BRCA2 gene, which increases risk for breast and ovarian cancer
- Family history of heart disease
References
1Centers for Disease Control and Prevention. Achievements in public health, 1900–1999 motor-vehicle safety: A 20th century public health achievement [Internet]. MMWR Weekly. 1999 May 14;48(18);369–74 [cited 2010 August 27]. Available from: //www.cdc.gov/mmwr/preview/mmwrhtml/mm4818a1.htm.
2State of the Air [Internet]. Washington, DC: American Lung Association. Available from: //www.stateoftheair.org.
3Agency for Healthcare Research and Quality (AHRQ). National healthcare disparities report, 2008. Rockville (MD): U.S. Department of Health and Human Services, AHRQ; 2009 Mar. Pub no. 09-002. Available from: //www.ahrq.gov/qual/nhdr08/nhdr08.pdf [PDF – 2.6 MB].
Additional Resources
Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health [Internet]. Geneva: World Health Organization; 2008 [cited 2010 May 10]. Available from: //whqlibdoc.who.int/hq/2008/WHO_IER_CSDH_08.1_eng.pdf [PDF – 4.3 MB].
Harris K, Holden C, Chen M. Background information on national indicators for social determinants of health. Paper presented to the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, National Opinion Research Center; January 5, 2010.
Institute of Medicine. Unequal treatment: Confronting racial and ethnic disparities in health. Washington, DC: National Academies Press; 2003.
U.S. Department of Health and Human Services. Draft report of the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 on Social Determinants; revised 2009 Sep 9.
Wilkinson R, Marmot M, editors. Social determinants of health: The solid facts [Internet]. 2nd ed. Copenhagen: World Health Organization; 2003 [cited 2010 May 26]. Available from: //www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf [PDF – 470 KB].
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Social determinants of health are an individual’s personal circumstances that impact their health and well-being. They include political, socioeconomic, and cultural factors, alongside how easily someone can access healthcare, education, a safe place to live, and nutritious food.
The World Health Organization (WHO) defines social determinants of health as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”
Social determinants of health are an extensive range of factors that exist throughout all aspects of society. However, they are separate from medical care or a person’s individual lifestyle choices.
A study cited by the National Academy of Medicine found that medical care itself only accounted for 10–20% of the contributors to people’s health outcomes.
By contrast, the many social determinants of health play a much bigger role in influencing a person’s health, making up 80–90% of the contributing factors.
This article explores social determinants of health, including their forms and the roles they play in shaping healthcare outcomes.
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Social determinants of health fall into five broad groups:
- Healthcare: This group encompasses a person’s access to healthcare and its quality. Factors include:
- access to primary healthcare
- health insurance coverage
- health literacy
- Economic stability: This refers to the link between a person’s finances and their health. Examples of factors are:
- poverty
- employment
- food security
- housing stability
- Education: This category focuses on the connection between a person’s access to education and its quality, and their health. Examples include:
- secondary education
- higher education
- language and literacy
- childhood development
- Social and community life: This group revolves around the ways a person lives, works, plays, and learns and how these relate to the person’s health. Factors include:
- civic participation
- discrimination
- incarceration
- conditions within a workplace
- Neighborhood: This group considers a person’s housing and environment and the role they play in the person’s health. Factors include:
- quality of housing
- transportation
- access to healthy foods
- water quality
- crime and violence
The factors in each group are interwoven and often related to each other.
Around 1 in 10 people in the United States are living without health insurance. This means they may not have a primary healthcare professional. They may also not have the money to make vital purchases for their health, such as medications or tests.
Additionally, people may live too far away from a healthcare clinic to get the quality of care they deserve.
Black Americans are more likely to be uninsured than white Americans. In 2018, 9.7% of Black Americans did not have health insurance. Among white Americans, this rate was 5.4%.
Improving quality healthcare access
There are many ways to help improve public access to quality healthcare. For example, clinics could offer remote appointments where possible.
The Healthy People 2030 campaign has several objectives in place to improve healthcare access. For example, it aims to:
- reduce the wait time in emergency departments
- increase the proportion of adults who receive lung cancer screenings
- increase community services that can provide health screenings
Learn more about health equity here.
Economic stability is vital to affording lifestyle choices and paying for quality medical care that keeps people healthy.
A well-paying, steady job is critical for food security and housing stability. Savings are essential for managing chronic conditions or emergencies.
However, 1 in 10 people in the U.S. live in poverty.
Those in steady work may not earn enough to gain access to good quality healthcare. Moreover, chronic conditions or disabilities may put people at an even greater disadvantage.
Many studies have shown wide gaps in health outcomes between countries and communities that have different social determinants of health. People living in high income countries have a life expectancy that is 19 years higher than that of people living in low income countries.
Improving economic stability
The Healthy People 2030 campaign is organizing programs to increase funding for many institutions, including:
- employment programs
- career counseling
- high quality child care
Establishing certain policies can help people pay for their:
- food
- housing
- healthcare
- education
Learn more about health insurance here.
Data from the U.S. and Europe show a strong association between health indicators and an individual’s income and education level.
Whether a child or adolescent can access quality education throughout their development can determine their future living conditions.
Early childhood education is essential for social and mental development, and good quality high school education can open new doors to further education and employment opportunities.
Children that come from low income households, have disabilities, or experience social discrimination at an early age may be less likely to do well in school. They also face barriers to higher levels of education.
As a result, people from low income households often struggle to get safe, well-paying jobs. It also means they are more likely to experience health conditions such as heart disease, diabetes, or depression.
The stress of having economic difficulties can also adversely impact a person’s health and well-being. For example, living in poverty can negatively affect a child’s brain development.
Improving access to education
The funding of Title I schools in the U.S. has encouraged continued education among those living in low income communities.
The Health People 2030 campaign has several programs in place to improve the proportion of people who have access to high quality education across all age groups.
Interactions between individuals and their family members and co-workers can affect their health.
For example, workplace conditions and discrimination can have an impact on peoples’ moods and self-esteem.
Moreover, high incarceration rates, absent parents, and bullying can all affect a child’s development and feelings of loneliness. This negative effect on a child’s health can continue into their adulthood.
Learn about the effects of racism on mental health here.
Improving community environment
Many social determinants of health are factors that people cannot control individually. Fostering positive relationships at home, at work, or in a person’s community can improve public well-being.
Programs that can better people’s social determinants of health include the social campaigns on the implementation of smoke-free zones that curbed tobacco use and decreased smoking-related disease.
The Healthy People 2030 campaign aims to help people get the social support and care they might need.
For example, it is working to reduce anxiety and depression by providing more support to children and those caring for people with disabilities, among other groups.
A person’s neighborhood and living conditions can directly impact their health and safety.
Many individuals worldwide live in areas with:
- elevated rates of violent crime
- high levels of environmental pollutants
- unsafe air and drinking water
Marginalized racial and ethnic groups, as well as people from low income households, are more likely to live in places that carry these risks.
Even at work, people can come into contact with things that could harm their health, such as secondhand smoke.
Improving living conditions
At local, state, and national levels, people can make changes to improve public environments and overall health.
For example, company owners can reduce health and safety risks at work, and local councils can establish pedestrian or cycle paths.
Learn about how air pollutants affect health here.
The effects of the social determinants of health are more pronounced during crises, as seen in the ongoing COVID-19 pandemic.
A 2021 study found that racial background and socioeconomic status affected COVID-19 incidence and mortality. Marginalized groups are more likely to experience discrimination, crowded living conditions, reliance on public transport, and financial insecurity.
These issues can lead to significant differences in health outcomes during a pandemic.
The conditions into which people are born and in which they live their lives have a profound effect on their health.
Where a person is born, lives, goes to school, and works is what experts refer to as social determinants of health. These factors influence the opportunities a person has to eat a nutritious diet, have a good education, live and work in a toxin-free environment, access healthcare, and more.
The WHO and governmental bodies continually work toward improving the social determinants of health for all citizens to allow equal access to essential healthcare.