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Social Determinants
A range of personal, social, economic, and environmental factors contribute to individual and population health. For example, people with a quality education, stable employment, safe homes and neighborhoods, and access to preventive services tend to be healthier throughout their lives.1 Conversely, poor health outcomes are often made worse by the interaction between individuals and their social and physical environment.
Social determinants are in part responsible for the unequal and avoidable differences in health status within and between communities. The selection of Social Determinants as a Leading Health Topic recognizes the critical role of home, school, workplace, neighborhood, and community in improving health.
The Social Determinants Leading Health Indicator is:
Although education is the Leading Health Indicator for this topic, many of the Healthy People 2020 objectives address social determinants as a means to improve population health.
Health Impact of Social Determinants
Social and physical determinants affect a wide range of health, functioning, and quality of life outcomes. For example:
Access to parks and safe sidewalks for walking is associated with physical activity in adults.2
Education is associated with:
Longer life expectancy
Improved health and quality of life
Health-promoting behaviors like getting regular physical activity, not smoking, and going for routine checkups and recommended screenings.3
Discrimination, stigma, or unfair treatment in the workplace can have a profound impact on health; discrimination can increase blood pressure, heart rate, and stress, as well as undermine self-esteem and self-efficacy.3
Family and community rejection, including bullying, of lesbian, gay, bisexual, and transgender youth can have serious and long-term health impacts including depression, use of illegal drugs, and suicidal behavior.4
Places where people live and eat affect their diet. More than 23 million people, including 6.5 million children, live in “food deserts”—neighborhoods that lack access to stores where affordable, healthy food is readily available (such as full-service supermarkets and grocery stores).5
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Social Determinants Across the Life Stages
From infancy through old age, the conditions in the social and physical environments in which people are born, live, work, and age can have a significant influence on health outcomes.
Children
Early and middle childhood provide the physical, cognitive, and social-emotional foundation for lifelong health, learning, and well-being. A history of exposure to adverse experiences in childhood, including exposure to violence and maltreatment, is associated with health risk behaviors such as smoking, alcohol and drug use, and risky sexual behavior, as well as health problems such as obesity, diabetes, heart disease, sexually transmitted diseases, and attempted suicide.6
Features of the built environment, such as exposure to lead-based paint hazards and pests, negatively affect the health and development of young children.
Adolescents
Because they are in developmental transition, adolescents and young adults are particularly sensitive to environmental influences. Environmental factors, including family, peer group, school, neighborhood, policies, and societal cues, can either support or challenge young people’s health and well-being. Addressing young people’s positive development facilitates their adoption of healthy behaviors and helps to ensure a healthy and productive future adult population.
Adolescents who grow up in neighborhoods characterized by poverty are more likely to be victims of violence; use tobacco, alcohol, and other substances; become obese; and engage in risky sexual behavior.7
Adults
Access to and availability of healthier foods can help adults follow healthful diets. For example, better access to retail venues that sell healthier options may have a positive impact on a person’s diet. These venues may be less available in low-income or rural neighborhoods.
Longer hours, compressed work weeks, shift work, reduced job security, and part-time and temporary work are realities of the modern workplace and are increasingly affecting the health and lives of U.S. adults. Research has shown that workers experiencing these stressors are at higher risk of injuries, heart disease, and digestive disorders.8
Older Adults
Availability of community-based resources and transportation options for older adults can positively affect health status. Studies have shown that increased levels of social support are associated with a lower risk for physical disease, mental illness, and death.9, 10
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Disparities and Social Determinants
Race and ethnicity, gender, sexual identity, age, disability, socioeconomic status, and geographic location all contribute to an individual’s ability to achieve good health. It is important to recognize the impact that social determinants have on health outcomes of specific populations. Social determinants are often a strong predictor of health disparities. For example:
In 2007 to 2008, the Asian or Pacific Islander population had the highest rate of high school graduation among racial and ethnic groups, with 91.4% of students attending public schools graduating with a diploma 4 years after starting 9th grade compared to rates among non-Hispanic white (81.0%), American Indian or Alaska Native (64.2%), Hispanic (63.5%), and non-Hispanic black (61.5%) populations.
According to the National Assessment of Adult Literacy, African American, Hispanic, and American Indian or Alaska Native adults were significantly more likely to have below basic health literacy compared to their white and Asian or Pacific Islander counterparts. Hispanic adults had the lowest average health literacy score compared to adults in other racial and ethnic groups.11
In 2007, African Americans and Hispanics were more likely to be unemployed compared to their white counterparts. Further, adults with less than a high school education were 3 times more likely to be unemployed than those with a bachelor’s degree.12
Low socioeconomic status is associated with an increased risk for many diseases, including cardiovascular disease, arthritis, diabetes, chronic respiratory diseases, and cervical cancer as well as for frequent mental distress.12
Low-income minorities spend more time traveling to work and other daily destinations than do low-income whites because they have fewer private vehicles and use public transit and car pools more frequently.12
About the Disparities Data
Standard errors are not available, so the statistical significance of stated disparities could not be assessed.
Data for this measure are available annually and come from the Common Core of Data, U.S. Department of Education, National Center for Education Statistics. National data include data from 49 states and Washington, DC. Data by race and ethnicity include data from 48 states and Washington, DC. See the annual publication Public School Graduates and Dropouts From the Common Core of Data for more information and data years not currently included in Healthy People: http://nces.ed.gov/ccd/pub_dropouts.asp .
References
1 National Prevention Council, Office of the Surgeon General, U.S. Department of Health and Human Services. National Prevention Strategy . Washington, DC: 2011. p.6. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf [PDF - 4.67MB]
2 Booth ML, Owen N, Bauman A, et al. Social-cognitive and perceived environment influences associated with physical activity in older Australians. Prev Med . 2000;31:15–22.
3 National Prevention Council, Office of the Surgeon General, U.S. Department of Health and Human Services. National Prevention Strategy . Washington, DC: 2011. p.22. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf [PDF - 4.67MB]
4 National Prevention Council, Office of the Surgeon General, U.S. Department of Health and Human Services. National Prevention Strategy . Washington, DC: 2011. p.48. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf [PDF - 4.67MB]
5 National Prevention Council, Office of the Surgeon General, U.S. Department of Health and Human Services. National Prevention Strategy . Washington, DC: 2011. p.34. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf [PDF - 4.67MB]
6 National Prevention Council, Office of the Surgeon General, U.S. Department of Health and Human Services. National Prevention Strategy . Washington, DC: 2011. p.41. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf [PDF - 4.67MB]
7 National Prevention Council, Office of the Surgeon General, U.S. Department of Health and Human Services. National Prevention Strategy . Washington, DC: 2011. p.25. Available from http://www.healthcare.gov/prevention/nphpphc/strategy/report.pdf [PDF - 4.67MB]
8 Rosa RR, Colligan MJ. Plain Language About Shiftwork . Cincinnati, OH: National Institute for Occupational Safety and Health, U.S. Department of Health and Human Services; 1997. Available from http://www.cdc.gov/niosh/pdfs/97-145.pdf [PDF - 572KB]
9 Seeman TE. Health promoting effects of friends and family on health outcomes in older adults. Am J Health Promot . 2000;14:362–370.
10 Stroebe W. Moderators of the stress-health relationship. In: Stroebe W. Social Psychology and Health . Philadelphia, PA: Open University Press; 2000:236–273.
11 Kutner M, Greenberg E, Jin Y, et al. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy . Washington, DC: National Center for Education Statistics, U.S. Department of Education; 2006.
12 Brennan Ramirez LK, Baker EA, Metzler M. Promoting Health Equity: A Resource To Help Communities Address Social Determinants of Health . Atlanta, GA: Centers for Disease Control and Prevention; 2008. Available from http://www.cdc.gov/nccdphp/dach/chhep/pdf/SDOHworkbook.pdf [PDF - 4.64MB]
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