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Social Determinants of Health

Social Determinants of Health


Create social and physical environments that promote good health for all.


Health starts in our homes, schools, workplaces, neighborhoods, and communities. We know that taking care of ourselves by eating well and staying active, not smoking, getting the recommended immunizations and screening tests, and seeing a doctor when we are sick all influence our health. Our health is also determined in part by access to social and economic opportunities; the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships. The conditions in which we live explain in part why some Americans are healthier than others and why Americans more generally are not as healthy as they could be.

Healthy People 2020 highlights the importance of addressing the social determinants of health by including “Create social and physical environments that promote good health for all” as one of the four overarching goals for the decade.1 This emphasis is shared by the World Health Organization, whose Commission on Social Determinants of Health in 2008 published the report, Closing the gap in a generation: Health equity through action on the social determinants of health.2 The emphasis is also shared by other U.S. health initiatives such as the National Partnership for Action to End Health Disparities 3 and the National Prevention and Health Promotion Strategy.4

The Social Determinants of Health topic area within Healthy People 2020 is designed to identify ways to create social and physical environments that promote good health for all. All Americans deserve an equal opportunity to make the choices that lead to good health. But to ensure that all Americans have that opportunity, advances are needed not only in health care but also in fields such as education, childcare, housing, business, law, media, community planning, transportation, and agriculture. Making these advances involves working together to:

  • Explore how programs, practices, and policies in these areas affect the health of individuals, families, and communities.
  • Establish common goals, complementary roles, and ongoing constructive relationships between the health sector and these areas.
  • Maximize opportunities for collaboration among Federal-, state-, and local-level partners related to social determinants of health.

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Ensure social and physical environments that promote optimal health for all.


Individual-level factors such as access to health care, health behaviors, and genetics have an influence on health, but they do not fully explain patterns of health and illness within communities and across populations.* It is the job of public health professionals to step back and look at these larger patterns and their causes. Across cities, towns, regions, and countries, disadvantaged populations consistently have poorer health than populations advantaged by greater economic and social resources.

Social determinants of health are the conditions in which people are born, live, work, and age that affect their health. Understanding the importance of social determinants of health is central to the history and practice of public health. For example, the links between health and housing have been clear since the earliest days of the U.S. public health system. In the 19th century, outbreaks of infectious diseases such as cholera, typhoid, and tuberculosis swept through crowded urban slums. Inquiries into the causes of these epidemics pointed to filthy and substandard living conditions, revealing an urgent need for effective public health administration.1

More recently, the World Health Organization’s (WHO’s) Commission on Social Determinants of Health noted that the social and physical circumstances in which people find themselves affect the way they live and their risk of illness and premature death.2 Healthy People 2020 stresses the importance of social determinants of health by highlighting them as 1 of the 4 overarching goals for the decade: Create social and physical environments that promote good health for all.

Why Are Social Determinants of Health Important?

Addressing the social determinants of health is important because:

  • These factors underlie preventable disparities in health status and disease outcomes. Poor health outcomes are often the result of the interaction between individuals and their social and physical environment.
  • Policies that result in changes to the social and physical environment can affect entire populations over extended periods of time, while simultaneously helping people to change individual-level behavior.3
  • Improving the conditions in which people are born, live, work, and age will ensure a healthier population, thereby improving national productivity, security, and prosperity through a healthier workforce.4

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Understanding Social Determinants of Health

Social and physical determinants of health impact a wide range of health, functioning, and quality-of-life outcomes. Social and physical determinants of health are often the result of decisions made at the higher levels of society. Answers to questions such as how available resources should be used and whose wishes will be given priority have shaped not only the current social and physical environments, but also health services and individual behaviors. The context in which individuals stay healthy or become ill is created by powerful decisions that are often made without their knowledge or input. Decision-making is influenced by:

  • Who is, and is not, at the table.
  • What is on the agenda.
  • Where and when the decisions are being made.
  • Why decisions are made, including social norms and values.

Understanding Social Determinants of Health

Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.”5 In addition to the more material attributes of “place,” the patterns of social engagement and sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.

Understanding the relationship between how population groups experience “place” and the impact of “place” on health is fundamental to the social determinants of health—including both social and physical determinants.

Examples of social determinants include:

  • Availability of resources to meet daily needs (e.g., safe housing and local food markets)
  • Access to educational, economic, and job opportunities
  • Access to health care services
  • Quality of education and job training
  • Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
  • Transportation options
  • Public safety
  • Social support
  • Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
  • Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)
  • Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
  • Residential segregation
  • Language/Literacy
  • Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
  • Culture

Examples of physical determinants include:

  • Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
  • Built environment, such as buildings, sidewalks, bike lanes, and roads
  • Worksites, schools, and recreational settings
  • Housing and community design
  • Exposure to toxic substances and other physical hazards
  • Physical barriers, especially for people with disabilities
  • Aesthetic elements (e.g., good lighting, trees, and benches)

By working to establish policies that positively influence social and economic conditions and those that support changes in individual behavior, we can improve health for large numbers of people in ways that can be sustained over time. Improving the conditions in which we live, learn, work, and play and the quality of our relationships will create a healthier population, society, and workforce.

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Healthy People 2020 Approach to Social Determinants of Health

A “place-based” organizing framework, reflecting five (5) key areas of social determinants of health (SDOH), was developed by Healthy People 2020.

These five key areas (determinants) include:

  • Economic Stability
  • Education
  • Social and Community Context
  • Health and Health Care
  • Neighborhood and Built Environment


a diagram of the five social determinants of health


Each of these five determinant areas reflects a number of critical components/key issues that make up the underlying factors in the arena of SDOH.

  • Economic Stability
    • Poverty
    • Employment
    • Food Insecurity
    • Housing Instability
  • Education
    • High School Graduation
    • Enrollment in Higher Education
    • Language and Literacy
    • Early Childhood Education and Development
  • Social and Community Context
    • Social Cohesion
    • Civic Participation
    • Discrimination
    • Incarceration
  • Health and Health Care
    • Access to Health Care
    • Access to Primary Care
    • Health Literacy
  • Neighborhood and Built Environment
    • Access to Foods that Support Healthy Eating Patterns
    • Quality of Housing
    • Crime and Violence
    • Environmental Conditions

This organizing framework has been used to establish an initial set of objectives for the topic area as well as to identify existing Healthy People objectives (i.e., in other topic areas) that are complementary and highly relevant to social determinants. It is anticipated that additional objectives will continue to be developed throughout the decade.

In addition, the organizing framework has been used to identify an initial set of evidence-based resources and other key tools/examples of how a social determinants approach is or may be implemented at a state and local level.

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Emerging Strategies To Address Social Determinants of Health

A number of tools and strategies are emerging to address the social determinants of health, including:

  • Use of Health Impact Assessments to review needed, proposed, and existing social policies for their likely impact on health6
  • Application of a “health in all policies” strategy, which introduces improved health for all and the closing of health gaps as goals to be shared across all areas of government4, 7


1Secretary’s Advisory Committee on Health Promotion and Disease Prevention Objectives for 2020. Healthy People 2020: An Opportunity to Address the Societal Determinants of Health in the United States. July 26, 2010. Available from:

2World Health Organization, Commission on Social Determinants of Health. Closing the Gap in a Generation: Health equity through action on the social determinants of health. Available from:

3National Partnership for Action: HHS Action Plan to Reduce Racial and Ethnic Health Disparities, 2011; and The National Stakeholder Strategy for Achieving Health Equity, 2011. Available from:

4The National Prevention and Health Promotion Strategy. The National Prevention Strategy: America’s Plan for Better Health and Wellness, June 2011. Available from:

5The Institute of Medicine. Disparities in Health Care: Methods for Studying the Effects of Race, Ethnicity, and SES on Access, Use, and Quality of Health Care, 2002.

6Health Impact Assessment: A Tool to Help Policy Makers Understand Health Beyond Health Care. Annual Review of Public Health 2007;28:393-412. Retrieved October 26, 2010. Available from: 

7European Observatory on Health Systems and Policies. Health in All Policies: Prospects and potentials, 2006. Accessed on June 16, 2011. Available from: [PDF - 1.23 MB]

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