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Understanding Social Determinants of Health

Why are some people more likely to get sick?

Sometimes, the factors that go into whether someone has health challenges are straightforward – maybe they are genetically pre-disposed to having an illness or chronic health condition.  Perhaps they sustained a significant injury that has compromised their health. 

Sometimes, however, other factors come into play.  External forces and environmental conditions can negatively impact someone’s health.  In the field of health care, there is a growing recognition that these environmental circumstances have a considerable impact on our health.  These are known as the social determinants of health – that’s a mouthful, so it’s also called SDOH for short. 

What are these social determinants?

According to the U.S. Department of Health and Human Services, SDOH can be grouped into five broad areas:

  • Economic stability
  • Education access and quality
  • Health care access and quality
  • Neighborhood and built environment
  • Social and community context
Figure 1: Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved Aug. 2, 2023, from

What does all this mean?  Let’s break down each of these factors that influence our health. 

Economic Stability

Nationwide, 12.8% of Americans live in poverty, according to the most recent data from the U.S. Census Bureau.  In Texas, that percentage is even higher – 14.2%.  Even worse, one out of five Texas children under age 18 live in poverty. 

People without adequate financial resources may have a difficult time accessing basic needs, such as healthy foods, safe housing and of course, health care. 

At the same time, a person’s health challenges may in turn lead to economic insecurity.  For example, arthritis is a leading cause of people being unable to work.  If a condition like arthritis forces someone to leave the workforce, this can lead to financial hardship. 

Strategies such as career services, better access to affordable childcare and employment programs may help to mitigate economic instability, which in turn can positively impact someone’s health. 

Education Access & Quality

Studies show that people with higher levels of education have increased odds of living longer and healthier lives.  In general, people with higher levels of education tend to earn more money throughout their lives, directly increasing their economic stability and thereby improving health outcomes. 

Living in poverty is stressful for people of all ages, including children.  Stress has been shown to negatively impact children’s brain development, harming their ability to excel in school. 

Health Care Access and Quality

One of the best ways to safeguard your health is to have a primary care provider (PCP).  Having a regular visit with your PCP ensures that you have access to preventative care.  This includes important health screenings, such as those that detect high cholesterol, hypertension and diabetes.  Certain cancers, such as breast and colorectal, can also be caught early with regular screenings.  Your PCP also helps you stay on track with vaccines you need to receive and addresses any health concerns you may have. 

Unfortunately, too many people do not have access to a PCP.  Nationwide, 10% of people do not have health insurance, which makes it difficult for them to access routine health care.  In Texas, the uninsured rate is much higher – 18%, the highest in the country. 

When people don’t have access to affordable health care, they are more likely to let health problems go unaddressed.  When health conditions go undetected, they become harder to treat down the road.  People in these situations often are forced to seek care in a hospital emergency department. 

Having regular access to health care is one of the most important things we can do to safeguard and improve our health.  Through early detection of health conditions and preventative medicine, we can detect and treat problems before they become too serious. 

Neighborhood and Built Environment

Where we live has a direct impact on our health.  If you live in a violent or otherwise unsafe area, your chances of being unhealthy – or getting injured – increase.  For families who live in an area that is affected by pollution, their health can be negatively impacted. 

Some neighborhoods are considered “food deserts” – this is defined as an area that does not have convenient access to a grocery store.  People in food deserts may not be able to readily access fresh meat and produce and must rely more on the processed, packaged foods they can buy at a convenience store.  The food desert problem is compounded if people do not have access to reliable transportation. 

The neighborhood may also be detrimental to someone’s health if there is not a safe place to exercise.  Even going for a walk can be difficult in some areas, due to lack of sidewalks or dangerous streets. 

For people in Texas, lack of adequate air conditioning is a reality for many who live in older homes or apartment units that are not well-maintained.  Sustained exposure to heat increases strain on the heart and otherwise negatively impacts health.   

Social and Community Context

Negative experiences and interactions with people can adversely affect our health.  For example, people who experience racism and discrimination can suffer negative health consequences in a multitude of ways.  Children who face bullying can see their physical and mental health suffer. 

Racial disparities in health care access and health outcomes are a major social determinant.  For example, consider heart disease, the leading cause of death for men and women in the United States:

  • African Americans are 30% more likely to die from heart disease than non-Hispanic whites (2019 data),
  • African Americans are 30% more likely to have high blood pressure than non-Hispanic whites and are less likely to have their blood pressure under control and
  • African American women are 50% more likely to have high blood pressure, compared to non-Hispanic white women.

How is Medicine Addressing SDOH?

There is a growing recognition within the field of medicine that SDOH must be addressed as part of a comprehensive approach to health care.  “For many patients, the societal and environmental factors they live with have a negative impact on their health outcomes,” explains Dr. Travis Crudup, a general surgeon in Fort Worth.  “Those are things they cannot easily address on their own, and they’re also things that I cannot always solve in the exam room or by writing a prescription.  But we need to work together to figure out solutions.”

Professional medical groups, such as the American Medical Association, the Texas Medical Association and the American Academy of Family Physicians,  are increasingly emphasizing SDOH and giving physicians new resources to help respond to these factors. 

The Centers for Medicare and Medicaid Services is testing a Health-Related Social Needs Screening Tool to be used in the Accountable Health Communities model.  This tool is designed to help identify patient needs in five main areas:

  • Housing instability
  • Food insecurity
  • Transportation challenges
  • Utility needs
  • Interpersonal safety

Here is an excerpt from the questionnaire, which illustrates the types of challenges that need to be identified and addressed:

As you can see, these types of questions get to the heart of fundamental health and wellness determinants.  At the same time, they are also very personal questions. 

“One of the challenges in working through SDOH is that some patients are reluctant to discuss the challenges they are facing,” says Dr. Michelle Torres, a family practice and sports medicine physician in Fort Worth.  “Maybe they are embarrassed or otherwise uncomfortable – that’s understandable.”

Primary care providers – family doctors, internal medicine physicians, obstetricians/gynecologists and pediatricians – work to establish open and ongoing lines of communication with their patients to make these conversations less difficult. 

“We work intentionally to build trust with our patients, so they feel comfortable talking to us about what’s happening in their lives,” says Dr. James Harvey, a Fort Worth family practice physician.  “When we have that kind of dialogue, we may be able to connect the patient with resources to address the challenges they are facing.”

A Wholistic Approach

The complexities of the many social determinants of health require a comprehensive and wholistic response from a broad array of stakeholders:  doctors and other health care professionals, social service agencies, government, schools, non-profits and the business community. 

The challenges presented by SDOH did not arise overnight and will not be solved quickly.  However, with greater communication and collaboration among stakeholders and a greater willingness to acknowledge the tremendous heath impacts of these factors, we can make a meaningful difference for many going forward. 

This article has been reviewed and approved by a panel of Privia Medical Group North Texas physicians. 

This article contains information sourced from:

U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion

U.S. Department of Health and Human Services, Office of Minority Health

U.S. Census Bureau

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