Social Determinants of Health 2020

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.

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.

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.

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:

  1. Availability of resources to meet daily needs (e.g., safe housing and local food markets)
  2. Access to educational, economic, and job opportunities
  3. Access to health care services
  4. Quality of education and job training
  5. Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
  6. Transportation options
  7. Public safety
  8. Social support
  9. Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
  10. Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)
  11. Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
  12. Residential segregation
  13. Language/Literacy
  14. Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
  15. 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.

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:

  1. Economic Stability
  2. Education
  3. Social and Community Context
  4. Health and Health Care
  5. Neighborhood and Built Environment

a diagram of the five social determinants of health
Each of these five determinant areas reflects a number of key issues that make up the underlying factors in the arena of SDOH.

Economic Stability
Food Insecurity
Housing Instability
Early Childhood Education and Development
Enrollment in Higher Education
High School Graduation
Language and Literacy
Social and Community Context
Civic Participation
Social Cohesion
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
Crime and Violence
Environmental Conditions
Quality of Housing

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 examples of how a social determinants approach is or may be implemented at a state and local level.

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 health

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 government.

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