Social Determinants of Health

What are social determinants of health?

Social determinants of health (SDOH) are the personal, social and environmental things that shape your health and well-being. These are factors like how much money you make, where you live and what resources your neighborhood offers. SDOH are all the nonmedical aspects of your life that you might not think to talk about with your healthcare provider because you don’t see how they connect to your health.

Yet research shows SDOH aren’t just related to your health — they can actually determine your health. That means they influence your risk for certain medical conditions, the medical care you’re able to receive and how you feel from day to day.

For example, having a steady income and health insurance helps you buy nutritious foods and get regular health screenings. If you have a car, it’s easier to get to appointments or pick up your medications.

But working without paid time off or living far from a grocery store without reliable transportation can make it a lot harder to do things that support your health — like eating fresh produce or regularly seeing a primary care provider.

What are some examples of social determinants of health?

Examples of SDOH include:

• Your income.
• Your education level.
• Your job and its benefits — like health insurance and paid time off.
• The availability of resources in your neighborhood — like nutritious foods, public transportation and childcare.
• Your sense of safety and security in your neighborhood.
• The availability of medical care.
• The quality of the air you breathe and the water you drink.
• Your relationships and social connections.

These are just a few examples. SDOH are everywhere you live, work and hang out. It can help to sort examples of SDOH into groups, or what researchers call domains. These are the five domains of SDOH, according to the U.S. Department of Health and Human Services:

• Economic stability: Factors related to how much money you earn and how well your income can meet all your family’s health and other needs.
• Education access and quality: Factors related to the education you receive and how well it supports your individual learning needs — including those related to how your brain works.
• Healthcare access and quality: Factors related to the medical care you receive and how well it can meet all your physical and mental health needs.
• Neighborhood and built environment: Factors related to your zip code, or the specific community you live in — including resources that support your health and safety.
• Social and community context: Factors related to your relationships with family, friends, coworkers and community members.

The infographic below offers examples of SDOH within each domain.

It’s important to keep in mind that these factors all interact and influence one another. For example, poverty affects every aspect of your life — from what you eat to where you live and the resources you can access. When you have kids, lack of affordable childcare may affect your ability to work. A neighborhood without public transport or sidewalks makes it hard to shop for groceries or get to your medical appointments.

In other words, social determinants of health don’t exist in isolation — and even just one or two barriers can have a ripple effect on your life and your health.

So, what does all of this mean for you? How do you know which SDOH are affecting your life? Think about the questions below — they’re organized according to SDOH domain. Ideally, you should be able to answer “yes” to all of these questions. Make a note of which questions you answer “no” to. These are topics you may want to discuss with a loved one, mentor or healthcare provider.

Economic stability

• Do you have enough money to buy nutritious foods?
• Can you afford to pay for medical care, including appointments and medications?
• Do you have enough money to pay for housing?
• Do you have enough money to pay your utilities and other bills?
• Do you have access to affordable childcare?
• Do you feel you have job security?
• Does your employer offer health insurance?
• Does your employer offer paid time off or sick leave?
• If you’re unemployed, do you have access to programs to help you find a job?
• Do you have access to career counseling?

Education access and quality

For this domain, it may be most helpful to think about the resources available to your child (current or future). But you can also reflect on your own past or current educational experiences.

• Does your child have access to a high-quality K-12 education?
• Will your child likely have the opportunity to finish high school?
• Are there resources available to support your child’s individual needs — for example, support for learning disabilities or intellectual disabilities?
• Does your family have the funds to send your child to college or vocational school?
• Does your child have positive relationships with peers at school?

Healthcare access and quality

• Do you have health insurance?
• Do you have prescription drug insurance?
• Do you have dental insurance?
• Do you have a primary care provider?
• Can you understand your healthcare provider’s explanations?
• Do you feel comfortable talking to your provider?
• Can you access and understand health-related information?
• Are you able to access your medical records?
• Do you have access to preventive screenings for conditions like sexually transmitted infections (STIs) and cancer?
• Are you able to access the treatments you need for your medical condition(s)?
• Do you have a way to get to your medical appointments?

Neighborhood and built environment

• Can you easily access a well-stocked grocery store?
• Can you access a farmer’s market or another source of fresh produce?
• Do you have access to the internet?
• Do you feel safe in your home?
• Do you feel safe in your neighborhood?
• Are there sidewalks in your neighborhood?
• Are there bike lanes?
• Does your tap water contain fluoride?
• Is your housing affordable? (Affordable means it costs no more than 30% of your income.)
• Is your home free of lead?
• Is your street quiet enough that you can sleep?
• Does your building accommodate any mobility needs you have? (For example, are there ramps or elevators?)

Social and community context

• Do you have family and/or friends who make you feel supported and uplifted?
• Do you belong to any social groups, like a church, volunteer group or hiking club?
• Do you have someone you can talk to when you’re upset?
• Is there someone available to help you with basic needs if you’re recovering from a hospital stay or surgery?
• Do you have the resources you need to care for children or others who rely on you?
• Do you feel welcome at your workplace?
• Do you feel welcome in your neighborhood?
• Do you feel connected with others more often than you feel lonely?

Why are social determinants of health significant?

SDOH are significant because they can raise or lower your risk for various diseases, impacting your life expectancy. SDOH have this power because they influence how your genes work and the choices you can make from day to day. Let’s take a closer look.

SDOH and your genes

Your genes affect your disease risk. For example, you might inherit a genetic mutation (like changes in your BRCA1 or BRCA2 genes) that raises your risk for a condition like cancer. Or maybe there’s a history of heart disease among your biological family members that makes you more likely to develop heart issues.

But inherited genetic mutations are only one part of the story. Researchers who study epigenetics are just beginning to learn how your environment influences the way your genes work. We’re seeing how everything from the upbringing you received as a child to the quality of the air you breathe can turn certain genes “on” or “off.”

Such epigenetic changes aren’t the same as genetic mutations — your DNA sequence is still the same. But your genes aren’t working how they should. It’s like having light bulbs in your lamps but no one there to flip the switch.

Genes that are on when they should be off, or off when they should be on, can cause all sorts of harmful changes inside your body. Tumor growth is one example. This means social determinants of health (like social relationships and environmental toxins) can influence your genes — the parts of you that have always seemed so set in stone.

SDOH and your choices

Beyond genetics, your choices also play a role in influencing your disease risk. You can’t change your inherited risk factors. But knowing you’re at risk might lead you to make certain choices — like going for cancer screenings, following a Mediterranean Diet or getting your blood pressure checked regularly. Doing these things can help lower your risk for certain conditions or make it more likely to get early treatment and survive.

But is the choice truly up to you? Often, it’s not. Barriers might stand in your way, like lack of transportation to get to your appointments or lack of income to buy nutritious foods. And willpower can only get you so far.

In an ideal world, we’d have health equity — a situation where everyone has access to high-quality resources and opportunities to support their health. We’re not there yet, but identifying how social determinants of health affect you is the first step toward leveling the playing field. Healthcare providers use various screening tools to learn how SDOH are affecting you and what can be done to help.

What is a social determinants of health screening tool?

SDOH screening tools are surveys or questionnaires that you fill out before meeting with a healthcare provider. For example, you might fill out a digital form before a primary care visit. The form will ask you about different aspects of your life like housing, relationships and access to food. The questions may be similar to those listed earlier in this article. Your provider may talk about your responses during your appointment.

The more you feel comfortable sharing, the more your provider can help you. They might talk through possible solutions to issues you’re facing or connect you with community resources. Maybe there’s something else going on in your life that the form didn’t ask you about. If so, tell your provider when you meet. If your provider can’t help with a specific concern, they’ll point you to someone who can.

A note from Cleveland Clinic

Social determinants of health start affecting you from the moment you’re born, and they continue to shape your health as you get older. Some factors can change over time. For example, you might make a steady income for a while but then suddenly get laid off. Or you might move from an area with an extensive bus route and sidewalks to a neighborhood that’s unsafe to navigate without a car — and maybe you can’t afford one. Factors that used to support your health might suddenly undermine it.

But things can also go the opposite way. You might go many years without health insurance or paid time off only to find a job that offers you both — along with the ability to move to a home on a quiet street where you can finally get a good night’s sleep. Life has many moving parts, and the factors that affect your health aren’t set in stone.

That means that barriers you might be facing now don’t have to be permanent. If you don’t have access to the resources you need to support your health, talk to a healthcare provider or connect with a community group — like a church or nonprofit. They’ll provide advice and assistance and refer you to others who can help.