Section 5. Addressing Social Determinants of Health and Development

 

What are social determinants of health and development?

Health and development are influenced by far more than individual choices or access to medical care.

Social determinants of health are the conditions in which people are born, grow, learn, live, work, play, worship, and age, together with the wider systems and distribution of power, money, and resources that shape those conditions.

These conditions influence opportunities for health and well-being and help explain why some communities and populations experience better health outcomes than others.

Social determinants can include:

• Income and economic security
• Employment and working conditions
• Education access and quality
• Health care access and quality
• Housing
• Transportation
• Food access and affordability
• Neighborhood and environmental conditions
• Social support and community connection
• Discrimination and exclusion
• Public policies and institutional practices
• Access to political, economic, and social power

These determinants interact.

For example, unstable employment can affect income, housing, transportation, insurance or health care access, stress, and the amount of time available for family responsibilities. Poor transportation can affect access to work, school, food, health services, and community participation.

For many community health and development issues, there is no single social determinant or one root cause. Several conditions may operate together, and their importance may differ across communities and over time.

A practical framework

In the United States, one useful framework groups social determinants of health into five broad domains:

• Economic stability
• Education access and quality
• Health care access and quality
• Neighborhood and built environment
• Social and community context

These categories are useful for organizing analysis, but they should not be treated as isolated boxes.

Broader economic, social, environmental, and political systems can influence several domains at once.

Health equity

Differences in health are not automatically inequities.

Health inequities are differences that are linked to avoidable and unfair conditions or distributions of opportunity and resources.

Examining health equity means asking not only:

What is the average health outcome?

but also:

• Who experiences better or worse outcomes?
• What conditions contribute to those differences?
• Are some groups exposed to greater risks?
• Do some groups have fewer protective resources?
• Do the same health events have more serious consequences for some people because of economic, social, or institutional conditions?

Exposure, protection, and consequences

One way to examine social determinants is to consider how conditions affect:

1. Exposure. Are some people more likely to encounter environmental hazards, unsafe working conditions, violence, food insecurity, economic instability, or other risks?
2. Protection and access to resources. Do people have access to health care, safe housing, transportation, social support, legal protections, information, and other resources that can reduce risk?
3. Consequences. Does the same health or economic event create more serious effects for people with fewer financial reserves, less workplace flexibility, limited insurance, unstable housing, or other constraints?

These differences are produced by conditions, not by an inherent weakness of the people experiencing them.

Economic stability

Income, employment, job security, debt, benefits, and the cost of basic needs can affect health through many pathways.

Economic instability can influence:

• Housing stability
• Food security
• Transportation
• Access to health services and medication
• Exposure to stress
• Ability to take time away from work
• Educational opportunities

Avoid assuming that income alone explains an outcome. Examine how income interacts with costs, public benefits, household responsibilities, local services, discrimination, and other conditions.

Education access and quality

Education can affect health through employment opportunities, income, health literacy, social networks, access to information, and other pathways.

Relevant conditions can include:

• Early childhood opportunities
• School quality and resources
• Language access
• Disability access
• Safety
• Educational costs
• Opportunities for training and continuing education

More education does not automatically produce good health, and less formal education should not be treated as an individual deficiency. Examine the conditions connecting educational opportunity with health and development.

Health care access and quality

Health care is only one influence on health, but timely access to appropriate, high-quality services remains important.

Barriers may include:

• Cost
• Insurance or eligibility
• Distance and transportation
• Appointment availability
• Work schedules
• Disability access
• Language access
• Digital access
• Administrative complexity
• Quality of care
• Trust based on current or historical experiences with institutions

Neighborhood and built environment

Where people live can affect health through:

• Housing quality and stability
• Drinking water and sanitation
• Air quality
• Exposure to environmental hazards
• Transportation
• Street and pedestrian safety
• Parks and public spaces
• Food availability
• Broadband and other infrastructure
• Access to schools, services, employment, and health care

Describe these conditions directly rather than labeling communities as "blighted," "bad," or unhealthy.

Social and community context

Relationships and social conditions can influence health and development.

Relevant factors may include:

• Social support
• Community networks
• Civic participation
• Discrimination
• Social exclusion
• Community safety
• Trust
• Institutional relationships

Community connection can be protective, but do not assume that every family, neighborhood association, faith community, or other social network is equally available or beneficial to everyone.

Racism, discrimination, and exclusion

Discriminatory policies, practices, and treatment can affect access to:

• Employment
• Housing
• Education
• Health care
• Transportation
• Financial resources
• Public services
• Political and institutional influence

Discrimination can also produce chronic stress and affect trust in institutions.

Where inequities are linked to discrimination or institutional practice, identify those mechanisms directly rather than treating racial or ethnic identity itself as the cause.

Cultural context

Culture can shape communication, social relationships, food practices, beliefs about health, family roles, help-seeking, and other aspects of community life.

Culture should not be used as a convenient explanation for a health outcome without evidence.

Avoid assuming that everyone who shares a racial, ethnic, national, religious, or linguistic identity has the same beliefs or practices.

Use cultural humility:

• Ask rather than assume
• Recognize variation within communities
• Include relevant community knowledge
• Examine institutional barriers alongside individual practices

Language and communication access

People may experience barriers when important health, educational, employment, or public information is not available in a language or communication format they can use effectively.

Addressing the determinant may therefore involve improving:

• Interpretation
• Translation
• Accessible documents
• Plain-language communication
• Digital accessibility

The information and commercial environment

People's information environments now include television, news media, social media, online video, search systems, recommendation algorithms, advertising, influencers, messaging platforms, and AI-generated content.

These systems can influence:

• What health information people encounter
• Which products are promoted
• Perceptions of risk
• Social norms
• Trust in institutions and health information

Commercial conditions can also affect health through product design, pricing, marketing, availability, workplace practices, and business decisions.

Policy and governance

Laws, regulations, budgets, institutional rules, and public policies can shape health conditions at scale.

Policies may affect:

• Housing
• Employment and workplace protections
• Education
• Transportation
• Environmental exposure
• Food systems
• Health care
• Public benefits
• Civil rights and nondiscrimination

Policy choices may involve real tradeoffs among resources, costs, rights, economic interests, health, and other public priorities.

Analyze those tradeoffs directly rather than assuming that disagreement reflects bad motives.

Climate and environmental conditions

Environmental and climate conditions can affect health through heat, air quality, severe weather, infectious disease patterns, water availability, housing, food systems, displacement, and infrastructure.

These effects may be greater for people who have fewer resources to avoid or recover from hazards.

Why address social determinants of health and development?

Social determinants matter because interventions focused only on immediate symptoms may leave important conditions unchanged.

Addressing social determinants can:

• Prevent some health problems before they occur
• Reduce exposure to hazards
• Improve access to protective resources
• Reduce barriers to health care and other services
• Improve material and social conditions that influence health
• Reduce avoidable differences in health outcomes

This does not mean that immediate services should be withheld while organizations work on longer-term conditions.

A person who needs food, shelter, medical care, protection, or another urgent service needs an appropriate response now.

At the same time, organizations and communities can examine why the need keeps occurring and which conditions could be changed to reduce it.

Move beyond a single-root-cause model

Social determinants often operate through several interacting pathways.

For example, difficulty accessing preventive health care might involve:

• Cost
• Insurance
• Transportation
• Clinic location
• Work schedules
• Childcare
• Language access
• Disability access
• Appointment availability
• Trust

Several intervention points may therefore be more appropriate than one supposed root cause.

Improve prevention

Prevention often requires changing the conditions that repeatedly expose people to risk or limit access to protective resources.

For example, preventing waterborne disease involves not only knowledge about safe water but reliable infrastructure, water quality protections, sanitation, monitoring, and appropriate public-health response.

Reduce inequities

Overall health can improve while large differences between groups remain or even grow.

When evaluating a strategy, ask:

• Did average outcomes improve?
• Did people facing the greatest barriers benefit?
• Did gaps narrow, remain unchanged, or widen?
• Were new burdens or barriers created?

Who should address social determinants of community health and development?

Social determinants usually extend across sectors.

Health organizations alone cannot control housing, wages, transportation, education, environmental conditions, employment, or every other factor affecting health.

Depending on the issue, relevant participants and partners may include:

• People and communities directly affected
• Community-based organizations
• Public-health and health-care organizations
• Schools and educational institutions
• Housing organizations
• Transportation agencies
• Employers and workforce organizations
• Local, state, Tribal, territorial, or federal government
• Businesses
• Social-service organizations
• Researchers and evaluators
• Funders
• Advocacy organizations
• Other organizations with relevant authority, resources, expertise, or community relationships

Community engagement should be meaningful

People affected by an issue often hold knowledge that organizations and institutions do not.

Community engagement should therefore begin early enough to influence:

• How the problem is defined
• What priorities are identified
• Which strategies are considered
• How implementation occurs
• How success is evaluated

Engagement should not consist only of asking people for information after major decisions have already been made.

Be clear about power and decision authority

Collaboration does not automatically mean that everyone has identical authority.

Clarify:

• Who provides knowledge and experience
• Who makes recommendations
• Who controls funding or other resources
• Who has legal or institutional authority
• Who makes the final decision
• Who is responsible for implementation

Where shared governance is appropriate, establish it explicitly rather than implying shared power that does not actually exist.

Recognize community assets and self-determination

Communities are not empty settings waiting for outside organizations to provide capacity.

They already contain:

• Knowledge
• Relationships
• Organizations
• Leadership
• Informal support systems
• Skills
• Cultural and historical knowledge

External partners can contribute resources, technical expertise, connections, and support while respecting community priorities and existing strengths.

When should you address social determinants of community health and development?

Social conditions should be considered whenever they may meaningfully influence the issue.

They are particularly important to examine:

• When a health or development problem persists despite direct services
• When outcomes differ substantially among groups or places
• When people repeatedly encounter barriers to accessing services or opportunities
• When prevention is a major goal
• When policy, funding, or institutional change is being considered
• When environmental or economic conditions appear to influence the problem
• When an emergency reveals longstanding weaknesses in housing, transportation, communication, health care, food systems, or other infrastructure
• When a community is developing a long-term health or development strategy

When direct services are not enough

A service can be effective and still leave the conditions producing the need unchanged.

For example, a health organization may provide high-quality treatment while people continue to experience difficulty reaching the clinic because of transportation, cost, work schedules, or other barriers.

The appropriate response may include both the service itself and changes to the conditions affecting access.

When advocating for policy or funding

Policy and funding proposals should be based on a clear understanding of:

• The problem
• Who is affected
• Contributing conditions
• Expected benefits
• Costs and tradeoffs
• Possible unintended consequences
• How results will be evaluated

When focusing on prevention and community well-being

Prevention frequently requires action beyond individual education.

Knowledge matters, but so do the conditions that make healthier choices practical, affordable, safe, accessible, and sustainable.

How do you address social determinants of community health and development?

Addressing social determinants involves two broad tasks:

1. Understand which conditions influence the issue and how they interact.
2. Develop, implement, monitor, and adapt strategies that address conditions the organization or partnership can reasonably influence.

Identify relevant social determinants

Do not assume in advance which determinants are most important.

The same health outcome may have different contributing conditions in different communities.

Assess the community

A community assessment can combine:

• Community and lived experience
• Interviews
• Focus groups
• Surveys
• Administrative data
• Public-health data
• Geographic information
• Observation
• Research evidence
• Policy analysis
• Historical information
• Existing community assessments and plans

Talk with people who know the issue

Depending on the situation, this may include:

• People directly affected
• Community organizations
• Service providers
• Public officials
• Advocates and organizers
• Researchers
• Employers or businesses
• Other people or organizations with relevant knowledge

No individual should be expected to represent an entire racial, ethnic, religious, disability, neighborhood, professional, or other community simply because they belong to it.

Make engagement accessible

Consider:

• Language access
• Disability access
• Transportation
• Childcare or caregiving constraints
• Technology
• Meeting schedules
• Compensation where appropriate
• Confidential or anonymous participation where power differences create risk

Examine history

Current conditions may reflect earlier policies, investment patterns, institutional practices, economic changes, environmental decisions, or community experiences.

Ask:

• How did the present condition develop?
• What previous interventions were tried?
• What worked and what did not?
• Which groups experienced previous decisions differently?
• How have past experiences affected current trust?

Apply critical thinking

As you analyze the information:

• Check the accuracy and limitations of important evidence
• Distinguish evidence from interpretation
• Examine assumptions
• Consider competing explanations
• Identify important missing information
• Consider conflicts of interest and incentives
• Document uncertainty

Ask questions about distribution and power

Consider:

• Who is affected, and how?
• Where are outcomes better or worse?
• What conditions differ between those places or groups?
• Who controls relevant resources?
• Who has authority to change policies or practices?
• Who benefits from the current arrangement?
• Who bears the greatest costs or risks?
• What would action and inaction cost, and to whom?

Use the "But why?" technique carefully

Repeatedly asking why can help a group move beyond an immediate symptom.

Do not assume that the final answer in a chain is automatically the root cause.

Ask:

• What evidence supports this explanation?
• What else could contribute?
• Are several pathways operating at once?
• What protective factors are present?

For complex problems, process maps, causal diagrams, systems maps, or other tools may provide a more complete picture.

Develop strategies at appropriate levels

Social determinants can be addressed through many kinds of action.

Economic conditions

Depending on the issue and organizational authority, strategies may address:

• Employment opportunities
• Job quality and workplace conditions
• Income supports
• Benefits access
• Housing and food costs
• Financial barriers to services

Education and information

Education can be an important intervention when lack of useful information or skills contributes to an outcome.

It is less likely to be sufficient when the main barriers are structural.

For example, telling people how to use a service will not solve a problem if the service is unaffordable, inaccessible, unavailable, or does not meet their needs.

Health care access and quality

Strategies might address:

• Service availability
• Cost
• Location
• Transportation
• Scheduling
• Language and disability access
• Administrative barriers
• Quality and continuity of care

Social connection and community infrastructure

Communities may strengthen:

• Mutual support
• Community organizations
• Referral networks
• Civic participation
• Partnerships
• Community gathering spaces

Build on existing community relationships rather than assuming new organizations must always be created.

Access and administrative barriers

Organizations can examine whether their own systems create avoidable barriers through:

• Complicated eligibility rules
• Difficult application processes
• Excessive documentation requirements
• Limited hours
• Long wait times
• Inaccessible technology
• Lack of interpretation or translation
• Transportation barriers

Simplifying the process may sometimes be as important as expanding the service.

Environmental and occupational hazards

Reducing exposure may require:

• Enforcement of safety standards
• Infrastructure improvements
• Pollution control
• Safe water and sanitation
• Workplace protections
• Housing improvements
• Emergency preparedness

Use qualified technical expertise where interventions affect engineering, environmental safety, occupational health, utilities, or other specialized systems.

Policy and systems change

Policy can influence conditions for large numbers of people.

Potential actions may include:

• Changing organizational policy
• Improving implementation of existing policy
• Advocacy
• Administrative reform
• Funding changes
• Regulatory change
• Cross-sector agreements

Policy adoption is not the end of the process.

Monitor implementation, enforcement, access, and actual effects.

Use multisector collaboration when necessary

An organization may identify determinants it cannot directly control.

In that case, partnership may be necessary.

For example:

• A health organization may work with transportation agencies on access to care.
• A school system may work with housing and community organizations on student stability.
• Public-health agencies may work with planning departments on built-environment conditions.

Clarify responsibilities so collaboration does not mean that everyone is generally responsible and nobody is accountable for specific action.

Strengthen community capacity without treating communities as deficient

Capacity strengthening can include:

• Funding
• Technical assistance
• Leadership opportunities
• Data access
• Training requested by the community
• Stronger organizations and partnerships
• Support for community-led decision-making

Begin by identifying what capacity and assets already exist.

External organizations should not assume that community members need to be taught how to act in their own interests.

Start at a manageable scale when appropriate

A small organization may not be able to change every determinant affecting an issue.

It can still identify:

• Conditions it can change directly
• Conditions it can influence through partnership
• Longer-term policy goals

A focused pilot or staged approach may be appropriate when uncertainty is high or resources are limited.

Small steps should still connect to the broader analysis so that the organization does not mistake a limited intervention for a complete solution.

Monitor social determinants and health equity

Identify indicators that show whether relevant conditions are actually changing.

Depending on the strategy, monitor:

• Access
• Service use
• Economic conditions
• Housing stability
• Transportation
• Environmental exposure
• Education or employment outcomes
• Community experience
• Health outcomes

Where appropriate, examine whether outcomes differ among relevant groups or places rather than relying only on overall averages.

Evaluate effects and unintended consequences

Ask:

• Did the strategy change the determinant it was intended to change?
• Did health or development outcomes improve?
• Who benefited?
• Who did not?
• Did inequities narrow or widen?
• What unintended consequences occurred?
• What should be continued, changed, expanded, or stopped?

Adapt as conditions change

Social determinants are not static.

Economic conditions, policies, migration, climate, technology, services, institutions, and community priorities can change.

Continue to monitor the context and revise strategies when evidence shows that the original approach no longer fits.

Principles for collaborative action

Several principles can guide work on social determinants:

• Engage people affected by the issue early and meaningfully.
• Recognize multiple forms of knowledge, including community and lived knowledge, professional expertise, and research evidence.
• Build and maintain trust through transparent, reliable action.
• Recognize power differences and share decision-making where appropriate.
• Build on community assets and existing organizations.
• Match intervention scope to the evidence, problem, authority, and resources available.
• Work across sectors when the determinants extend beyond one organization's authority.
• Provide adequate resources for community participation and implementation.
• Monitor both overall outcomes and equity.
• Learn and adapt rather than assuming the original strategy will remain correct indefinitely.

In Summary

Social determinants of health and development are the social, economic, environmental, institutional, and policy conditions that shape people's opportunities for health and well-being.

They include conditions related to economic stability, education, health care, neighborhoods and the built environment, social and community context, and the broader systems that influence access to power, money, resources, protection, and opportunity.

These determinants interact. Complex health and development problems rarely have one social cause or one permanent solution.

Effective analysis therefore combines community knowledge, credible data, research, historical context, and an examination of policies, institutions, resources, power, and environmental conditions.

People directly affected by an issue should have meaningful opportunities to influence how it is understood and addressed. Engagement should be ongoing, accessible, trustworthy, and clear about decision authority.

Responses may include direct services, organizational changes, stronger access to resources, environmental improvements, economic strategies, community partnerships, policy change, and multisector action. Immediate assistance and longer-term structural action can occur together.

Finally, addressing social determinants requires monitoring and learning. Track whether relevant conditions change, who benefits, whether inequities narrow or widen, and whether unintended effects appear.

The goal is not to identify one root cause and declare the problem solved. It is to understand and improve the conditions that shape health, use the authority and resources available responsibly, and adapt as evidence and community conditions change.