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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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

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 Status
    • Access to Employment
    • Housing Stability (e.g., homelessness, foreclosure)
  • Education
    • High School Graduation Rates
    • School Policies that Support Health Promotion
    • School Environments that are Safe and Conducive to Learning
    • Enrollment in Higher Education
  • Social and Community Context
    • Family Structure
    • Social Cohesion
    • Perceptions of Discrimination and Equity
    • Civic Participation
    • Incarceration/Institutionalization
  • Health and Health Care
    • Access to Health services—including clinical and preventive care
    • Access to Primary Care—including community-based health promotion and wellness programs
    • Health Technology
  • Neighborhood and Build Environment
    • Quality of Housing
    • Crime and Violence
    • Environmental Conditions
    • Access to Healthy Foods

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.

Complementary Objectives

Economic Stability


Health and Health Care

Neighborhood and Built Environment

Social and Community Context





Determinants of Health

  • What makes some people healthy and others unhealthy?
  • How can we create a society in which everyone has a chance to live long healthy lives?

Healthy People 2020 is exploring these questions by:

  1. Developing objectives that address the relationship between health status and biology, individual behavior, health services, social factors, and policies.
  2. Emphasizing an ecological approach to disease prevention and health promotion. An ecological approach focuses on both individual-level and population-level determinants of health and interventions.


About Determinants of Health

The range of personal, social, economic, and environmental factors that influence health status are known as determinants of health.

Determinants of health fall under several broad categories:

It is the interrelationships among these factors that determine individual and population health. Because of this, interventions that target multiple determinants of health are most likely to be effective. Determinants of health reach beyond the boundaries of traditional health care and public health sectors; sectors such as education, housing, transportation, agriculture, and environment can be important allies in improving population health.

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Policies at the local, State, and Federal level affect individual and population health. Increasing taxes on tobacco sales, for example, can improve population health by reducing the number of people using tobacco products.

Some policies affect entire populations over extended periods of time while simultaneously helping to change individual behavior. For example, the 1966 Highway Safety Act and the National Traffic and Motor Vehicle Safety Act authorized the Federal Government to set and regulate standards for motor vehicles and highways. This led to an increase in safety standards for cars, including seat belts, which in turn, reduced rates of injuries and deaths from motor vehicle accidents.1


Social determinants of health reflect social factors and the physical conditions in the environment in which people are born, live, learn, play, work and age. Also known as social and physical determinants of health, they impact a wide range of health, functioning and quality of life outcomes.

Examples of social determinants include:

  • Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods
  • Social norms and attitudes, such as discrimination
  • Exposure to crime, violence, and social disorder, such as the presence of trash
  • Social support and social interactions
  • Exposure to mass media and emerging technologies, such as the Internet or cell phones
  • Socioeconomic conditions, such as concentrated poverty
  • Quality schools
  • Transportation options
  • Public safety
  • Residential segregation

Examples of physical determinants include:

  • Natural environment, such as plants, weather, or climate change
  • Built environment, such as buildings or transportation
  • Worksites, schools, and recreational settings
  • Housing, homes, and neighborhoods
  • Exposure to toxic substances and other physical hazards
  • Physical barriers, especially for people with disabilities
  • Aesthetic elements, such as good lighting, trees, or benches

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Poor health outcomes are often made worse by the interaction between individuals and their social and physical environment.

For example, millions of people in the United States live in places that have unhealthy levels of ozone or other air pollutants. In counties where ozone pollution is high, there is often a higher prevalence of asthma in both adults and children compared with State and national averages. Poor air quality can worsen asthma symptoms, especially in children.2

Health Services

Both access to health services and the quality of health services can impact health. Healthy People 2020 directly addresses access to health services as a topic area and incorporates quality of health services throughout a number of topic areas.

Lack of access, or limited access, to health services greatly impacts an individual’s health status. For example, when individuals do not have health insurance, they are less likely to participate in preventive care and are more likely to delay medical treatment.3


Barriers to accessing health services include:

  • Lack of availability
  • High cost
  • Lack of insurance coverage
  • Limited language access

These barriers to accessing health services lead to:

  • Unmet health needs
  • Delays in receiving appropriate care
  • Inability to get preventive services
  • Hospitalizations that could have been prevented

Individual Behavior

Individual behavior also plays a role in health outcomes. For example, if an individual quits smoking, his or her risk of developing heart disease is greatly reduced.

Many public health and health care interventions focus on changing individual behaviors such as substance abuse, diet, and physical activity. Positive changes in individual behavior can reduce the rates of chronic disease in this country.

Examples of individual behavior determinants of health include:

  • Diet
  • Physical activity
  • Alcohol, cigarette, and other drug use
  • Hand washing

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Biology and Genetics

Some biological and genetic factors affect specific populations more than others. For example, older adults are biologically prone to being in poorer health than adolescents due to the physical and cognitive effects of aging.

Sickle cell disease is a common example of a genetic determinant of health. Sickle cell is a condition that people inherit when both parents carry the gene for sickle cell. The gene is most common in people with ancestors from West African countries, Mediterranean countries, South or Central American countries, Caribbean islands, India, and Saudi Arabia.

Examples of biological and genetic social determinants of health include:

  • Age
  • Sex
  • HIV status
  • Inherited conditions, such as sickle-cell anemia, hemophilia, and cystic fibrosis
  • Carrying the BRCA1 or BRCA2 gene, which increases risk for breast and ovarian cancer
  • Family history of heart disease


1Centers for Disease Control and Prevention. Achievements in public health, 1900–1999 motor-vehicle safety: A 20th century public health achievement. MMWR Weekly. 1999 May 14;48(18);369-74. Accessed 2010 Aug 27. Available from:

2American Lung Association. State of the air 2010. Washington: American Lung Association. Available from: External Web Site Policy

3Agency for Healthcare Research and Quality (AHRQ). National healthcare disparities report, 2008. Rockville, MD: US Department of Health and Human Services, AHRQ; 2009 Mar. Pub no. 09-002. Available from: [PDF - 2.6 MB]

See also:

Commission on Social Determinants of Health. Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization; 2008. Accessed 2010 May 10. Available from: [PDF - 4.3 MB] External Web Site Policy

Harris K, Holden C, Chen M. Background information on national indicators for social determinants of health. Paper presented to the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020, National Opinion Research Center, January 5, 2010.

Institute of Medicine. Unequal treatment: Confronting racial and ethnic disparities in health. Washington: National Academies Press; 2003.

US Department of Health and Human Services. Draft report of the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 on Social Determinants. Revised 2009 Sep 9.

Wilkinson R, Marmot M, editors. Social determinants of health: The solid facts. 2nd ed. Copenhagen: World Health Organization; 2003. Accessed 2010 May 26. Available from: [PDF - 470 KB] External Web Site Policy



What is CADH's Health Equity Initiative?
The Health Equity Alliance (HEA) is an initiative of the Connecticut Association of Directors of Health (CADH) to enhance the capacity of local health departments, in partnership with community partners and leaders, to achieve health equity through a focus on the social determinants (including the social, political, economic, and environmental conditions) that affect health.
As part of that initiative, CADH has developed the Health Equity Index (Index), a web-based, community-specific tool, the first of its kind in the nation, that profiles and measures the social determinants of health and their correlations with specific health outcomes. The Index can produce community-specific scores, correlations, and GIS maps. The Index also provides direction for collecting additional qualitative data—the narrative of those experiencing or witnessing health inequities.
The ultimate goal of the HEA initiative is to achieve long-term health improvements for residents who presently experience avoidable and disproportionate rates of disease and disability.
Where Can I Learn More?
Please visit the links below to learn more about CADH’s health equity initiative and health equity in general:



Study Variables included as

Social Determinants of Health

Policies and laws Education

Violence Income

Social gradient Norms

Social networks Social support

Culture Social capital


Racism and other forms of discrimination

Aggregate characteristics of neighborhoods

Physical living conditions

Social Determinants of Health Information Sheet





Social determinants of health

The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.

Responding to increasing concern about these persisting and widening inequities, WHO established the Commission on Social Determinants of Health (CSDH) in 2005 to provide advice on how to reduce them. The Commission's final report was launched in August 2008, and contained three overarching recommendations:

The Rio Political Declaration of 2011 confirmed Member State commitment to take action to address the social determinants of health in five areas:

  • Adopt improved governance for health and development
  • Promote participation in policy-making and implementation
  • Further reorient the health sector towards promoting health and reducing health inequities
  • Strengthen global governance and collaboration
  • Monitor progress and increase accountability

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