Make a Dent in Social Determinants of Health

If you’ve ever tried to eat a salad in an airport at midnight, you know a basic truth about health: our choices are only as good as the options around us. Yet when we talk about “being healthy,” we still tend to focus on steps and lab results, not on rent, bus routes, or whether the nearest grocery store sells anything green.

That gap between what shapes health and what we actually fund or measure is where the social determinants of health come in. These are the nonmedical conditions that quietly decide who gets to live a long, healthy life and who spends more time in waiting rooms and emergency departments. In the United States, where healthcare spending is sky-high but outcomes lag behind many peer countries, it’s past time to stop treating social determinants as side notes and start treating them as core business.

This article breaks down what social determinants of health are, how they drive health disparities, and what it looks like to finally make a dent in themfrom policies and health systems all the way down to neighborhood projects and individual advocacy. We’ll also look at real-world experiences that show this work is not only possible but already underway.

What Are Social Determinants of Health, Really?

“Social determinants of health” (often shortened to SDOH) is a big phrase for a simple idea: the conditions in which people are born, grow, live, learn, work, play, worship, and age. These conditions include everything from housing quality to school resources, from job opportunities to whether your neighborhood has sidewalks or streetlights.

Healthy People 2030, the U.S. national health agenda, groups SDOH into five key domains:

Economic stability – income, employment, debt, and the ability to afford basic needs.
Education access and quality – early childhood education, literacy, graduation rates, and school resources.
Health care access and quality – insurance coverage, provider availability, cultural and linguistic competence, and quality of care.
Neighborhood and built environment – housing, transportation, green space, safety, environmental exposures, and food access.
Social and community context – social support, discrimination, civic engagement, and community cohesion.

In other words, social determinants of health are all the upstream factors that shape daily life long before anyone shows up at a clinic.

Why Social Determinants Matter More Than We Think

For decades, we behaved as if healthcare alone could fix health. The evidence says otherwise. Researchers estimate that traditional medical care explains only about 10–20% of overall health outcomes. The rest is shaped by social and environmental factors, individual behaviors, and the policies that structure our lives.

Think about two kids born on the same day in the same city. One grows up in a safe neighborhood with good schools, stable housing, and easy access to fresh food and health care. The other grows up in overcrowded housing, attends an underfunded school, and lives miles from a grocery store but close to busy highways and industrial pollution. They may share a city, but their life expectancyand their risk for chronic conditions like asthma, diabetes, and heart diseasecan differ by years.

These differences show up clearly in U.S. data. Communities of color, particularly Black, Hispanic, American Indian, and Alaska Native populations, often face higher rates of poverty, lower access to quality care, and more exposure to unsafe environments. Not coincidentally, they also experience higher rates of many chronic diseases and shorter life expectancy. Health inequities are not random; they are patterned, persistent, and deeply tied to social determinants of health.

Everyday Examples: When ZIP Code Beats Genetic Code

It’s easy to think of social determinants of health as abstract. In reality, they show up in small, everyday moments. Here are a few concrete scenarios that illustrate how powerful these forces can be:

Housing and Health

Imagine a family living in an older apartment building with leaky windows and visible mold. The rent is relatively low, but the cost shows up somewhere else: their child has asthma attacks every few weeks. Trips to the emergency department become routine. Missed school days pile up. The parents juggle missed work, lost wages, and mounting medical bills. A mold-free, energy-efficient home could cut those hospital visits dramaticallybut that upgrade is often out of reach.

Food Access and Chronic Disease

In many neighborhoods, it’s easier to find three fast food restaurants than one full-service grocery store. For people working multiple jobs, affordable, quick calories win over cooking from scratch. Over time, this environmentcombined with limited time, stress, and lack of safe spaces for exerciseraises the risk for obesity, type 2 diabetes, and heart disease. It’s not that people don’t care about being healthy; they’re swimming against a strong current.

Transportation and Missed Care

For someone without reliable transportation, the simple act of “go see your doctor” is anything but simple. They may depend on a bus that runs only once an hour, a ride from a friend, or a costly rideshare. One missed bus can mean a missed appointment, which can mean delayed cancer screening, uncontrolled blood pressure, or untreated depression.

Education, Income, and Opportunity

Higher education is strongly linked to better health outcomes. People with more education tend to have higher-paying jobs, better benefits, and more control over their working conditions. Meanwhile, limited education can trap people in low-wage jobs with unstable hours and few protections. That stress doesn’t just stay at work; it affects sleep, diet, mental health, and the ability to afford medications or healthy food.

None of these examples are about someone making a “bad choice.” They’re about the environments that shape which choices are available, affordable, and realistic.

Where We Are Falling Short

The good news is that health agencies, hospital systems, and communities around the country increasingly recognize the importance of social determinants of health. The less good news: awareness has outpaced action.

Common challenges include:

Fragmented funding – Health, housing, transportation, and education dollars often live in separate silos with different rules and timelines.
Short-term thinking – Grant cycles and yearly budgets don’t always match the long time horizons needed to shift neighborhood conditions.
Data gaps – Many systems collect some SDOH data, but definitions and measures vary, making it hard to track progress and compare across communities.
Underinvestment in prevention – It’s still easier to get reimbursed for treating a complication than for preventing it by addressing social needs.
Limited community power – Policies are often made about communities rather than with them, leading to solutions that don’t fit local realities.

If we want to make a dent in social determinants of health, we have to stop treating them as a “pilot project” and start treating them as essential infrastructurelike roads, water systems, and power grids for health.

How to Actually Make a Dent in Social Determinants of Health

Fixing SDOH sounds hugeand it is. But that doesn’t mean we’re powerless. The work happens at multiple levels: policy, health systems, community organizations, employers, and individuals. Here’s what meaningful progress can look like.

1. Policy Moves That Reshape the Playing Field

Policy is the invisible hand behind many social determinants of health. To move the needle, we need:

Living wage and income supports so that full-time workers aren’t stuck choosing between rent and medications.
Affordable, safe housing backed by policies that prevent discrimination, reduce environmental hazards, and support energy efficiency.
Investments in education from early childhood through higher education, targeted especially toward under-resourced communities.
Transportation and built environment planning that prioritizes walkability, public transit, and access to jobs, schools, and healthcare.
Antidiscrimination and civil rights protections that address racism and other forms of structural discrimination that show up in health data every day.

These aren’t “extras” for when there’s money left over; they are core strategies for improving population health and reducing healthcare costs downstream.

2. Health Systems That Treat Social Needs as Health Needs

Healthcare organizations can’t fix poverty or housing alone, but they can stop pretending those issues are “not our lane.” Many systems are already experimenting with:

Screening for social needs during visitsasking about housing, food security, transportation, and safety, not just symptoms.
Embedding care managers, social workers, and community health workers who can connect patients to resources and help navigate complex systems.
Partnering with community organizations like food banks, legal aid groups, and housing agencies to create “closed-loop” referrals where follow-up is tracked.
Investing directly in community assets such as housing initiatives, community gardens, or mobile clinics.
Aligning payment models so preventive and social care are financially sustainable, not just nice extras.

When health systems treat social needs as part of health care, they can reduce avoidable hospitalizations, improve outcomes, and build trust with communities historically underserved or mistreated by the system.

3. Community Organizations as Essential Health Partners

Community-based organizations have always worked on social determinantsoften long before the term became popular. They run after-school programs, food pantries, housing support, job training, and neighborhood safety initiatives. To make a real dent in SDOH, we need to treat these organizations as equal partners, not as “nice-to-have” add-ons.

That means providing stable, multi-year funding, involving them in data and decision-making, and valuing lived experience alongside professional credentials. It also means stepping back and letting communities define what “health” and “success” look like for them.

4. Employers and Businesses as Health Actors

Employers often shape health more than they realize. Work schedules, wages, benefits, and workplace culture all function as social determinants of health. Businesses can contribute by:

Offering predictable schedules and paid sick leave.
Providing health insurance and mental health benefits.
Supporting remote or flexible work where possible.
Investing in local communities through hiring, training, and procurement practices.

Yes, it’s good PR. It’s also smart risk management: healthier employees mean less turnover, fewer injuries, and higher productivity.

5. What Individuals and Advocates Can Do

No single person can “fix” the social determinants of health, but individual actions matterespecially when they add up. You can:

Support policies and candidates that prioritize housing, transportation, education, and equity.
Partner with local organizations through volunteering, donations, or board service.
Ask your healthcare providers whether they screen for social needs and how they partner with community resources.
Share storiesyour own or others’that highlight how social conditions shape health, helping shift the conversation beyond personal blame.

When enough people treat SDOH as everyone’s business, it becomes harder for decision-makers to ignore them.

Measuring Progress: From Buzzword to Better Outcomes

To know whether we’re making a dent in social determinants of health, we have to measure more than hospital readmissions or blood pressure numbers. We need indicators that capture the upstream picture.

Examples include:

Housing stability, eviction rates, and homelessness.
Food insecurity and distance to full-service grocery stores.
High school graduation and literacy rates.
Unemployment and underemployment, especially in marginalized communities.
Exposure to pollution, extreme heat, and other environmental hazards.
Self-reported experiences of discrimination and social support.

Public health agencies, local governments, and national surveys increasingly track these measures. The challenge now is to use the data not just to describe problems but to redesign systems, reallocate resources, and hold institutions accountable for change.

Experiences from the Field: What Real Change Looks Like (500+ Words)

So what does it look like when people stop just talking about social determinants of health and start reshaping them? The details vary by community, but a few patterns show up again and again.

Food “Prescriptions” That Treat Health Like a Team Sport

Picture a primary care clinic where, instead of simply telling someone with diabetes to “eat better,” the provider writes a prescription for fresh produce. That prescription can be “filled” at a local food pantry or farmer’s market where fruits and vegetables are discounted or free. Community health workers help patients learn how to cook new foods on a tight budget, and the clinic tracks changes in A1C levels over time.

Patients get support instead of judgment. Local farmers gain customers. Health systems see fewer complications. It’s a modest intervention in the grand scheme of things, but it shifts the script: food security becomes part of the care plan, not a footnote.

Housing First, Health Follows

Another example comes from programs that provide “Housing First” for people who are chronically homeless and living with serious mental illness or substance use disorders. Instead of demanding that people become perfectly stable before offering help, these programs provide permanent, supportive housing firstno endless hoops, no temporary shelter that disappears after a few weeks.

Once people have a door they can lock and a bed to sleep in, everything else becomes easier: managing medications, keeping appointments, reconnecting with family, even looking for work. Hospitals often see dramatic reductions in emergency visits and admissions. Taxpayers save money. Individuals gain dignity and stability. A social determinant of healthhousingturns from barrier into foundation.

School-Based Health and the Power of Convenience

School-based health centers show how addressing SDOH can be as simple as bringing care to where kids already are. In many communities, these centers provide primary care, mental health services, dental care, and health education right on campus. They reduce barriers like transportation, parent work schedules, and stigma around seeking help.

For students, this can mean getting asthma under control, receiving counseling after a traumatic event, or getting vision care that makes it possible to actually see the board. For families, it means fewer missed workdays and less scrambling to fit appointments into already stretched schedules. For schools, it can mean better attendance and improved academic performanceclear examples of how health and education are intertwined.

Community Voices at the Center

Some of the most powerful SDOH initiatives start by asking community members a basic question: “What does health look like for you?” The answers aren’t always what professionals expect. People might talk about wanting safe places for kids to play, a grocery store that doesn’t require two bus transfers, or a community center where seniors can socialize and get support.

When community members sit on advisory boards, co-design programs, and share data back in accessible language, projects are more likely to stick. Instead of outsiders “fixing” a neighborhood, you see residents leading the waywith technical and financial support from government agencies, health systems, and nonprofits.

Learning as We Go

Most efforts to address the social determinants of health are still works in progress. Some will fall short. Others will succeed in ways that surprise everyone. That’s okay. This is complex, generational work. The key is to treat each project as a chance to learn: what worked, what didn’t, who benefited, and who was left out.

Over time, the lessons add up. The “one-off pilot” becomes standard practice. The line between health care and social care gets blurrierin the best possible way. And slowly, the health gap between neighborhoods, races, and income groups can start to narrow.

Conclusion: From Slogan to Structural Change

“Social determinants of health” can sound like a buzzword you nod politely at during meetings. But underneath the jargon is a simple reality: our health is shaped by the world we live in, not just by the pills we take or the advice we receive.

It is time to make a dent in those determinantsnot with one flashy initiative, but with consistent, coordinated, and community-driven efforts. That means policies that support stable housing and living wages, health systems that treat social needs as real needs, businesses that understand their impact on employee well-being, and individuals who see health equity as a shared responsibility.

We don’t need to fix everything overnight. But we do need to start everywhere we can. Every bus route improved, every school resourced, every family housed, every barrier reduced is a small dent in a very large wall. Put enough dents together, and the wall starts to crack.