perceived job insecurity has been shown to negatively impact physical and mental health.5


Food insecurity Food insecurity refers to the household condition of scarce or uncertain access to adequate food. This condition may be transient or long-term in its nature. In 2020, it was determined that 13.8 million American households (10.5%) had been food insecure during the previous year.6 This condition negatively impacts the quality, variety and desirability of food and in its most severe forms leads to disrupted eating patterns and reduced caloric intake. The risk for household food insecurity is associated with employment, income, race, ethnicity and overall health.7


Understandably, households with unemployed adults leave children exposed to higher rates of food insecurity.8


Those affected with


chronic medical problems often have less disposable money due to unemployment and increased health- related expenses, in turn exposing them to an increased risk of food insecurity.9 The prevalence of insecurity is significantly higher in Black households (21.7%) and Hispanic households (17.2%) compared to the national average (10.5%).6


Higher rates of unemployment and neighborhood design—such as lack of proximity to full-service grocery stores and robust transportation infrastructure—are the most likely contributing factors.


Housing instability Households whose costs exceed 30% of income are considered cost burdened and those whose costs exceed 50% of income are considered severely cost burdened. Accordingly, such households have less disposable income to spend on food and healthcare. This reality affected more than 37 million American households in 2019 and is twice as common in Black and Hispanic households than in white households.10,11 Those on the lowest rungs on the socioeconomic ladder often live in housing that is substandard, exposing them to health and safety risks. The most severe form of housing instability is homelessness, affecting over a half-million Americans.12


Studies have


shown those affected have significantly higher rates of chronic disease such as diabetes, hypertension, asthma, depression and substance use disorder than the overall population. Mortality rates are 3.5 times higher among the non-elderly unhoused population than those who have reliable housing.13


2. Education access and quality The quality and level of educational attainment are key SDOH in that they influence most of the others, primarily by affecting income. Educational achievement directly contributes to job attainment and that in turn affects income, housing, healthcare access and transportation. Further, a higher level of education is linked to higher health literacy and greater proficiency in navigating the healthcare system.14 Attainment of higher levels of education is directly associated with longer life expectancy.15


Children who have access


to high-quality early education with healthcare and nutritional supports have better health than those who do not have access to such programs.


It’s not difficult to appreciate the concept that racial disparities in education amplify racial healthcare disparities.16


A 2021


report from UnitedHealthcare American’s Health Rankings Health Disparities showed that educational attainment was a leading SDOH contributing to racial health disparities, with those without a high school degree faring the worst in health outcomes.


3. Healthcare access and quality For healthcare to be impactful, it needs to be affordable, easily accessible and high quality. Access to insurance increases the likelihood that patients will seek out preventative and routine care. Proximity to local healthcare centers and telehealth services improves access for many. Reliable mass transit is imperative for urban dwellers. Mobile health units may be a supplement for rural communities and places where transportation is unreliable.


4. Neighborhood and built environment Where we live has a direct impact upon our health and sense of well-being. Our living environment interacts with our


individual choices and biology to affect our personal outcomes.


Many of us have heard news stories regarding lead contamination of drinking water supplies and neighborhoods with inexplicably high levels of cancer. Environmental conditions such as air and water quality, noise level, and proximity to hazardous wastes directly impact health. Communities that are more walkable and those with recreational resources are associated with higher levels of physical activity and better health outcomes. Neighborhoods where the housing is in subpar condition and the closest accessible food is via fast food establishments and liquor stores are associated with poorer health outcomes. Communities with higher rates of crime and violence understandably have measurably lower life expectancies.17


The legacy of redlining—the historic practice of racially-based housing discrimination which led to segregated communities—has ensured a multigenerational impact on population health in many American cities. Statistically significant associations have been measured between greater incidents of redlining and chronic medical conditions of current-day inhabitants such as asthma, diabetes, hypertension, diabetes, chronic kidney disease and stroke. Such neighborhoods have greater rates of racial minorities and poverty and lower life expectancy.18,19


5. Community and social context The relationships an individual has with their family, friends and communities have an important impact on their personal health. Social and civic connections can be powerful in influencing some health and safety dangers.


For example, adolescents are less likely to engage in high-risk behaviors if they have a close adult to confide in.20


There


is a positive linkage between parents who read out loud with their children at least 4 days a week and improved childhood language and literacy skills as well as better health.21


The impact of racism, structural and individual, and incarceration are also potent contributors to the well-being of individuals and families. Children


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