What Are Determinants of Health? Behavioral, Environmental, and Social Factors of Public Health

May 10, 2021

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Women wearing a medical mask, holding a phone showing a smog alert. A person’s health and longevity depend in large part on place of birth. The question is: Can we create a world in which everyone has the opportunity to live a long, healthy life, regardless of the circumstances of birth? The solution lies in what are called health determinants: personal, social, environmental, and economic conditions that affect a person’s health status, as the Office of Disease Prevention and Health Promotion (ODPHP) describes.

Health determinants that can directly influence a person’s health include genetics and individual behaviors, as well as socioeconomic and environmental factors. When combined, these factors represent an individual’s complete health profile. The goal of health determinants from a public health perspective is to direct efforts to improve the population’s health and promote social support systems that offer easy access to health, education, and employment opportunities.

Behavioral Determinants of Health: Examples

A proven approach to improving public health is to replace the negative behaviors that cause many health problems with positive behaviors that promote physical and mental well-being. Among the most important behavioral determinants of health are dietary choices and eating patterns, alcohol and tobacco use, and physical activity level. In addition, many individual behaviors affect a person’s risk of developing a range of life-threatening diseases:

Sleep and Exercise Patterns. Maintaining a regular schedule of exercise and getting seven to eight hours of sleep each night contribute to a person’s physical and mental health. By contrast, a lack of sleep and a sedentary lifestyle are associated with higher rates of health problems.
Psychological Assets. People who keep a positive outlook are more likely to be conscientious, optimistic, and humble. By contrast, a negative outlook tends to increase levels of stress and may exacerbate feelings of hopelessness, anxiety, and depression.
Risk-Related Behavior. Just as certain professions, such as emergency responders, face higher health risks, specific activities affect people’s mental and physical health. Among these risky activities are gun behavior, some sexual behaviors, and motor vehicle behavior.

“Behavioral determinants of health are important in the development of effective interventions,” says Dr. Caroline Kingori, interim associate dean for research at the Ohio University College of Health Science and Professions. “For example, where sexual behaviors are concerned, people who are HIV-positive may suffer from depression or anxiety due to the stigma and taboo associated with receiving a positive diagnosis. To cope, an HIV-positive individual can engage in maladaptive behaviors, such as inconsistent use of condoms or substance use. Thus, access to mental health services for such individuals is important.”

Research reported in The American Journal of Managed Care describes a socio-behavioral phenotype that helps health care professionals identify individuals at higher risk of physical and mental health problems due to social, behavioral, or environmental factors, including food insecurity and housing instability. For example, by identifying individuals who are most likely to be homeless, health care providers can adapt a telephone-based outreach program to accommodate communication with people who can’t be contacted by telephone.

Cognitive and Affective Determinants: Knowledge, Attitudes, Social Norms, Values, and Beliefs

The theory of planned behavior (TPB) demonstrates the influence of cognitive and affective health determinants as they relate to health-promoting behaviors. Research reported in the Journal of Applied Social Psychology indicates that people who regret behaviors that put their health at risk are more likely to adopt healthy behaviors. Likewise, people who take pride in their healthy activities are less likely to engage in unhealthy behaviors, such as smoking, drinking to excess, and avoiding regular medical checkups and testing, such as receiving regular flu shots.

However, the researchers concluded that the immediate rewards people feel when they engage in health risk behaviors are greater than the pride that accompanies abstaining from such behaviors. The study highlights the strong link between social constructs and both conscious and subconscious beliefs, values, and actions.

Environmental Determinants of Health: Examples

Examples of environmental determinants of health are represented in the six themes of the ODPHP’s Healthy People 2020 and Healthy People 2030 programs:

Poor air quality is linked to premature death, cancer, and cardiovascular and pulmonary diseases.
Surface water and groundwater quality includes drinking water and recreational bodies of water, both of which can become contaminated with chemicals and infectious agents.
Toxic substances and hazardous waste require greater efforts to reduce exposure and more study to determine the impact of these substances on people’s health.
Homes, schools, and work facilities may pose environmental threats due to such factors as indoor air pollution, improper heating or sanitation, electrical and fire hazards, and structural shortcomings.
Infrastructure and surveillance entail identifying and responding quickly to environmental hazards, as well as implementing preventive measures that bring together partners from all levels of government.
Global environmental health focuses primarily on improving the quality of water and sanitation facilities, but it extends to climate change, disaster preparedness, and other aspects of emerging global issues.

The Impact of Climate Change on Health

The World Health Organization (WHO) estimates that the effects of climate change will result in about 250,000 additional deaths each year between 2030 and 2050, as Medical News Today reports. Among the likely causes of climate-related death are heat stress, malnutrition, diarrhea, and malaria. These are some of the many aspects of health that climate change affects:

Mental Health. People who live in areas subject to extreme weather and natural disasters suffer mental distress as a result of displacement, injury, the death of loved ones, and the loss of possessions.
Infectious Diseases. Waterborne diseases and insectborne infections are forecast to increase as the season during which infections occur lengthens.
Developmental and Neurological Disorders. As people are exposed to more toxins in food and water, they may have a higher risk of Parkinson’s disease and Alzheimer’s disease, among other neurological conditions. These toxins can also affect a developing fetus.

Pollution and Other Human-Caused Threats to Children’s Health

Human Rights Watch points out that every year, more than 1.7 million children under the age of 5 die because of avoidable environmental degradation. Biodiversity loss; natural resource exploitation; toxic waste exposure; and air, soil, and water pollution threaten children’s right to a healthy, productive life.

Air Pollution. Climate change causes more dust, ozone, and fine particles to be dispersed in the atmosphere, causing and worsening such conditions as asthma, chronic obstructive pulmonary disease (COPD), lung inflammation, and lung cancer.
Toxic Chemical Exposure. Children are more susceptible to the damage from toxins that they contact through food and water contamination. Government programs are required to monitor children’s exposure to toxic substances, as well as the impact the toxins have on children’s mental and physical health.

The Worldwide Impact of Local Pollution and Contamination

One short-term effect of the COVID-19 pandemic is a sharp decline in air pollution levels across the world, as reported in the International Journal of Environmental Science and Technology. Worldwide, a 37% decline in coal production and an approximately one-third decline in oil consumption have resulted in about 11,000 fewer air pollution deaths.

However, COVID-19 has increased worldwide plastic consumption in the health care industry. Most of this waste is polluted by pathogens, which ultimately end up in the soil and the ocean. The pandemic has also resulted in more waste fires, which increased from 45% of all fires from 2016 to 2019 to 56% of all fires as of March 2020.

Social Determinants of Health: Examples

Our health is affected by our homes, schools, workplaces, neighborhoods, and communities, as the ODPHP explains. Preventive health care services; healthy foods; social and economic opportunities; and clean air, water, and food lead to people living longer, healthier lives. One of the five core goals of the ODPHP’s Healthy People 2020 and Healthy People 2030 campaigns, each of which spans the 10-year period leading to the years 2020 and 2030, respectively, is to “create social and physical environments that promote good health for all.”

Other U.S. health initiatives with social and economic goals are the National Partnership for Action to End Health Disparities (U.S. Department of Health and Human Services) and the Community Health and Economic Prosperity initiative (Office of the Surgeon General).

The Impact of Public Safety on Health

Two of the five key domains in the ODPHP’s Healthy People initiatives focus on health determinants related to neighborhoods and infrastructure, and the social support available in communities:

Neighborhood and Built Environment includes access to foods that support healthy eating patterns, access to health services, and crime and violence reduction. The program also promotes higher education, quality housing, and social cohesion.
Social and Community Context promotes civic participation, eliminating housing and workplace discrimination and reducing incarceration levels. It too addresses health care access, higher education, and social cohesion.

How Residential Segregation Impairs Public Health

Housing and community conditions have a direct impact on public health. Research reported in the International Journal of Environmental Research and Public Health found higher rates of chronic diseases, sleep problems, depression, and anxiety in people who live in areas with poor ventilation, lack of open public spaces, and poor access to cleaning and medical supplies; these characteristics are also associated with poorer health education and behavior, and lower overall health scores.

A PublicSource survey on the correlation between segregated housing and public health identified a direct correlation between children growing up in high-poverty neighborhoods and “negative long-term socioeconomic and health-based adult outcomes.” In Pittsburgh, for example, 59% of African American residents live in high or extreme poverty neighborhoods compared to 14% of white residents.

Children raised in high-poverty neighborhoods whose parents were also raised in high-poverty neighborhoods had standard IQ scores that were 8 or 9 points lower than average, which is the equivalent of missing two to four years of schooling.
From 1985 to 2000, 31% of African American children lived in high-poverty areas, an increase from 29% from 1955 to 1970; only 1% of white children grew up in high-poverty areas in both time periods.

Educating the Public About Behavioral, Environmental, and Social Determinants of Health

The success of efforts to understand and respond to social and environmental health determinants depends on work that public health professionals at the community, state, and federal levels have done. These important positions are responsible for educating at-risk populations in particular about the threats to their health from environmental and social factors and teaching people how they can mitigate those threats.

For example, many different public health organizations have partnered with the ODPHP’s Healthy People 2030 project to focus on social determinants of health (SDOH) interventions:

The National Institute on Minority Health and Health Disparities offers standard SDOH measures that public health officials can use to formulate effective strategies promoting healthy living.
In Atlanta’s Buckhead community, residents and leaders lobbied for tougher liquor law enforcement, leading directly to less violent crime in the area.
The Minneapolis Health Department helps small food stores, including those in gas stations, offer customers healthy foods.

Effective Approaches to Public Education About the Importance of Behavioral Health

Efforts to create a public health framework for the U.S. health care system have focused primarily on people’s physical health. The CDC emphasizes the heightened need for including behavioral health in the public health framework in light of the impact of the COVID-19 pandemic on people’s mental health. Physical distancing, isolation, school closures, and rising unemployment have raised stress and uncertainty to unprecedented levels throughout the population.

Public health professionals play a central role in the formidable task of educating the public about the need to understand and, if necessary, seek treatment for behavioral health issues related to the COVID-19 pandemic. The current approach that focuses on a one-on-one approach for people who’ve been clinically diagnosed with a mental health problem falls far short of the spike in demand for behavioral health education and support.

The CDC concludes that the long-term behavioral health needs of the population make the implementation of coordinated public mental health strategies a critical component of our recovery. The goal is to increase overall resilience in the population at the national and local levels. However, the CDC acknowledges the serious challenges that local public health providers face in gaining the resources, knowledge, and data they need to address the behavioral health needs of the population.

The American Psychological Association’s population health framework for promoting behavioral health addresses three categories of people in need of such services:

People whose behavioral health conditions require clinical intervention
People who experience subclinical psychological distress and are at high risk of experiencing clinically significant behavioral health issues
People who are relatively healthy but who need to be educated about appropriate responses to stress and the importance of behavioral wellness

To improve the effectiveness of outreach on behavioral health in crisis situations, the U.S. Bureau of Justice Assistance provides a Police-Mental Health Collaboration (PMHC) Toolkit that involves cross-training the police and behavioral health professionals. The goal is to increase awareness of the roles each team member plays in addressing behavioral health and to bring behavioral health workers into the process of developing policies and procedures for treatment and services to people experiencing a mental health crisis.

How Public Health Officials Raise Awareness of Social and Environmental Health Issues

The COVID-19 pandemic has eliminated any distinction between social and environmental health issues. The Organization for Economic Cooperation and Development (OECD) explains that in the short term, public health officials must focus on strengthening public health systems and responding to the economic crises resulting from the pandemic. Beyond the short term, public health must push policymakers to make social and environmental health protections a public health priority.

The single most dangerous threat to public health worldwide is air pollution. The WHO estimates that 9 out of 10 people on the planet breathe indoor and outdoor air contaminated with substances known to cause millions of premature deaths each year.
An important tool in preventing the spread of the coronavirus and other pathogens is to wash hands regularly, yet billions of people lack access to basic water and sanitation facilities. The WHO and UNICEF report that about 2.2 billion people don’t have safe drinking water available, and roughly 4.2 billion don’t have safe sanitation services.

Strategies for Disseminating Public Health Information

Public health officials face many challenges in their efforts to distribute health information to people in their communities, as well as to policymakers, supporting organizations, and the media. The Centers for Disease Control and Prevention (CDC) has issued interim guidance for preparing communities for pandemics and other health emergencies.

The guidance is intended for state and local public health information officers, health communication specialists, health educators, and public health professionals. It offers advice for what to do before, during, and after a coronavirus outbreak.

Before an outbreak occurs, test and strengthen the public health communication network over all channels and media, including online and text messages.
During an outbreak, maintain regular communication with partners, stakeholders, and the media. Ensure a single, consistent message, and make sure that the messages are timely, accurate, empathetic, and effective.
After an outbreak, collaborate with partners to determine when specific precautions can be eased. Maintain a state of preparedness, and keep all stakeholders and the media informed of relevant developments and plans. Assess the effectiveness of communications during the outbreak.

“There have been mixed messages surrounding the prevention of COVID-19 that may have created a certain level of uncertainty in the populace,” notes Dr. Kingori. “Effective communication across the health sector is important in order to motivate people to take up the preventive strategies. In addition, the language used in educational materials needs to consider the populace’s level of education and level of fluency with the dominant language (English), as well as beliefs and attitudes.”

Examining the Behavioral, Social, and Environmental Determinants of Mental Health

Public health professionals are at the center of strategy development to improve environmental and socioeconomic factors that contribute to mental health. Current Psychiatry Reports emphasizes the potential benefits of using advanced data analytics tools to identify SDOH’s negative effects on mental health. The analyses can also be used to devise strategies to counteract these effects.

However, doing so requires standardization of data relating to social and environmental determinants of mental health in electronic health records; this data includes dosage information, definitions, and demographic categories.

How Behavioral Factors Impact Mental Health

The goal of public health is to minimize the vulnerabilities of people in the community to physical and mental health problems while maximizing their resilience to diseases. This goal is accomplished by assessing the risk factors and protective factors that impact a person’s health. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) describes the variable and individual risk factors and protective factors that determine how likely a person is to develop mental health or substance abuse problems:

Variable Risk Factors. These include income level, peer group, adverse childhood experiences, and employment.
Individual Risk Factors. The two primary examples are genetic predisposition to addiction and prenatal exposure to alcohol.
Variable Protective Factors. Parental involvement and supervision, access to faith-based resources and after-school activities, and laws and policies that discourage specific behaviors, such as underage drinking, are key factors in preventing mental health problems and substance abuse.
Individual Protective Factors. By helping people develop problem-solving and social skills, behavioral health professionals bolster the community’s resilience to a range of risk factors, including anxiety about the future and poor self-image.

The Effect of Extreme Weather and Hazardous Work Environments on Mental Health

Even people who aren’t directly affected by tornados, hurricanes, floods, extreme heat, and other weather events can have their mental health impacted as a result, as Scrubbing In, a health site, explains. The events can trigger anxiety, depression, and post-traumatic stress disorder (PTSD). For people who experience such events firsthand, access to the mental health services they need is likely to be sporadic or completely disrupted.

Similarly, hazardous work conditions, such as dealing with hazardous agents; working in extremely cold environments; and having to work in tiring, painful physical positions, have been shown to have a negative effect on workers’ mental health. The fifth European Working Conditions Survey published in April 2019 found that increased levels of anxiety, depression, and sleep disorders correlated to high levels of workplace stress.

How Poverty and Other Socioeconomic Factors Negatively Impact Mental Health

A primary reason that poverty remains a major risk factor for mental illness is the increased likelihood that poor children will experience traumatic events during their childhood. Social isolation and loneliness, discrimination, and a disconnection from school and work reduce a person’s sense of control, self-efficacy, sense of community, and hope, as a Federal Reserve Bank of San Francisco report states.

How the Coronavirus Pandemic Has Affected Mental Health

The COVID-19 pandemic has exacerbated these negative experiences, worsening the impact of mental diseases on low-income communities. An effort is underway to link mental health with community development, in part by identifying symptoms of mental illness in children as early as possible, which improves educational outcomes. Another aspect of the effort stresses the importance of economic development and financial security to promote mental health in these communities.

A Kaiser Family Foundation survey found that as of August 2020, 53% of adults reported that their mental health had been negatively affected by the coronavirus. This compares to 32% who reported the same in a March 2020 survey. In an August 2020 survey, 24% of people ages 65 and over reported feelings of anxiety or depression as a result of the coronavirus. This compares to 11% of the age group who reported feelings of anxiety or depression in the 2018 Medicare Current Beneficiary Survey.

Building a Healthier World

Now more than ever, public health information saves lives. The job of reducing the negative impact of environmental and social determinants of health falls to public health professionals trained in creating, implementing, and monitoring lifesaving public health initiatives.

Ohio University’s online Master of Public Health (MPH) program emphasizes the importance of rigorous coursework combined with hands-on experience in planning and implementing effective public health programs.

For example, the program curriculum includes Social and Behavioral Sciences, which examines social concepts, diversity issues, and theories of health education and promotion as they apply to public health. The course also covers intervention strategies via communication and collaboration with diverse stakeholders in public health efforts.

Learn more about how the online MPH prepares students to fill vital roles in educating the public about the importance of preventing and treating illness.