Social Determinants of Health

Social determinants of health are the conditions in which people are born, grow, live, work, and age. They include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care. In addition, people who are noncitizens and who do not speak English well face increased barriers to accessing health coverage and health care. There has been extensive research and recognition that improving health and achieving health equity will require broader approaches that address social, economic, and environmental factors that influence health. The COVID-19 pandemic exacerbated existing health disparities and underlying inequities for a broad range of populations, but specifically for people of color. For example, Black and Hispanic adults have had more difficulty paying household expenses, experienced higher rates of food insufficiency, and have been more likely to live in a household that experienced a loss of employment than White adults during the pandemic.

Overall, Black, Hispanic, AIAN, and NHOPI people fared worse compared to White people across most examined measures of social determinants of health for which data were available (Figure 27). Experiences for Asian people were more mixed relative to White people across these examined measures. Reliable or disaggregated data for AIAN and NHOPI people were also missing for several measures.

Work Status, Family Income, and Education

Across racial and ethnic groups, most nonelderly people live in a family with a full-time worker, but Black, Hispanic, AIAN, and NHOPI people are more likely than White people to be poor (Figure 28). Across racial and ethnic groups most people lived in a family with a full-time worker, but Black, Hispanic, and AIAN people are less likely than White people to have a full-time worker in the family as of 2019. Despite most people living in a family with a full-time worker, Black, Hispanic, AIAN, and NHOPI nonelderly people were more likely than their White counterparts to have family income below the federal poverty level ($21,960 for a family of three as of 2021).

Black, Hispanic, AIAN, and NHOPI people have lower levels of educational attainment compared to their White counterparts. Among people ages 25 and older, over two thirds of White people had completed some post-secondary education, compared to less than half (42%) of Hispanic people, just over half (51%) of AIAN people, 53% of NHOPI people, and 56% of Black people as of 2019 (Figure 29). Asian people were more likely than White people to have completed at least some post-secondary education, with 74% completing at least some college.

Assets and Debt

Black and Hispanic families have less wealth than White families. Wealth can be defined using net worth, a measure of the difference between a family’s assets and liabilities. The median net worth for White households in 2019 was $189,100 compared to just $24,100 for Black households and $36,050 for Hispanic households (Figure 30). Disaggregated data for other groups were not available.

People of color are less likely to own a home than White people (Figure 31). The homeownership rate among White people was 76% in 2019, compared to 67% for Asian people, 60% for AIAN people, 52% for Hispanic people, and less than 50% for both Black and NHOPI people (46% and 45%, respectively).

Food Security, Housing, and Internet Access

Black, Hispanic, and AIAN nonelderly adults are more likely to experience food insecurity compared to White adults, and Black and Hispanic children are more likely to be food insecure than their White counterparts. Among nonelderly adults, 16% of Black adults, 13% of Hispanic adults, and one in five (20%) AIAN adults had low or very low food security compared to 6% of White adults as of 2019 (Figure 32). Disaggregated data for NHOPI adults were not available. Among children, Black (20%) and Hispanic (16%) children were over twice as likely to be food insecure than White children (7%). Disaggregated data for AIAN and NHOPI children were not available.

People of color are more likely to live in crowded housing than their White counterparts (Figure 33). As of 2019, 3% of White people reported living in a crowded housing arrangement, that is having more than one person per room, as defined by the American Community Survey. In contrast, almost one third (29%) of NHOPI people, roughly one in five Hispanic (19%) and AIAN (15%) people, and about one in ten Asian (12%) and Black (8%) people reported living in crowded housing.

AIAN, Black, NHOPI, and Hispanic people are less likely to have internet access than White people (Figure 34). Black (12%), AIAN (20%), and NHOPI (10%) people were more likely than White people (7%) to report no internet access as of 2019. In contrast, Asian people were less likely to report no internet access than White people (3% vs. 7%).

Transportation

People of color are more likely to live in a household without access to a vehicle than White people (Figure 35). Black and AIAN people were the most likely to live in a household without a vehicle available (13% and 10%, respectively) followed by Asian (8%), Hispanic (7%) and NHOPI (6%) people. White people were the least likely to report not having access to a vehicle in the household (4%).

Citizenship and Language

Among the nonelderly population, Black, Hispanic, Asian, and NHOPI people include higher shares of noncitizens compared to White people. Asian and Hispanic people have the highest shares of noncitizens at 28% and 20%, respectively, as of 2019 (Figure 36). Asian people are projected to become the largest immigrant group in the United States by 2055, surpassing Hispanic people. Immigrants are more likely to be uninsured than citizens and face increased barriers to accessing health care.

Hispanic and Asian people are more likely to speak English less than very well compared to White people. Almost one in three Hispanic people (29%) and Asian people (31%) reported not speaking English very well 1% of White people as of 2019 (Figure 37). Moreover 14% of Hispanic people and 16% of Asian people report that no one in the household ages 14 and older speaks English well compared to 1% of White people. There were also small but statistically significant differences for Black, AIAN, and NHOPI people compared to White people for this measure.

Racism and Adverse Childhood Experiences (ACEs)

Parents of Black, Hispanic, and Asian children are more likely to report their children were treated or judged unfairly because of their race/ethnicity than parents of White children. Over one in ten (13%) parents of Black children, 7% of parents of Hispanic children, and 5% of parents of Asian children reported their children were treated or judged unfairly because of their race/ethnicity compared to 2% White children in 2019-2020 (Figure 38). Disaggregated data were not available for parents of AIAN and NHOPI children. Federal health surveys do not include national measures of experiences with racism among adults. However, a recent KFF survey found that Black and Hispanic adults were more likely than White adults to experience race-based discrimination while shopping working, getting health care, or interacting with the police.

Some adults and children of color are more likely to report adverse childhood experiences (ACEs) than their White counterparts (Figure 39). ACEs are potentially traumatic events that occur in childhood, such as experiencing violence, abuse, or neglect; witnessing violence; or growing up in a household with substance use problems or mental health problems. ACEs are linked to chronic health problems, mental illness, and substance use problems in adulthood. Research shows that the more ACEs a person experiences, the higher at risk they are for negative health and well-being and generally accepted thresholds for identifying adults and children at risk based on ACEs have been established in literature. The BRFSS survey measures eleven types of ACEs among adults in 28 states. As of 2020, AIAN adults were more likely than White adults to have experienced four or more ACEs (36% vs. 19%), while Asian adults were less likely than their White counterparts to report four or more ACEs (10% vs. 19%). Among children, the National Survey of Children’s Health measures nine types of ACEs. In 2019-2020, Black and Hispanic children were more likely than White children to report experiencing two or more ACEs (25% and 20% vs. 16%). Asian children were less likely than White children to report experiencing two or more ACEs (6% vs. 16%). Disaggregated data were not available for AIAN or NHOPI children.

Health Status, Outcomes, and Behaviors Disparities in COVID-19 Impacts

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