Going to the doctor regularly is important, but it turns out getting there is not the biggest factor determining a patient’s overall health.

Social determinants of health (SDOHs)—nonclinical and environmental factors including race, gender, ethnicity, housing status, and income level—can play a bigger role in a person’s health than access to healthcare or genetics, according to the CDC. In fact, they account for about 30% to 55% of someone’s health outcomes, according to the World Health Organization, and environmental factors may account for up to 90% of diseases, according to the CDC.

And while the connection between some SDOHs and their effect on health are relatively clear, there are numerous other factors that may be less obvious.

For example, it’s not hard to imagine a lower-income patient avoiding going to the doctor due to concerns about paying medical bills. But education, social capital, and stress levels are also major factors contributing to health, experts say.

Back to school

There are two main ways education affects health, Prince Michael Amegbor, assistant professor of global and environmental health at New York University, told Healthcare Brew.

First, more formal education is often correlated with higher income in the US, he said. People with higher incomes in the US are more likely to be insured and less likely to worry about accumulating medical debt—13.4% of people with annual household incomes under $25,000 were uninsured in 2022, compared to 3.4% of people with annual household incomes over $75,000, according to data from the University of Minnesota.

Second, people with a higher education level are more likely to engage in healthier activities, like getting yearly check-ups, exercising, and eating nutritious meals, according to Amegbor.

“The assumption is that educated people often have the knowledge and information available to them to engage in preventive health behavior,” he said.

The social network

Another important SDOH is social capital, Amegbor said, which comes in two forms: cognitive and structural. A 2021 study from Chongqing University in China analyzed data from China and found that “cognitive and structural social capital can significantly promote individual health.”

Cognitive social capital refers to someone’s emotional connections with others, while structural social capital refers to their social networks, he said.

“These networks play a very important role in the sense that often they can be a vital resource or asset in terms of your health,” Amegbor said.

For instance, when a patient is going through a health crisis, having a social network gives them both emotional and material support, which can help improve their recovery, he said.

Cognitive social capital also refers to how safe that patient feels in their community. If they don’t feel safe in their neighborhood, for example, they may isolate, which raises the risk of depression and other mental health disorders or could lead them to avoid exercise, according to Amegbor.

Stressed out

In addition to education and social structure, the amount of stress a person experiences is a significant SDOH, according to Rachel Donnelly, an assistant professor of sociology at Vanderbilt University who specializes in SDOH research.

Most people experience stress, but some are more likely to experience stress chronically. For example, those who work in industries with high levels of job insecurity often stress over potentially losing employment, she said. And people with lower incomes may be under even more stress over things like food and housing security.

Stress has both a physical and psychological effect on patients, according to Donnelly, as it causes the body to release hormones like adrenaline and cortisol that can be damaging over time. Chronic stress can lead to hypertension, Type 2 diabetes, and arthritis, according to Yale Medicine.

“If I stress every single day about making ends meet, then that high level of activation biologically starts taking a toll on all sorts of systems in our body, like cardiovascular functioning, immune functioning,” Donnelly said. “It just totally sends the body haywire.”

What can be done

Clinicians can play an important role in combating the negative effects SDOHs may have on their patients’ health, both experts said.

For instance, they can ask patients about their housing status and food security, and put them in touch with community resources if needed, according to Donnelly.

Providers can also educate themselves on racial biases that may affect how they treat patients, Amegbor said. For example, studies have shown that Black women are less likely to receive pain medications during birth, and Black patients are less likely to receive pain medication in general due to racist misconceptions that they feel pain differently than white patients, according to Amegbor.

“Having more education and awareness can, at the facility level, mitigate some of the discrimination and also improve maternal healthcare outcomes,” he said.

But combatting the effects of SDOHs requires broader structural change, according to Amegbor. Federal policies would need to be put in place to ensure people of all income levels have access to a quality education or to create equitable housing programs, for example.

“It requires a multiskill approach if you want to address the social determinants of health from the individual to the higher levels, like the federal government,” Amegbor said.