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About the Social Determinants of Health

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks, as per Healthy People 2030.[1] SDOH often drive health inequities, leading to health disparities in and among already vulnerable populations and communities. SDOH are not siloed variables operating independently of each other. Instead, they often converge to impact overall health outcomes. Health disparities can be exacerbated by the unmet socio-economic needs within historically underserved and marginalized populations. Hard-to-reach populations grapple with many complex issues and barriers to care that HIV service providers and other stakeholders must consider to engage with clients, provide services effectively, close the equity gap, and reach EHE goals.
For all EHE priority areas and all U.S. States, AHEAD displays seven social determinants of health that are closely aligned with EHE indicators, Healthy People 2030 objectives, and the National HIV/AIDS Strategic Plan (NHAS) objectives.

Poverty

Poverty data (percent of civilian labor force, 16 years and over, that is below the poverty level), are sourced from the Small Area Income and Poverty Estimates (SAIPE), American Community Survey (ACS) 1-year estimates.
Poverty status is defined by family; either everyone in the family is in poverty or no one in the family is in poverty. The characteristics of the family used to determine the poverty threshold are: number of people, number of related children under 18, and whether or not the primary householder is over age 65. Family income is then compared to the poverty threshold; if that family's income is below that threshold, the family is in poverty. [6]

Employment

Employment data (unemployment rate) are sourced from the Bureau of Labor Statistics. The unemployment rate represents the U-3 unemployment rate. These rates are 1-year annual averages.
The unemployment rate represents the number unemployed as a percent of the labor force. [2]
Unemployed persons (Current Population Survey) as per the U.S. Bureau of Labor and Statistics is Persons aged 16 years and older who had no employment during the reference week, were available for work, except for temporary illness, and had made specific efforts to find employment sometime during the 4-week period ending with the reference week. Persons who were waiting to be recalled to a job from which they had been laid off need not have been looking for work to be classified as unemployed. [2]

Insurance

Health insurance coverage data (percent of population under 65 that is insured) are sourced from the U.S. Census - Small Area Health Insurance Estimates (SAHIE), American Community Survey (ACS) 1-year estimates.
The SAHIE definition of Insured person “Is this person CURRENTLY covered by any of the following types of health insurance or health coverage plans?”
  • Insurance through a current or former employer or union (of this person or another family member)
  • Medicare, for people 65 and older, or people with certain disabilities (Note: SAHIE does not report insurance rates for people over 65 since over 98% of people over the age of 65 are insured)
  • Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability
  • TRICARE or other military health care
  • Indian Health Services*
  • VA (including those who have ever used or enrolled for VA health care)
  • Any other type of health insurance or health coverage plan (user specified)
*People whose only health coverage is Indian Health Service are uninsured as IHS is not considered comprehensive coverage.[7]

Education

Educational attainment data (percent of population 25 and older that graduated high school are sourced from the U.S. Census, American Community Survey (ACS) 1-year estimates.
The definition used for educational attainment were individuals 25 and older that have a High School Graduate or Higher defined by the ACS as – This category includes people whose highest degree was a high school diploma or its equivalent, people who attended college but did not receive a degree, and people who received an associate’s, bachelor’s, master’s, or professional or doctorate degree. People who reported completing the 12th grade but not receiving a diploma are not included. [8]

Income Inequality

Gini coefficient of income inequality (estimated Gini coefficient) are sourced from the U.S. Census, American Community Survey (ACS) 1-year estimates.
Income inequality is the extent to which income is distributed unevenly among a population. [9]
The Gini is a measure of how much a distribution varies from a proportionate distribution. A purely proportionate distribution would have every value in the distribution being equal (that is 20% of the values would equal 20% of the aggregate total of all the values). This also is known as “perfect equality” – all households have an equal share of income. An example of a distribution that deviates the most from perfect equality would have every value except one equal to zero, and one value that would be equal to the nonzero aggregate total for all the values. This also is known as “perfect inequality” – one household has all income. [8]
The Gini ranges from zero (perfect equality) to one (perfect inequality), and it is calculated by measuring the difference between a diagonal line (the purely proportionate distribution) and the distribution of actual values (a Lorenz curve). This measure is presented for household income. [8]

Unstable Housing or Homelessness

Housing Instability or Homelessness among persons living with HIV data are sourced from CDC’s Medical Monitoring Project and are only available at the national level.
Unstable housing or homelessness is defined as experiencing unstable housing (i.e., moving in with others due to financial issues, moving 2 or more times, or being evicted at any time) or homelessness (i.e., living on the street, in a shelter, in a single-room–occupancy hotel, or in a car at any time) during the past 12 months. [10]

HIV Stigma

HIV stigma among persons living with HIV data are sourced from CDC’s Medical Monitoring Project and are only available at the national level.
HIV stigma is negative attitudes and beliefs about people with HIV. It is the prejudice that comes with labeling an individual as part of a group that is believed to be socially unacceptable. [11]
Defined as a median score on a 10-item scale ranging from 0 (no stigma) to 100 (high stigma) that measures 4 dimensions of HIV stigma: personalized stigma during the past 12 months, current disclosure concerns, current negative self-image, and current perceived public attitudes about people living with HIV. [10]

Data Sources

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Ending the HIV Epidemic (EHE) seeks to reduce the number of new HIV infections in the United States by 75 percent by 2025, and then by at least 90 percent by 2030, for an estimated 250,000 total HIV infections averted. AHEAD is paid for by EHE.
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