The state of health in America is shaped not just by clinical care, but by the conditions in which people live, learn, and work. These conditions, known as the Social Determinants of Health (SDOH), include economic stability, education access, the built environment, healthcare access, and social and community factors, and they greatly influence health inequities. Currently, over 41 million Americans live in poverty, a widespread economic instability that is responsible for increasing stress, limiting access to necessary resources, and contributing to poor health outcomes, including an estimated 295,000 poverty-related deaths each year (Poor People’s Campaign: A National Call for Moral Revival, 2023). Furthermore, education is linked to this stability, as educational achievement shapes employment, income, and overall opportunities, whereas inadequate education is associated with higher rates of chronic health problems like heart disease and diabetes (The Lancet Public Health, 2020).
The reality of these determinants is visible in the physical spaces we live in. The difference between well-resourced neighborhoods—with safe parks, fresh food, and quality schools—and those just miles away, which lack essential infrastructure, public safety, and reliable services, directly shows how the SDOH dictate well-being and quality of life (U.S. Department of Health and Human Services, 2024). The neglect of these SDOH domains widens inequality gaps and creates unnecessary, avoidable health disparities. Public health nursing is grounded in community assessment, employing “shoe leather epidemiology” and windshield surveys to systematically gather essential data and diagnose a community’s unique strengths and weaknesses before moving forward with intervention (Nies & McEwen, 2024).
An example of researching the neighbors in which we live to identify SDOH can be seen through a comprehensive community profile created by Senior nursing students at John Carroll, located near University Heights, Ohio. This research effectively addresses gaps related to SDOH and contributes to equitable, culturally competent care for those within the neighborhood. This example will demonstrate why understanding a community’s unique environmental and social community is the foundational step toward improving health equity for all residents.
In Cuyahoga County, Ohio, education quality and public-school funding rely on property taxes, creating deep inequities. Wealthier districts, such as Shaker Heights and Beachwood, generate more revenue per student than lower-income neighbors like Cleveland Heights, often spending thousands more per student nationally. This results in underfunded districts facing disadvantages in classroom resources and teacher experience. For example, the Cleveland Heights-University Heights (CH-UH) School District is projected to see a 4% decrease in state funding, while wealthier districts anticipate substantial increases (Stein, 2025). Access challenges complicate this financial disparity. In University Heights, immigrant communities, including Arabic, Spanish, and East African populations, face many barriers. English Language Learners (ELLs) lack culturally responsive curricula and bilingual-trained teachers, leading to isolation and low engagement. Furthermore, schools that limit diversity, equity, and inclusion (DEI) initiatives negatively impact the school climate for marginalized students. Addressing the gaps requires expanding community partnerships, such as successful school-based health centers that improve attendance and mental health by providing on-site vision screening, counseling, and primary care (Boose, 2025).
Cleveland residents frequently delay essential medical care due to critical gaps in affordable health care access. The 2025 Cleveland Healthy Survey, conducted by Case Western Reserve University and the Cleveland Department of Public Health (2025), found that only 65.4% of residents aged 18–34 received a routine check-up, missing crucial preventive opportunities. Our windshield survey in University Heights confirmed the structural barriers: limited walk-in clinics, poorly maintained facilities, and inadequate public transportation. For families in this community, the reality is often choosing between missing work or delaying a child’s needed medical appointment due to high co-pays or a total lack of insurance. Delaying care leads to worse health outcomes, demonstrating that these inequities are not incidental but are rooted in deep structural issues. As public health experts, Nies and McEwen (2024) emphasize, quality healthcare is a fundamental social determinant of health. Achieving population health requires an “upstream preventive focus” combined with a social justice lens. Simply having a clinic nearby is not enough; accessibility must include affordability, timeliness, and culturally competent care that respects patient values. Underserved populations deserve equitable attention in all health policy and community planning efforts (Nies & McEwen, 2024).
Economic stability is crucial for individual security and maintaining a safe living environment. Insecurity related to low income or job instability increases the risk of housing instability and frequent relocation. This upheaval disrupts access to employment and healthcare, leading to increased exposure, inadequate sanitation, and poor nutrition, which, in turn, raises the likelihood of chronic illness. Economic stability is also essential for food security, allowing individuals to afford the nutritious options necessary for a healthy lifestyle. Individuals in low-income communities often struggle with consistent access to valuable food options (Birk, 2023). Furthermore, the chronic stress from financial struggle severely impacts physical and psychological health. Psychologically, the uncertainty of basic needs like food and shelter can cause or worsen anxiety and depression. While the Affordable Care Act (ACA) expanded Medicaid and essential services (2010), challenges remain, as comprehensive plans sometimes increase overall costs, hindering the very access people need.
Well-maintained green spaces and quality infrastructure in neighborhoods and built environments are crucial for community health. Parks, like the eight identified in our survey, promote physical activities such as walking and biking—which help prevent chronic diseases while reducing stress and anxiety through peaceful environments. Conversely, poor infrastructure, including broken sidewalks and low-quality street maintenance, discourages activity and increases injury risk, despite its high importance to residents (Western Reserve Land Conservancy, 2024). To address these structural deficiencies, Cleveland Heights uses programs like the “Grow” Community Reinvestment Area and Job Creation Grants to incentivize renovation and development, aiming to stabilize the tax base and improve the quality of the local housing stock.
In addition to poor infrastructure, critically, unsafe neighborhoods and exposure to violence dramatically limit opportunities for physical exercise and social interaction. Children exposed to violence face significantly higher risks for developing both physical and mental health conditions, including anxiety, PTSD, asthma, and chronic diseases (Hinckley, 2024). Therefore, improving and maintaining the built environment—from parks to public safety—is essential for promoting physical activity, mental well-being, and overall public health equity.
The health landscape in communities like University Heights is shaped by inequities across the Social Determinants of Health (SDOH). Systemic barriers, including property-tax- dependent school funding, structural housing instability, and critical gaps in affordability, quality healthcare, fuel unnecessary health disparities. These factors, from economic stress to environmental risks, perpetuate cycles of poor outcomes. Addressing this complex reality requires more than just clinical intervention; it demands a comprehensive, “upstream preventive focus.” Public health nursing must utilize community assessment as the foundational step to diagnose these structural issues and implement targeted, culturally competent solutions that lead to true health equity for all residents.
References:
Boose, J. (2025, May 14). Students bring opposition to proposed school funding changes to Ohio Statehouse. Ideastream Public Media. https://www.ideastream.org/education/2025-05-14/students-bring-opposition-to-proposed-school-funding-changes-to-ohio-statehouse
Birk, J. (2023, May 19). Chronic stress can hurt your overall health. ColumbiaDoctors. https://www.columbiadoctors.org/news/chronic-stress-can-hurt-your-overall-health
Case Western Reserve University & Cleveland Department of Public Health. (2025). 2025 Cleveland Health Survey: Demographics. Prevention Research Center for Healthy Neighborhoods. https://prchn.org/wp-content/uploads/2025/04/2025-Cleveland-Health-Survey-Demographics.pdf
Hinckley, J. (2024, October 2). Neighborhood violence is linked to using more acute care and unmet preventive and mental health care needs. Penn LDI. https://ldi.upenn.edu/our-work/research-updates/neighborhood-violence-is-linked-to-using-more-acute-care-and-unmet-preventive-and-mental-health-care-needs/
Nies, M. A., & McEwen, M. (2024). Community/Public Health Nursing (8th ed.). Elsevier. https://pageburstls.elsevier.com/books/9780323831833
Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010).
Poor People’s Campaign: A National Call for Moral Revival. (2023, June 16). 2023 National fact sheet. https://www.poorpeoplescampaign.org/resource/2023-national-fact-sheet/
Stein, B. (2025, July 17). Legislators abandon Fair School Funding Plan, funnel state support away from high-poverty districts. Policy Matters Ohio. https://policymattersohio.org/research/lawmakers-underfund-ohio-schools-by-2-86b-in-fy26-27/
The Lancet Public Health. (2020). Education: A neglected social determinant of health. The Lancet Public Health, 5(7), 361. https://doi.org/10.1016/s2468-2667(20)30144-4
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2024). Social determinants of health. Healthy People 2030. Retrieved from https://health.gov/healthypeople/priority-areas/social-determinants-health
Western Reserve Land Conservancy. (2024, August 27). Neighborhood stabilization | Green space. https://wrlandconservancy.org/neighborhood-stabilization/
