Table 3 Description of Themes for Social Determinants of Health Codes in Order of Frequency

Economic Opportunity (N = 90)

Themes included poverty, income inequality, high cost of living, unemployment, limited job opportunities, limited high-quality job opportunities, and struggling economies locally and regionally. Economic opportunity was often viewed as inextricably linked with other factors such as healthcare, education, and secure housing. Access to quality, high-speed internet impacted connectivity and access to services.

“We don't have a consistent permanent employment base that keeps our community growing, competitive, or sustainable. There is a lack a critical infrastructure (water, internet, educated human capital work force) that would entice industry or business to move here creating employment growth.” [Fire chief, health and human services]

“Lack of affordable housing, lack of high paying jobs, lack of jobs that offer healthcare and other benefits to employees, lack of medical providers.” [Economic development coordinator, community and economic development]

Access to Care (N = 51)

Leaders described a lack of healthcare providers and healthcare services within their communities, particularly as compounded by rurality. Healthcare costs, insurance status and coverage, and distance to health services were stated as potential challenges to access to care. A small handful of the participants mentioned an unequal distribution of health services in the communities they serve but did not further elaborate on why that inequality may exist.

“The root causes of health inequity in our area are due to limited rural supportive of services with access to care for families/individuals in need. Often times barriers include education of services, transportation, and financial support.” [Community impact director, multisector]

“Poverty, distances people need to travel to health practitioners or facilities. Difficulty to attract health professionals to the area. Lack of access to specialized care, i.e. speech therapists, oncologists. Language barriers for the Native American elderly, and many reside in areas without running water or electricity. High level of addictions and social problems exceeds the practitioners and facilities that can intervene with the care needed.” [Library district director, multisector]

Social and Cultural Cohesion (N = 34)

 Participants described a lack of support for mental health and lack of support systems and supportive relationships, families, and homes. Social and cultural cohesion was linked to or contributed to high rates of poor mental health, abuse, and childhood or family trauma, substance use, and stigma related to substance use and other health conditions like HIV. Fewer described topics such as language barriers and lack of opportunities to be engaged in the community.

Both social and physical isolation were considered a function of rurality and the unique challenges rural communities face, including limited services and resources and lack of connection across sectors.

“High proportion of low-income jobs. High proportion of jobs without benefits. Use of illegal substances disproportionate to the size of the population. Children at high risk due to early traumas and dysfunctional families. Distance to specialized medical services.” [Superintendent, education]

“My community has a higher cost of living with limited job opportunities and low pay. The youth lack support services and safe places to go. Community resources are limited and mental health resources are lacking.” [Health educator, multisector]

Educational Opportunity (N = 31)

“Lack of education” or just “education” were commonly listed with no further explanations. Some of the participants noted the lack of secondary education opportunities and support in their communities. Multiple participants also mentioned that low education status and low education standards are interlinked with the low employment within their communities.

“A lack of the education necessary to obtain a long term career.” [Regional director, early childhood development]

“Lack of education, lack of money to attend school after free public education, lack of role models, lack of teamwork / communication for benefits of community, poor food options at the local store (soda, chips, candy), unhealthy lifestyle decisions.” [Superintendent, education]

Transportation (N = 26)

A lack of transportation (both personal and public transportation) was a major issue in leaders' communities. Multiple participants mentioned distance to services and rurality being contributing factors in transportation issues. Some tied their community’s transportation challenges to issues with the ability to work and to access food and health services.

“Much of our ridership is comprised of seniors, the disabled, tribal residents and low income families dependent on public transit to travel to medical appointments, the pharmacy and grocery store and government services. Public transportation is primary in alleviating one of the major root causes of health inequity; without a reliable mobility service, the health and welfare of our communities are significantly impacted.” [Grants and transit manager, transportation]

“Economics and the high cost of living also many of the residents live out in the country where transportation is difficult.” [Public defender, law, justice, and public safety]

Housing (N = 24)

Housing concerns included lack of adequate and affordable housing, both to rent and buy, limited housing options, and homelessness in leaders' communities. Housing was often compounded by other factors, particularly by a lack of economic opportunities.

“We have relatively low unemployment but do have a lot of low income citizens. Affordable housing seems to be a big cause of some of our issues. People have to pay more towards their living conditions so takes away from other issues such as health care. [Director, health and human services]

“Lack of affordable housing, transient population, inability to maintain job security.” [CEO, health and human services]

Community Safety (N = 16)

Leaders discussed issues such as domestic violence, child abuse, felony convictions, and substance (drugs and alcohol) abuse. Participants also mentioned homelessness, mental health challenges, and a lack of safe places for youth.

“Mental health challenges (depression, helplessness, anxiety, stigmas) high levels of poverty, low levels of education minimal job opportunity, somewhat closed off community, high rates of alcohol, drugs, suicide, STIs, violence, domestic violence.” [Public health nurse, health and human services]

“Homelessness in the community which relates to economics. Drugs and alcohol affect families and especially the children. Number of individuals in jail. Not enough mental health providers.” [President, multisector]

Social Justice (N = 12)

Themes of incarceration policies and practices were described, including convictions and the criminalization of substance use in lieu of treatment for substance use disorders; historical and generational trauma, lack of intergenerational wealth, land distribution policies that disproportionately affect  indigenous communities; lack of cultural and community representation in local and county policy; structural and institutional racism and discrimination, including how these are barriers for policy goals.

“The root causes of health inequity in the community I serve is the criminalization of people who use drugs. There is also institutional racism, sexism, and other stigma tied to this. The separation of mental health disorders from substance use disorders feeds this as well.” [Programs director, multisector]

“Wealth inequity and the lack of generational wealth that sustains generations. Housing market that predominantly serves college residents and the tourism market. Racism and discrimination remain a significant problem for all policy goals.” [Public affairs director, policy]

Food (N = 8)

When food was highlighted as a concern in leaders' communities, food deserts, access to nutritious food, food insecurity, and poor nutrition were described. Similar to other SDoH, food systems were often talked about in synchrony with other factors affecting the community’s overall wellbeing and health, such as economic opportunities and transportation.

“We serve the poorest and neediest senior over 60 and those under with a disability. These clients do not make enough money on their Social Security to afford housing, food, and health. If a client is just 5 dollars over the limit for AHCCCS [Arizona Health Care Cost Containment System, Arizona’s Medicaid program] they can't afford food.” [Client services manager, health and human services]

“Low employment opportunities, vast low-income neighborhoods, diet-related disease, lack of transportation i.e.: valley-wide transit line, diminished access to healthy food with widespread food desert.” [Executive director, multisector]

Environmental Quality (N = 6)

This theme largely focused on  a lack of basic and critical utilities such as running, drinking or wastewater, and electricity. These issues were often described in connection with economic opportunity and living in rural or tribal lands with limited access to resources compared to cities and more urban areas of the region.

“The root causes of health inequity in our community have to do with access, many of our community live in very rural areas that require travel of great distances to get access to care. There is also in the same vein a very poor population that live without even basic necessities like electricity, running water and internet service.” [County manager, policy]

“Agricultural challenges due to heat & environment.” [Executive director, multisector]

Community Design (N = 3)

Community design as a cause of inequity was defined by lack of infrastructure, including limited land development, lack of physical infrastructure such as streets and sidewalks, and little interest in improving or developing infrastructure. A couple of examples described how insufficient physical infrastructure affects  the  communities served and made connections between community design and inequity.

“[My] county is a politically conservative community and there is little interest in improving and building infrastructure needed to address the environmental inequities (neighborhoods with paved and unpaved streets, no sidewalks, etc.).” [Director, health and human services]

“Topography, high desert with little infrastructure. Limited land development and ownership.” [Economic development manager, multisector]