Advancing Health Equity Research on Social 

Determinants of Health Using the National 

Health and Nutrition Examination Survey 

(NHANES)

Denys T. Lau, PhD; Namanjeet Ahluwalia, PhD; Cheryl D. Fryar, MSPH; 

Matthew Kaufman; Irma E. Arispe, PhD; and Ryne Paulose-Ram, MA, PhD 

National Center for Health Statistics, Division of Health and Nutrition Examination Surveys

2022 FCSM Research & Policy Conference

October 27, 2022, 1:30 pm 
Introduction

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Health Equity and Social Determinants of Health

• Health equity is defined as “attainment of the highest level of 

health for all people”

• Health equity research looks beyond the existence of health 

disparities towards social determinants of health (SDOH)

• SDOH are conditions in which people are born, live, work, play, 

worship, and age

• SDOH drive differences in exposures to social risks:

o e.g., unhealthy foods, poor housing conditions

• Inequitable exposures to social risks manifest in health 

disparities
National Health and Nutrition Examination Survey (NHANES)

• A series of cross-sectional surveys on nationally 

representative samples of adults and children in the US.

• Standardized interviews, physical examinations, and 

biospecimens such as blood and urine samples

• National estimates and trends in diseases, dietary 

intake, physical activity, and environmental exposures

• Released data publicly in two-year cycles (~10,000 

participants)

• Due to COVID-19, 2019-2020 was not completed so 

combined 2017-March 2020 Pre-Pandemic Data files 

were released

Mobile Examination Center
NHANES and Health Disparities Research

• Tracks our Nation’s 

progress towards meeting 

Healthy People 

objectives.

• Provides evidence of 

disparities across multiple 

health and nutrition 

indicators

Health Indicator Examples

Chronic conditions Diabetes, hypertension, respiratory 

and kidney disease, obesity

Infectious diseases HIV, HPV, herpes simplex virus, 

hepatitis

Dietary intake Fruits and vegetables, added sugar, 

sodium, fast food

Environmental and dietary chemical 

exposures

Volatile organic compounds (VOCs), 

blood lead levels, mercury, 

arsenic, second-hand tobacco smoke
To examine how 1999-2020 NHANES data support health equity research 

related to social determinants of health (SDOH):

• Part 1: Provide examples of NHANES data use for SDOH and health 

equity research

• Part 2: Present potential future opportunities to further NHANES’ capacity 

to advance health equity science

Objectives

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Part 1: NHANES Data Supporting 

SDOH Research

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NHANES: Supporting Health Equity Research

• Household interview items on social risks and personal attributes 

• Indoor sample collection to identify household allergen exposures 

• Oversampling of subpopulations at disproportionate social risks

• Data linkage to examine health disparities driven by SDOH
Household Interview

• Data on self-reported social risks that can be 

categorized into five SDOH domains:

• Respondents’ personal attributes like sociodemographic 

characteristics

• Data collected vary by survey cycle
Interview Items on Social Risks

Education Access and Quality

• 1999-2020: Highest education completed

Economic Stability

• 1999-2020: Annual family income, poverty-income ratio

• 1999-2020: Occupation type and work schedule

o 1999-2004: codes for asthma-related jobs

o 1999-2014: codes for current and longest-held jobs

• 1999-2020: Home ownership

• 1999-2020: U.S. Food Security Survey Module

o 2003-2010: Missed meals, not enough money to buy food

o Varied: SNAP, WIC, home-delivery meals, school breakfast/lunch
Interview Items on Social Risks

Health Care Access and Quality

• 1999-2020: Health insurance

o 1999-2004: Dental care coverage

o 2005-2020: Prescription drug coverage

• 1999-2020: Usual source of health care

• 2003-2020 (except 2005-2010): Needed but could not get dental care

Social and Community Context

• 1999-2008: Emotional and financial support
Interview Items on Social Risks

Neighborhood and Built Environment

• 1999-2018: crowding, # of rooms and # of people in the home

• Housing conditions

o 1999-2004: recent renovation, paint conditions, age of home

o 1999-2007: products with VOCs

o 1999-2010: tap water, water treatment 

o 2005-2006: mildew, musty smells, cockroaches, pets

• Workplace conditions

o 1999-2020 (except 2013-2014): noise and protective hearing devices

o 2007-2012: dust, exhausts and other fumes

• 1999-2020: second-hand smoking in the home and workplace 

o 2013-2020: other indoor areas like restaurants

• 2017-2020: mode of transportation by walking and biking
Personal Attributes 

• 1999-2020: race and ethnicity

o 1999-2020: Mexican American, Non-Hispanic Black, and Non-Hispanic White

o 2007-2020: Hispanic

o 2011-2020: Non-Hispanic Asian American

• 2001-2016: sexual orientation*

• 1999-2020: marital/relationship status

* 2017-2020 data available only in NCHS Research Data Center
Personal Attributes 

• 1999-2020: country of birth (nativity)

• 1999-2018: citizenship

• 1999-2020: language spoken

• 1999-2020: years living in the U.S.

• 1999-2018: prior military service

• 1999-2018: physical functioning in daily activities

o 2013-2018: disability status
Indoor Sample Collection

Dusts (floor, windowsill, beds)

• 1999-2004: Lead

• 2005-2006: Allergens

Drinking water

• 1999-2010: VOCs

• 2005-2010: Perchlorate

• 2013-2016: Fluoride

Table salt

• 1999-2020: Iodine

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Oversampling of Subpopulations

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Survey years 1999-2006 2007-2010 2011-2014 2015-2018 2019-2020

Race / Ethnicity

Hispanic Mexican American Hispanic Hispanic Hispanic Hispanic

Non-Hispanic Black Black Black Black Black

Asian Asian Asian

Age 12-19 years old; 

and 

Non-Hispanic 

White and other 

race/ethnicities 

ages 70+

Non-Hispanic 

White and other 

race/ethnicities 

ages 80+

Non-Hispanic 

White and other 

race/ethnicities 

ages 80+

Non-Hispanic White 

and other 

race/ethnicities 

ages 0-11 and 80+

Non-Hispanic 

White and other 

race/ethnicities 

ages 0-11 and 80+

Income Low-income (≤ 

130% of FPL*) nonHispanic White and 

other 

race/ethnicities

Low-income (≤ 

130% of FPL*) 

non-Hispanic 

White and other 

race/ethnicities

Low-income (≤ 

130% of FPL*) 

non-Hispanic 

White and other 

race/ethnicities

Low-income (≤ 

185% of FPL*) nonHispanic White and 

other 

race/ethnicities

Low-income (≤ 

185% of FPL*) nonHispanic White and 

other race/ 

ethnicities

Supplemental 

sample

Pregnant women

*FPL = Federal Poverty Level
Data Linkage

• Conducted at the individual level

• Examples of linked data:

o National Death Index

o Medicare and Medicaid 

o U.S. Renal Disease System ESRD data

o Department of Housing and Urban Development

o Department of Veterans Affairs 

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Merged Data

• Merge external sources of contextual data with 

NHANES data by geocodes

• Offers insights into respondents’ community 

context

• Examples of contextual-level data are available 

in the Agency for Healthcare Research and 

Quality SDOH Database

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Part 2: Future Opportunities in 

NHANES SDOH Research

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Future Opportunities

• Evaluate new SDOH-related household interview items

• Examine new ways to collect indoor samples

• Consider oversampling different subpopulations

• Consider follow-up data collection among survey participants

• Expand data linkages and access to linked data

• Engage with local programs to understand SDOH in diverse communities
Future Opportunities

Household Interviews

• Evaluate new items on social risks and personal attributes

o e.g., discrimination and gender identity items

• Challenges: respondent burden, survey space, validated measures

Indoor Samples

• Examine new ways to collect dust, water, and other indoor samples

• Challenges: survey costs, respondent burden, privacy, in-person interactions during COVID-19 

Pandemic
Future Opportunities

Oversampling

• Oversample different subgroups of specific characteristics

• Reintroduce population-specific surveys

o e.g., Hispanic HANES 1982-1984 and the 2012 NHANES National Youth Fitness Survey

• Challenges: survey costs, sampling frames, community engagement

Follow-up Data Collection

• Follow up participants to enhance trend assessment and causal inference of SDOH’s impact

• Challenges: survey costs, respondent burden, attrition rates
Future Opportunities

Data Linkage

• Increase number and types of external sources

o e.g., Medicaid and CHIP claims

• Privacy preserving record linkage strategies

• Challenge: Many NHANES linked files must be accessed through the RDC

Engagement with Local Programs

• Engage with state/local survey and research programs to better understand SDOH in 

communities with high social vulnerabilities

• Challenges: Programs with different priorities, willingness to engage, approaches to measuring 

SDOH
Conclusions

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• NHANES has a rich history of supporting studies examining markers of 

health disparities

• NHANES data can be used to inform researchers and policymakers on 

both social drivers and markers of health disparities

• For future opportunities identified, implementation challenges will need to 

be evaluated

• NHANES can inform researchers and policymakers on health equity and 

SDOH

Conclusions

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