HLTH 4073 Module 2 Social Determinants of Health Analysis Example

The Same Aquifer, Different Risks: A Social Determinants of Health Analysis of Unsafe Private Well Water in a Rural County

Student Name

American College of Education

HLTH4073: Fundamentals of Public Health

Module 2 Assignment

Instructor Name

October 12, 2026

The Problem

The first module described the private well program of a composite farming county in the Midwest, where most households drink from their own wells, 11% of tested wells exceed the federal nitrate limit and 6% exceed the arsenic limit, and fewer than one household in five has tested recently. Nitrate is the more immediate concern in this farming county. Ward et al. (2018), updating a review of drinking water nitrate and health, note that the regulatory limit was set to protect infants from methemoglobinemia, a condition that reduces the blood's ability to carry oxygen, and that more than 30 epidemiologic studies since 2005 have examined links with cancers and birth defects, which may be more likely when nitrate is ingested under conditions that favor the formation of N-nitroso compounds.

The aquifer beneath the county is shared, but the risk of drinking contaminated water is not spread evenly. This paper uses the social determinants of health to explain why, drawing on the county's testing records, its housing and census profile, and conversations with its two environmental health specialists.

The Framework

The federal Healthy People 2030 initiative describes social determinants as the conditions surrounding people across their lives, at home, school, work, worship and play, that shape their health risks and outcomes. It sorts those conditions into five domains, covering people's financial footing, their schooling, the care available to them, the physical surroundings of their homes, and the web of relationships and institutions around them (Office of Disease Prevention and Health Promotion, n.d.). The framework is useful for an environmental hazard because it moves the question from whether a contaminant is present to who is in a position to find it, avoid it and fix it. Each domain is examined below.

Economic Stability

Money shapes every step. A full well test through a certified laboratory costs a household about $55 in this county, and the department's subsidized kit still costs $20. Fixing a problem costs far more: a point-of-use reverse osmosis system at the kitchen sink, which removes nitrate and arsenic from drinking water, runs about $900 installed plus filters, and a new, deeper well can cost $12,000 or more. For a family living paycheck to paycheck, a test that might reveal an unaffordable problem can seem pointless. Renting adds another barrier. Tenants depend on landlords for any change to the water system, and about one in five households on private wells in the county rents.

Education Access and Quality

Knowing that a risk exists, and what to do about it, is unevenly distributed. In a mailed survey of 525 households in an area of Maine with frequent arsenic in groundwater, Flanagan et al. (2015) found that better educated, higher income homeowners who had bought their homes more recently were the most likely to have included arsenic when they last tested. Significant predictors of testing included knowing that years of exposure increase risk, knowing whom to contact for a test, believing that testing does not take too much time, and having neighbors who test. Residents also tended to see their own risk as lower than their neighbors'. A family cannot act on a hazard it cannot see, taste or smell unless someone has told it where to look. In this county, the department's mailings are written at about a twelfth-grade reading level, well above what many residents read comfortably.

Neighborhood and Built Environment

The physical setting concentrates risk in particular places. Shallow, older wells, especially hand-dug wells and those with cracked casings, are more easily reached by nitrate from surface runoff than deep, modern drilled wells. In the county's data, high nitrate results cluster in two townships with sandy soils, heavy row-crop agriculture and a housing stock that includes many farmhouses more than 70 years old. Arsenic, by contrast, follows geology and appears in deeper bedrock wells in the county's northern townships regardless of land use. Location therefore determines which contaminant a household faces, and the oldest housing, often the cheapest to rent, sits where nitrate risk is highest.

Social and Community Context

Norms and relationships matter as much as facts. In a county where agriculture is the economic base, discussing fertilizer and manure as a source of well contamination can feel like an accusation against neighbors, and some farm families distrust county regulation. Testing is also invisible: unlike a new roof, nobody knows whether the house down the road has tested, which weakens the neighborly norms that Flanagan and colleagues found predict testing. Farmworker families add another layer. Many are Spanish-speaking, some have uncertain immigration status, and they may avoid contact with a government office even when it offers help.

Health Care Access and Quality

Clinical care is the last chance to catch an exposure, and it often misses. Pediatric and prenatal visits rarely include a question about the family's water source, although parents of infants mixing powdered formula with well water are the group for whom nitrate is most dangerous. The county has one pediatric practice and a federally qualified health center, and neither routinely asks. Families without a regular provider are even less likely to hear the question.

Where the Domains Interact

The domains do not act one at a time; they stack. Consider a Spanish-speaking farmworker family renting a 1940s farmhouse on a shallow dug well at the edge of a cornfield, with a four-month-old who drinks formula. The location puts nitrate risk at its highest. The family's income makes a $55 test and a $900 filter hard to afford, and as renters they cannot install a filter without the owner's agreement. The department's letter, if it reached them, would arrive in English and at a reading level above what the parents read comfortably. They may hesitate to call a county office, and the clinic where the baby is seen has never asked where the formula water comes from. No single barrier explains the family's exposure; each one closes off a route by which the family might have learned about the risk or escaped it. A homeowner with a college degree in a new house on a deep drilled well a mile away faces the same aquifer with almost none of these barriers. That contrast is the core finding of this analysis and the reason public health responses must work across several domains at once.

What the Analysis Means

Taken together, the five domains show that unsafe well water in this county is not only a geological problem. The households most exposed are likely to be renters, lower-income families, Spanish-speaking farmworkers and families with infants in older farmhouses, and each of those groups faces barriers to testing and treatment that have nothing to do with the chemistry of the water. Interventions that only mail information to property owners address one domain and reach the groups least at risk. The next module examines an intervention designed to reach further upstream.

References

Flanagan, S. V., Marvinney, R. G., & Zheng, Y. (2015). Influences on domestic well water testing behavior in a Central Maine area with frequent groundwater arsenic occurrence. Science of the Total Environment, 505, 1274-1281. https://doi.org/10.1016/j.scitotenv.2014.05.017

Office of Disease Prevention and Health Promotion. (n.d.). Social determinants of health. Healthy People 2030. U.S. Department of Health and Human Services. https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health

Ward, M. H., Jones, R. R., Brender, J. D., de Kok, T. M., Weyer, P. J., Nolan, B. T., Villanueva, C. M., & van Breda, S. G. (2018). Drinking water nitrate and human health: An updated review. International Journal of Environmental Research and Public Health, 15(7), Article 1557. https://doi.org/10.3390/ijerph15071557