# Social Determinants of Health and Health Equity in Clinical Practice ## Introduction **Social determinants of health (SDOH)** are the conditions in which people are born, grow, live, work, and age that shape health outcomes. These non-medical factors account for an estimated **30-55% of health outcomes**, far exceeding the impact of clinical care alone (estimated at 10-20%). Addressing SDOH is essential for advancing **health equity** -- the attainment of the highest level of health for all people. ## Domains of Social Determinants ### Economic Stability - **Income and poverty**: poverty is the single strongest predictor of poor health outcomes - **Employment**: job insecurity, occupational hazards, and lack of employer-sponsored insurance - **Food insecurity**: affects 10-12% of US households; associated with diabetes, hypertension, and depression - **Housing instability**: homelessness, unaffordable housing, and frequent moves disrupt continuity of care ### Education Access and Quality - **Health literacy**: limited health literacy affects 36% of US adults; associated with poorer medication adherence and outcomes - **Educational attainment**: each additional year of education is associated with improved life expectancy - Individuals with less education have higher rates of chronic disease and premature mortality ### Healthcare Access and Quality - **Insurance status**: uninsured adults are less likely to receive preventive care and more likely to present with advanced disease - **Geographic barriers**: rural populations face provider shortages, longer travel distances, and limited specialty access - **Implicit bias** in healthcare delivery contributes to disparities in treatment, pain management, and outcomes ### Neighborhood and Built Environment - **Environmental exposures**: air pollution, lead, contaminated water disproportionately affect low-income and minority communities - **Access to healthy food**: food deserts limit access to fresh produce and nutritious options - **Safety and violence**: neighborhood violence contributes to chronic stress, PTSD, and limited outdoor physical activity - **Transportation**: lack of reliable transportation is a major barrier to appointment attendance ### Social and Community Context - **Social isolation and loneliness**: associated with increased mortality comparable to smoking 15 cigarettes per day - **Discrimination and racism**: chronic exposure to racism is a risk factor for hypertension, depression, and adverse birth outcomes - **Incarceration history**: formerly incarcerated individuals face barriers to employment, housing, and healthcare - **Community cohesion**: strong social networks and community engagement are protective factors ![Social determinants of health domains and clinical impact](images/sdoh-domains.png) ## Screening for SDOH in Clinical Practice ### Validated Screening Tools - **PRAPARE (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences)**: comprehensive SDOH screening tool - **AHC-HRSN (Accountable Health Communities Health-Related Social Needs)**: CMS-developed screening for 5 core domains - **Hunger Vital Sign**: 2-question validated screener for food insecurity - Screen for **housing, food, transportation, safety, and financial strain** at minimum ### Implementation Considerations - Integrate SDOH screening into **intake workflows** and electronic health records - Train staff to administer screens with **empathy and cultural sensitivity** - Screening without linkage to resources causes frustration; **close the loop** with referrals - Address potential stigma by normalizing screening: "We ask all patients these questions" ## Linking Patients to Resources - **Community health workers (CHWs)**: bridge clinical care and community resources; improve outcomes in underserved populations - **Social work referrals**: for housing, benefits enrollment, legal assistance - **2-1-1 helpline and resource platforms**: connect patients to local food banks, utility assistance, and social services - **Medical-legal partnerships**: address legal needs (housing, immigration, benefits) that directly impact health - **Closed-loop referral systems**: track whether patients successfully connected with resources ![SDOH screening and resource linkage workflow](images/sdoh-screening-workflow.png) ## Health Disparities: The Evidence - **Black Americans** have a life expectancy 5 years shorter than White Americans and higher rates of maternal mortality, cardiovascular disease, and cancer mortality - **Hispanic/Latino Americans** face higher rates of diabetes and lower rates of insurance coverage - **Indigenous populations** have the highest rates of poverty, substance use disorders, and suicide - **LGBTQ+ individuals** face elevated rates of depression, suicide, and barriers to affirming healthcare - **Rural populations** have higher age-adjusted mortality and less access to specialty care - Disparities are **not explained by genetics** but by differential exposure to SDOH and systemic inequities ## The Role of the Clinician ### Structural Competency - Move beyond individual-level cultural competency to understand **structural and systemic drivers** of health inequity - Recognize how **institutional policies, laws, and resource allocation** create and perpetuate disparities - Advocate for policy changes that address root causes: housing, education, environmental justice, insurance access ### Implicit Bias Awareness - All clinicians hold **implicit biases** that can affect clinical decision-making - Take the **Implicit Association Test (IAT)** as a starting point for self-reflection - Implement **structured clinical decision-making** to reduce bias (e.g., standardized pain protocols, screening criteria) - Diversify the healthcare workforce: concordant patient-provider race/ethnicity improves trust and outcomes ### Advocacy and Community Engagement - Participate in **health policy advocacy** at local, state, and national levels - Support **community-based participatory research** that centers affected communities - Engage in **upstream interventions**: housing programs, school-based health, food access initiatives ![Clinician roles in advancing health equity](images/clinician-health-equity-roles.png) ## Key Clinical Pearls - Social determinants account for 30-55% of health outcomes; addressing them is clinical care. - Screen all patients for food insecurity, housing instability, and transportation barriers using validated tools. - Screening without resource linkage can worsen patient trust; always close the loop with referrals. - Implicit bias affects all clinicians; structured decision-making and ongoing self-reflection mitigate its impact. - Health equity requires both clinical excellence and advocacy for structural change. ## References 1. Braveman P, Gottlieb L. The Social Determinants of Health: It's Time to Consider the Causes of the Causes. *Public Health Reports*. 2014;129(Suppl 2):19-31. 2. National Academies of Sciences, Engineering, and Medicine. *Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health*. Washington, DC: The National Academies Press; 2019. 3. Metzl JM, Hansen H. Structural Competency: Theorizing a New Medical Engagement with Stigma and Inequality. *Social Science & Medicine*. 2014;103:126-133. 4. Bailey ZD, Krieger N, Agenor M, et al. Structural Racism and Health Inequities in the USA: Evidence and Interventions. *The Lancet*. 2017;389(10077):1453-1463.