Residency · Residency · Internal Medicine

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

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

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

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.

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