April 2022 REPORT 2
INTRODUCTION
Despite significant investments to improve access to high-quality health care, health inequities in the United
States persist by race, ethnicity, sexual orientation, gender identity, and disability, as well as by economic and
community level factors such as geographic location, poverty status, and employment. Black, Latino
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American Indian and Alaska Native (AI/AN), Asian American, Native Hawaiian, and Pacific Islanders (AANHPI),
and LGBTQ+, individuals, people who live in rural areas, and people with disabilities fare worse than their
White, heterosexual, and urban counterparts and people without disabilities. These disparities exist for many
health outcomes, including infant and maternal mortality, heart disease, diabetes, hypertension, chronic
illness, disability, cancer, mental illness, substance use, and overall life expectancy.
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While opportunities to advance health equity through clinical care continue to be important,
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addressing the
ways in which social determinants of health (SDOH) increase or decrease the risk of poor health outcomes is
critical to improving the nation’s health and wellbeing. SDOH are the conditions where people are born, live,
learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life
outcomes.
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When one or more of these conditions pose challenges, such conditions can become risk factors
for poor health outcomes. SDOH are fundamental social and structural factors that touch people’s lives and
impact their wellness and longevity. Health and wellness are shaped by and within overarching systems,
including structural racism, ableism, homophobia, and transphobia; and broad neighborhood and community
structures including physical safety, environmental quality, and occupation-related hazards. Educational
attainment, income, and the stress of financial hardship, along with discrimination due to nativity and racial or
ethnic origin, disability, sexual orientation, and gender identity, are key determinants that influence a variety
of more proximal factors (such as access to affordable housing) that impact the risk of morbidity, mortality,
and health throughout the life course.
Social and structural factors play a critical role in driving disparate health outcomes. One study estimated that,
on average, clinical care impacts only 20 percent of county-level variation in health outcomes, while SDOH
affect as much as 50 percent of health outcomes.
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More specifically, socioeconomic factors alone may
account for 47 percent of health outcomes, while health behaviors, clinical care, and the physical environment
account for 34 percent, 16 percent, and 3 percent of health outcomes, respectively.
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Moving from the county
level to the individual level, a given person’s physical health, behavioral health, and well-being are also
influenced by factors that are specific to the individual. At the individual level, we use the term health-related
social needs (HRSNs) to refer to an individual’s needs that might include affordable housing, healthy foods, or
transportation. An unequal distribution of SDOH is the root cause of HRSNs at the individual level. For
example, a particular community may lack abundant affordable housing, but local individuals may experience
housing needs differently. Distinguishing between SDOH and HRSNs is critical for developing measures,
evaluating data sources, assessing evidence and especially for formulating policy responses.
Figure 1, below, provides a pictorial representation of the SDOH and HRSNs ecosystem. The diagram includes
three segments depicting different points at which there are opportunities to address SDOH, with the river
representing the level of action and primary actors, and the banks representing the objectives and approaches
for each segment. Importantly, addressing structural racism and enhancing data infrastructure, noted in
boxes, are key factors for success. In the upstream segment are the underlying social and economic conditions
that create differences in SDOH. Interventions relevant to this segment apply at the community level and
attempt to address the root causes of socioeconomic and health inequities (such as poverty, employment, and
education). The midstream segment is human services (i.e., social service providers and community-based
organizations) that address individuals’ HRSNs in order to mitigate the effects of SDOH. The downstream
segment focuses on individual health care, which may refer or connect an individual to assistance for a social
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This brief uses the term “Latino” to refer to all individuals of Hispanic and Latino origin.