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We are mitigating the harmful social determinants of health.

 

Join our efforts to put an end to health inequities and harmful social determinants of health (SDOH).

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DUSON
 
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We are advancing a nurse-led model of care that can transform health care by expanding access, improving outcomes and lowering costs.

 

Join our efforts to put an end to health inequities and harmful social determinants of health (SDOH).

We’re onto something big at DUSON
 
DUSON
 
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We are committed to end health inequities through transformative excellence in education, clinical practice, and nursing science.

 

Join our efforts to put an end to health inequities and harmful social determinants of health (SDOH).

We’re onto something big at DUSON
 
DUSON
 
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We are preparing future nurse leaders and scientists to transform health care.

 

Join our efforts to put an end to health inequities and harmful social determinants of health (SDOH).

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8 Defining
SDOH Principles

Discover eight principles about the mechanisms of social determinants of health that can inform your work.

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A New Approach
to SDOH Mitigation

Explore our framework for nurse-led programs that can help mitigate the harmful social determinants of health.

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Stay updated on the Duke University School of Nursing’s latest efforts to transform health care.

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The enormous impact of SDOH

The Impact of Health Inequities.

The United States faces an increasing burden of disease largely driven by stark health inequities—systematic, unfair, and avoidable health differences between segments of the population.

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The enormous impact of SDOH

An Unsustainable Problem.

Source: Deloitte

If left unaddressed, the growing cost of health inequities in the United States is unsustainable and threatens the future health and economic wellbeing of the country.

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The enormous impact of SDOH

The Importance of Addressing Social Determinants of Health.

SDOH drive about 80% of a person's health outcomes.
SDOH include the conditions in which people are born, grow, work, live and age.

If efforts to reduce health inequity are to be successful, new thinking is needed to design and implement more effective programs that can mitigate the harmful social determinants of health.

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The DUSON/CLAFH Approach.

In an effort to shift the paradigm, the Center for Latino Adolescent and Family Health (CLAFH) at the Duke University School of Nursing has synthesized the existing research on social determinants of health. Our team identified eight key SDOH principles that should be considered when designing and implementing programs to mitigate harmful social determinants of health.
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View the 8 Principles
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8 Defining SDOH Principles

A review of landmark research identifies eight key principles about the mechanisms of social determinants of health.

SDOH are Underlying Causes of Health Inequities

SDOH Context Shapes Health Inequities

SDOH Contextual Disadvantage is Not Deterministic

SDOH Shapes Health Over the Life Course

SDOH Operate Through Biological Embedding

SDOH Operate Intergenerationally

SDOH Shapes Clustering and Synergies of Health Inequities

SDOH and Social Injustices Interact to Produce Health Inequities

After clicking each icon to learn more about the eight principles, scroll down to discover how they inform the Duke University School of Nursing (DUSON) Center for Latino Adolescent and Family Health’s (CLAFH) framework for mitigating harmful SDOH.

A new framework for mitigating harmful SDOH

The DUSON/CLAFH framework serves as a roadmap for educators, practitioners, researchers, policymakers and other stakeholders designing programs to mitigate harmful SDOH and bolster strength-based resilience factors that set communities up to thrive despite structural adversity.

DUSON Trailblazer SDOH Toolkit

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    True or False: About 20% of a person’s health and wellbeing is driven by social factors.

    q1
    You are right! The correct answer is: "False".

    About 80% of a person’s wellbeing is impacted by the Social Determinants of Health, defined as the conditions in the places where they live, learn, work, and play. These conditions include economic status, health care access and quality, neighborhood and built environment, education access and quality, and social and community context.

    Sorry your answer is not correct. The correct answer is: "False".

    About 80% of a person’s wellbeing is impacted by the Social Determinants of Health, defined as the conditions in the places where they live, learn, work, and play. These conditions include economic status, health care access and quality, neighborhood and built environment, education access and quality, and social and community context.

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    The Enormous Impact of SDOH

    American Hospital Association. Health for life focus on wellness. 2007. Accessed November 17, 2022. health life focus wellness.

    Boersma P, Black LI, Ward BW, Prevalence of multiple chronic conditions among US adults, 2018. Prev Chronic Dis. 2020;17;200130. doi:http://dx.doi.org/10.5888/pcd17.200130.

    National Center for Chronic Disease Prevention and Health Promotion. Chronic diseases in America. cdc.gov. Last reviewed October 7, 2022. Accessed November 17, 2022. cdc.gov/chronicdisease.

    National Center for Health Statistics. Life tables, 2001-2021. cdc.gov. Page reviewed September 7, 2022. Accessed November 17, 2022. cdc.gov/~/life_tables.

    Medina L, Sabo S, Vespa J. Living longer: Historical and projected life expectancy in the United States, 1960 to 2060. U.S. Census Bureau. 2020;25-1145. census.gov Accessed November 17, 2022.

    OECD. Health at a glance. Oecd-ilibrary.org. Accessed November 17, 2022. https://doi.org/10.1787/19991312.

    Rothstein B, Uslaner EM. Equality, corruption, and social trust. World Politics. 2005;58:41-72. gvptsites.umd.edu/~/rothsteinuslanerworldpolitics.pdf. Accessed November 17, 2022.

    Schoch D. 1 in 5 Americans now provide unpaid family care. AARP. Updated June 18, 2020. Accessed November 17, 2022. aarp.org/~/unpaid-family-caregivers-report.

    Umberson D, Olson JS, Crosnoe R, et al.. Death of family members as an overlooked source of racial disadvantage in the United States. Proc Natl Acad Sci. 2017;114(5). doi: https://doi.org/10.1073/pnas.1605599114.

    Healthy People 2030. Social cohesion. Health.gov. Accessed November 17, 2022. health.gov/~/social-cohesion.

    Dhar A, Bhatt J, Batra N, Rush B, Gerhardt W, Davis A. US health care can’t afford health inequities. Deloitte. Published June 22, 2022. Accessed November 17, 2022. deloitte.com/~/economic-cost-of-health-disparities.

    Magnan S. Social determinants of health 101 for health care: Five plus five. National Academy of Medicine. 2017. doi: https://doi.org/10.31478/201710c.

    World Health Organization. Social determinants of health. who.int. Accessed November 17, 2022. who.int/~/social-determinants-of-health.

    Healthy People 2030. Social determinants of health. health.gov. Accessed November 17, 2022. health.gov/~/social-determinants-health.

    Thimm-Kaiser M, Benzekri A., Guilamo-Ramos V. Conceptualizing the mechanisms of social determinants of health: A heuristic framework to inform future directions for mitigation. 2022. (under review).

    Quiz questions

    About SDOH. Centers for Disease Control and Prevention. Page reviewed June 28, 2021. Accessed November 17, 2022. https://www.cdc.gov/socialdeterminants/about.html.

    Hood CM, Gennuso KP, Swain GR, Catlin BB. County Health Rankings: Relationships Between Determinant Factors and Health Outcomes. Am J Prev Med. 2016;50(2):129-135. https://doi.org/10.1016/j.amepre.2015.08.024.

    Magnan S. Social determinants of health 101 for health care: Five plus five. National Academy of Medicine. 2017. doi: https://doi.org/10.31478/201710c.

    Health inequities and their causes. World Health Organization. Published February 22, 2018. Accessed November 17, 2022. health inequities and their causes.

    Dhar A, Bhatt J, Batra N, Rush B, Gerhardt W, Davis A. US health care can’t afford health inequities. Deloitte. Published June 22, 2022. Accessed November 17, 2022. economic cost of health disparities.

    What is health equity? Centers for Disease Control and Prevention. Page reviewed July 1, 2022. Accessed November 17, 2022. www.cdc.gov/healthequity/whatis.

    Clair M, Denis JS. Sociology of racism. International Encyclopedia of the Social & Behavioral Sciences. 2015;(19)857-63. doi:http://dx.doi.org/10.1016/B978-0-08-097086-8.32122-5.

    Chae DH, Snipes SA, Chung KW, Martz CD, LaVeist TA. Vulnerability and resilience: Use and misuse of these terms in the public health discourse. Am J Pub Health. 2021;(111)1736-1740. doi:https://doi.org/10.2105/AJPH.2021.306413.

    Exposure. Merriam Webster. Updated November 13, 2022. Accessed November 17, 2022. www.merriam-webster.com/dictionary/exposure.

    Traub F, Boynton-Jarrett R. Modifiable Resilience Factors to Childhood Adversity for Clinical Pediatric Practice. Pediatrics. 2017;139(5):e20162569. doi: https://doi.org/10.1542/peds.2016-2569

    Hoke MK, McDade T., Biosocial inheritance: A framework for the study of the intergenerational transmission of health disparities. Annals of Anthropological Practice. 2015;30(2):187-213. doi:https://doi.org/10.1111/napa.12052.

    Hahn S, Hasler P, Vokalova L, et al. Feto-maternal microchimerism: The pre-eclampsia conundrum. Front Immunol. 2019;10(659):1-9. doi:https://doi.org/10.3389/fimmu.2019.00659.

    Lapehn S, Paquette AG. The placental epigenome as a molecular link between prenatal exposures and fetal health outcomes through the DOHaD hypothesis. Curr Environ Health Rep. 2022;9(3): 490-501. doi:https://doi.org/10.1007/s40572-022-00354-8

    Treiner E, Duban L, Bahram S, et al. Selection of evolutionarily conserved mucosal-associated invariant T cells by MR1 [published correction appears in Nature. 2003 Jun 26;423(6943):1018]. Nature. 2003;422(6928):164-169. doi:https://doi.org/10.1038/nature01433.

    SDOH and Social Injustices Interact to Produce Health Inequities

    What this means

    Health inequities are the biological expression of inequitable social processes, also known as social injustice.

    Why it matters

    Successful efforts to reduce health inequities mitigate the ways in which unjust social processes such as racism, classism, sexism, xenophobia, and homophobia, etc., shape the health of individuals and communities.

    SDOH Shape Clustering and Synergies of Health Inequities

    What this means

    Communities or populations affected by harmful SDOH tend to experience multiple co-occurring health inequities that further exacerbate each other.

    Why it matters

    Because co-occurring health inequities interact, one health inequity can seldomly be addressed in isolation. One important element of mitigating the impact of harmful SDOH is to understand and address the health of a community or population comprehensively and holistically.

    SDOH Operate Intergenerationally

    What this means

    The health impact of harmful SDOH can be transmitted across multiple generations (both through social and biological mechanisms).

    Why it matters

    Focusing on the family unit as a primary context for shaping individual health outcomes represents an underrecognized opportunity for health interventions, including for mitigating the impact of harmful SDOH.

    SDOH Operate Through Biological Embedding

    What this means

    The social conditions we experience over the course of life result in changes to our biology.

    Why it matters

    SDOH can trigger and sustain biological changes in people’s bodies (epigenetic, brain, immune, hormonal, microbiome, etc.) that may contribute to a person’s chances of negative health outcomes.

    SDOH Shapes Health Over the Life Course

    What this means

    The health effects of SDOH accumulate over the course of a person’s lifetime.

    Why it matters

    The social, economic, psychological, environmental, and other SDOH influences that an individual experiences early in life continue to impact health outcomes later in life, which is why mitigating harmful SDOH influences in childhood and adolescence is particularly important.

    SDOH Contextual Disadvantage is Not Deterministic

    What this means

    Harmful SDOH do not always result in negative health outcomes. There are structural, institutional, and individual factors that can offset the impact of harmful SDOH.

    Why it matters

    Identifying and understanding the factors that enable individuals and communities to thrive despite experiencing harmful SDOH is a major opportunity to enhance current efforts to reduce health inequities.

    SDOH Context Shapes Health Inequities

    What this means

    Our health outcomes are largely shaped by the context in which we are embedded, not solely by our genetics or behavior.

    Why it matters

    Efforts to reduce health inequities need to move beyond individual-level interventions and adopt mitigation measures tailored to the unique health risk and protective factors in a given community context.

    SDOH are Underlying Causes of Health Inequities

    What this means

    Health inequities are the result of structural causes, not of individual or community characteristics.

    Why it matters

    In order to be successful, efforts to reduce health inequities have to recognize and mitigate the ways in which structural factors, such as income and educational inequality, quality of available housing, accessibility and quality of health care services, etc., shape the health of individuals and communities.

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    Dhar A, Bhatt J, Batra N, Rush B, Gerhardt W, Davis A. US health care can’t afford health inequities. Deloitte. Published June 22, 2022. Accessed November 17, 2022.

    https://www2.deloitte.com/us/en/insights/industry/health-care/economic-cost-of-health-disparities.html.

    Thimm-Kaiser M, Benzekri A, Guilamo-Ramos V. Conceptualizing the Mechanisms of Social Determinants of Health: A Heuristic Framework to Inform Future Directions for Mitigation. Milbank Q. 2023;101(2):0416.

    SDOH are usually grouped into five broad, static domains.

    Economic
    Stability

    Education Access
    and Quality

    Health Care Access
    and Quality

    Neighborhood and
    Built Environment

    Social and
    Community Context