Stay updated on the Duke University School of Nursing’s latest efforts to transform health care.
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.
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.
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
DUSON
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Test your SDOH IQ
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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.
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.
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.
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).
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.
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.
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.
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).
SDOH are usually grouped into five broad, static domains.