Physicians are increasingly aware of the studies that show the relationships between factors such as ZIP codes, socioeconomic status and health outcomes. COVID-19’s deeply inequitable impact has only further laid bare these tragic associations. The phenomenon is commonly referred to as the social determinants of health.
The AMA recognizes that public health is often determined by factors outside the health care system and is committed to addressing the social determinants of health to improve health outcomes for all Americans.
The AMA also recognizes racism as a serious threat to public health, as a barrier to appropriate medical care, and to the advancement of health equity—defined as “optimum health for all.” The AMA’s “Organizational Strategic Plan to Embed Racial Justice and Advance Health Equity: 2021–2023” provides a framework for advancing greater equity in health care and includes a commitment to push upstream to address determinants of health and root causes of inequities.
The vocabulary that physicians and others use when addressing the underlying problems that lead to poor health isn’t always uniform.
In an effort to standardize the language that physicians and others in the clinical, social services, businesses and government settings use when talking about addressing social needs and the social determinants of health, Burbank, California-based HealthBegins created the “Upstream Communication Toolkit.”
HealthBegins is a physician-run, mission-driven consulting firm that helps health care systems and community partners improve health outcomes, control costs and advance equity by addressing social determinants of health.
The AMA recognizes the importance of addressing social conditions that affect health and offers an education module via the AMA Ed Hub™ that teaches medical students—and residents and physicians who may not have received such training—what they need to know about the topic.
These are the seven terms the HealthBegins toolkit says physicians, health care team members and others working together to improve the social determinants of health should know when talking about and addressing the issue.
Social determinants of health
These include underlying communitywide social, economic, political, cultural and physical conditions people experience when they are born and as they grow, live, work and age.
These experiences shape individual material and psychosocial circumstances as well as biologic and behavior factors. The term commonly refers to defined communities or regions, which are typically defined by geography. All patients experience social determinants of health.
These include the climate, socioeconomic-political context—for example, societal norms and macroeconomic, social and health policies—and the structural mechanisms that shape social hierarchy and gradients, including power, class, racism, sexism and exclusion. It commonly refers to cities, states, nations or the world and typically is defined by political jurisdictions, cultural boundaries or economic relationships.
These include individual material resources and psychosocial circumstances required for long-term physical and mental health and well-being. Material circumstances describe physical living and working conditions, including housing, food, water, air and sanitation. Psychosocial circumstances include stressors such as negative life events, stressful living circumstances and lack of social support. It commonly refers to specific individuals or defined populations.
A multisector, multidisciplinary collaborative enterprise that uses public health science, evidence-based strategies and other approaches to engage and work with communities in a culturally appropriate manner to optimize the health, quality of life and social determinants of health for all people who live, work or are otherwise active in defined communities.
Levels of change
There are three levels: micro, meso and macro. The micro level involves direct interaction to address individual problems, for example, helping people find housing, health care and social services.
The meso level involves interaction with groups to address group problems, with groups of people and organizations working to create small-scale institutional, social and cultural change.
The macro level involves interventions and advocacy on a large scale, impacting entire communities, states or countries. It can involve crafting laws, petitioning policy makers or shaping social norms.
This term refers to the health outcome of a group of individuals, including the distribution of such outcomes within a group. The term is often used when talking about the Triple Aim of improving the quality of care, improving health outcomes and reducing health care costs.
Public health 3.0
Beyond maintaining essential governmental public health functions, this model emphasizes collaborative engagement and actions that directly impact social determinants of health, health inequities and structural determinants. It aims to confront institutionalized racism, sexism and other oppressive systems that create inequitable conditions that lead to poor health.
Systemwide bias and institutionalized racism continue to contribute to inequities across the U.S. health care system. Learn how the AMA is fighting for greater health equity by identifying and eliminating inequities through advocacy, community leadership and education.
Essential Tools & Resources
Read AMA policies on health equity
Explore health equity on JAMA Network™️
Read the latest on health equity from AMA Journal of Ethics®️
Learn more about health disparities on AMA Ed Hub™️
COVID-19 Q&A: health equity in pandemic
Release the Pressure: Heart health equity with Essence