Social determinants of health (SDOH) are the conditions under which people are born, grow, live, work and age,1 and include factors such as socioeconomic status, access to health care, education, employment, social support networks, housing, neighborhood characteristics, racism and the justice gap.1,2 These are thought to have a greater impact on population health than factors like biology, behavior and medical care.3 SDOH, especially poverty, structural racism and discrimination, are the primary drivers of health inequities.1,4 Reducing health inequities is important because they are pervasive, unfair and unjust; individuals affected have little control over their contributing circumstances; they affect everyone; and they can be alleviated and/or avoided with existing policy solutions.1,5,6
The purpose of this position paper is to:
Before we address the purposes of this paper, it is necessary to define some key terms and concepts we will be referring to throughout this paper.
Social determinants of health: Also called social drivers of health, SDOH refer to the conditions under which people are born, grow, live, work and age.1
Political determinants of health (PDOH): PDOH can be drivers of the SDOH and health inequities in the United States and encompass a broad range of structural barriers to equity. According to Daniel E. Dawes, “the [PDOH] involve the systematic processes of structuring relationships, distributing resources and administering power, operating simultaneously in ways that mutually reinforce one another to shape opportunities that advance health equity or create, perpetuate and exacerbate health inequities.”7 They include the ability for the population to have a vote or a voice, the existence of governmental barriers (i.e., structural, institutional, interpersonal and intrapersonal) and the implementation of policies, or a lack thereof, to encourage or discourage political participation.8 Thus, they constitute the political factors and structural barriers that shape the environments where people grow, live, work and age, influencing overall health outcomes.
Justice gap: The justice gap refers to “the difference between the civil legal needs of low-income Americans and the resources available to meet those needs.”9 This results in many individuals who are economically disadvantaged to “navigate complex legal systems alone, often facing adverse effects on crucial aspects of their lives.”10
Racism: The American Medical Association (AMA) defines racism as “a system of structuring opportunity and assigning value based on phenotype—race—that unfairly disadvantages some individuals and communities, unfairly advantages others and undermines the realization of the full potential of the whole society through the waste of human resources.”11 It can operate at structural, institutional, interpersonal and internalized levels.
Structural determinants of health inequities: The social, economic and political mechanisms which generate social class inequalities in society.12
Health equity: As policy, the AAFP has adopted the Healthy People 2020 definition of health equity as "the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices and the elimination of health and health care disparities."
Health disparity: Healthy People 2020 define health disparity as “a particular type of health difference that is closely linked with economic, social or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age or mental health; cognitive, sensory or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”13
Health inequity: Health inequities are avoidable, unnecessary and unjust health differences.14 The most prevalent and severe health inequities occur where there is “poverty, structural racism and discrimination.”15 Some of the most common and well-researched health inequities are experienced between groups based on socioeconomic status, race and ethnicity, sexual orientation and gender expression, as well as geographic location.15,16
The following sections help characterize health inequities, but they are not all-encompassing and do not address all health inequities.
Socioeconomic status refers to the social and economic factors that influence individuals’ positions in society.16 This includes factors like occupation, class, education, income and wealth.15,16 Individuals with higher socioeconomic status consistently experience better health outcomes than those with lower socioeconomic status, and this gradient persists across social classes. It is not just the very poor who are affected. Research has shown17-20:
Race and ethnicity are associated with many indicators of health status, even after considering socioeconomic status, behavior and other characteristics. Systematic, persistent and long-felt racism and discrimination are thought to be the primary contributors.21 Examples to support this includes the following22,23:
Reprinted from National Center for Health Statistics. Life expectancy. Centers for Disease Control and Prevention. Accessed August 12, 2025. www.cdc.gov/nchs/products/visual-gallery/life-expectancy.htm
LGBTQ+ people also experience higher levels of discrimination, stigma, stress and worse outcomes for a variety of health status indicators. Research has shown31-33.
The physical features of an area can impact people’s health. Physical features like air and water quality and climate, as well as housing, parks and other recreation areas, all play a part in physical activity and life expectancy.34 Research has shown that35-37:
Health equity scholars use a metaphor of “upstream” and “downstream” factors to illustrate how societies impact health.12 The downstream factors include issues that medicine and public health typically deal with—morbidity and mortality, access to health care, behavioral risk factors and living conditions. The Public Health Framework for Reducing Health Inequities (Figure 2) illustrates common causes of morbidity and mortality and identifies reasons for disparities among populations. The upstream factors, which include corporate, business and government influences (i.e., institutional inequities in Figure 2), significantly impact economic, social and public policies that have led to long-standing inequities among different class, race, ethnic, immigrant, gender and sexual orientation groups (i.e., social inequities in Figure 2).12,38 To understand how these factors interrelate to impact health, it is important to examine both upstream and downstream factors and how differences in living conditions and exposures are physically embodied by individuals.
Used with permission from Bay Area Regional Health Inequities Initiative (BARHII). BARHII Framework. A Public Health Framework for Reducing Health Inequities. Accessed August 12, 2025. https://barhii.org/framework
Structural PDOH inequities (i.e., institutional inequities in Figure 2) are the social, economic and political mechanisms that can influence socioeconomic positions.12 Often, populations are stratified by income, education, occupation, gender, race, ethnicity and other factors that can determine health status. The macro-level social, economic and political mechanisms impact large populations. Examples of structural PDOH inequities of health include the degree to which government subsidizes health care, education and public services; policies and actions about pollution, including minimum standards of air and water quality or where toxic substances are stored or released; and policies and actions about the built environment, which can benefit or harm communities. These all contribute to social class inequities.
Jim Crow laws and redlining are more specific examples of structural PDOH inequities. Laws and corporate policies legislated segregation, restricted access to suitable housing for Black Americans and reduced their ability to influence governmental decisions or live in healthy neighborhoods.39 This had a substantial negative impact on the health of Black Americans. While health disparities still exist between Black and white Americans, data have shown that life expectancy and infant mortality improved for Black Americans after policies such as Jim Crow and redlining were eliminated.40,41
Social factors also influence health by providing or constraining people’s access to resources that promote better health. Individuals with low socioeconomic status are less likely to be able to acquire health care, nutritious foods, good educational opportunities, safe housing or safe spaces for exercise.42 Negative health behaviors, like tobacco, alcohol or explicit drug use, are often pervasive in disadvantaged communities.43 These types of behaviors are then socially patterned in children, who have not fully developed their ability to make rational decisions.44 These factors are shaped by more upstream factors.
Upstream and downstream factors shape the conditions in which people live. Differences in living conditions and opportunities to make healthy decisions result in differentials in exposures and chronic stress. Embodiment is a concept referring “to how we, like any living organism, literally incorporate, biologically, the world in which we live, including our social and ecological circumstances.”45 Social factors are embodied as individuals are exposed to repeated and chronic stress.46
The autonomic nervous system, the hypothalamic-pituitary-adrenal axis and the cardiovascular, metabolic and immune systems protect the body by responding to internal and external stressors. Chronic stress can increase the allostatic load, or the “wear and tear” that accumulates on the body over time. This wear and tear has health-damaging effects.46,47 Historically, disadvantaged groups have experienced a greater allostatic load (i.e., more wear and tear) than more advantaged groups.48 Embodiment and allostatic load are thought to explain why social factors are linked with almost every measure of health status throughout time.45,46
Access to civil legal services is an SDOH.49 Legal services are essential to alleviate barriers to social resources, particularly in disadvantaged communities, where a lack of access to legal services can further impact social and health problems.50 Examples in which health equity can be affected by access to legal aid include51,52:
The AAFP urges its members to become more informed about the impact of SDOH and PDOH on health and health inequities, and to identify tangible next steps they can take to address their patients’ SDOH and reduce health inequities within their scope of practice. The AAFP also urges hospitals and health care systems to consider the SDOH (and the PDOH that influence them) in their strategic plans and to provide their staff, including family physicians, opportunities to engage with and advocate on behalf of their community to advance health equity. In addition, the AAFP urges health insurers and payers to provide appropriate payment to support health care practices in identifying, monitoring, assessing and addressing SDOH.
Since health inequities also arise outside of the health care sector, the AAFP urges funders, including the federal government, to provide sufficient funding to address the SDOH and justice gap and reduce health inequities. In addition to other interventions, this includes robust financial support for the nation’s public health infrastructure to support their efforts to facilitate cross-sector community collaboration, strategic planning for health, Health in All Policies and the core public health functions.53
Family physicians can play a crucial role in addressing both the upstream and downstream PDOH and SDOH. They provide high-quality health care for more underserved populations than any other medical specialty.54 Family physicians can also work with their practice teams and community members to address SDOH in the following ways:
The AAFP has created resources to assist family physicians and their health care teams at The EveryONE ProjectÔ webpage hub for information.
The AAFP recognizes that the PDOH drives SDOH and supports public policies that address both the PDOH and SDOH, and that reduce health inequities through the approaches described below.
Access to health care: The AAFP recognizes that health is a basic human right for every person and that the right to health includes universal access to timely, acceptable and affordable health care of appropriate quality. All people of the world, regardless of social, economic or political status, race, religion, gender or sexual orientation, should have access to essential health care services. The AAFP urges its members to become involved personally in improving the health of people from minority and socioeconomically disadvantaged groups. The AAFP supports:
Health in All Policies: The AAFP supports the adoption of Health in All Policies strategies by all governing bodies at the local, state and federal levels. Health in All Policies strategies aim to improve the policymaking process by incorporating health implications, evidence-based information and community input.55 This is intended to help inform policymakers about how their decisions about laws, regulations and policies impact health and health equity.
Federal nutrition programs: The AAFP supports federal nutrition programs as a matter of public health. Access to affordable and healthy food significantly affects an individual’s health, education and development.56 Food access also supports medical treatment that requires patients to take medications with food. More than 47 million people in the United States (including more than 7 million children) were living in food-insecure households in 2023.57
Anti-poverty programs: The AAFP supports programs that lift people out of poverty and has issued the position paper, Poverty and health – the family medicine perspective. Poverty has been defined as the inability to acquire goods and services that are considered essential for participation in society. It negatively affects almost every indicator of health status.58 The poverty threshold in the United States was $15,650 for a single individual and $32,150 for a family of four in 2025,59 with 11.5% (37.9 million) of its residents living in poverty in 2023.60 Safety net programs and policies that are effective at lifting people out of poverty include the Supplemental Nutrition Assistance Program, Social Security, Medicare, Medicaid/Children’s Health Insurance Program, Supplemental Security Income, Special Supplemental Nutrition Program for Women, Infants, and Children, increased minimum wage, earned income tax credit, affordable child care, early childhood education, unemployment insurance, rental assistance programs and an overall expansion of access to health care.61,62
Support for people experiencing homelessness: The AAFP supports Housing First programs that offer rapid access to permanent, affordable housing integrated with health care and supportive services.63 Housing First is a model defined by the U.S. Department of Housing and Urban Development as a means to “quickly and successfully connect individuals and families experiencing homelessness to permanent housing without preconditions and barriers to entry, such as sobriety, treatment or service participation requirements.”
Housing impacts health care and sometimes vice versa. Access to safe and affordable housing is an SDOH.64 Homelessness may exacerbate existing physical and mental health conditions and lead to the development of new ones.65 Persons experiencing homelessness frequently experience co-occurring severe physical, psychiatric, substance use and social problems. Health care services are more effective when a patient is housed, and maintaining housing is more likely when comprehensive primary care services are available. Practical strategies to end homelessness must address the complexity of health conditions and disability faced by people experiencing homelessness.
Civil rights and anti-discrimination: The AAFP opposes all discrimination in any form, including, but not limited to, that which is based on actual or perceived race, color, religion, gender, sexual orientation, gender identity, ethnic affiliation, health, age, disability, economic status, body habitus or national origin.
Educational achievement: The AAFP supports programs that improve equitable access to high-quality education and equitable educational achievement. Education is associated with many health behaviors and, therefore, affects health status.66 Individuals with lower education are more likely to smoke, have an unhealthy diet and lack exercise. They also have a lower life expectancy.67 Despite this, school funding, teacher-to-pupil ratio and other important indicators of educational quality are not distributed evenly among states and communities.68 All schools should have sufficient funding to meet the educational needs of their students and promote success.
Special attention should be paid to urban and rural schools, which are often under-resourced and may need additional resources to meet their students’ needs. Based on strong evidence showing improved educational, social and health-related outcomes (especially in low-income or racial and ethnic minority communities), the AAFP supports funding for center-based early childhood education, full-day kindergarten and out-of-school-time academic programs. The AAFP also supports funding for grants, scholarships, and other financial support for low-income college students.
Built environment: The AAFP supports improvements to the built environment, such as designing walkable neighborhoods, complete streets and mixed-use zoning to improve community health. The AAFP also supports equitable improvements to the built environment, with a special emphasis on underserved communities and community input in these decisions to ensure that current residents are not displaced or otherwise negatively affected.
Home visitation programs in pregnancy and early childhood: The AAFP supports home visitation programs in pregnancy and early childhood where trained professionals visit families and provide information and training on health, development and the care of children. These programs have proven effective at providing families with the resources and skills to raise children who are physically, socially and emotionally healthy and ready to learn.69
Alternate payment models: The AAFP supports alternative payment models that ensure SDOH are appropriately accounted for in the payment and measurement design so that practices have adequate support to improve quality and outcomes for all patients, eliminate health disparities and reduce costs for the health care system.70
Medical education: The AAFP supports undergraduate and graduate medical education to ensure future physicians are adequately prepared to prevent and address health equity. The AAFP supports education on the PDOH and SDOH and their impacts on health equity integrated across all levels of medical education. Physicians should be knowledgeable about the effects of PDOH and SDOH and be able to work with patients to address these by tailoring treatment to address patients’ barriers to better health.
PDOH and SDOH have a substantial impact on the health of many Americans and are key drivers of health inequities. Family physicians have an essential role in addressing both upstream and downstream determinants of health and in positively impacting health equity by providing high-quality health care to underserved populations and advocating to raise public and policymakers’ awareness.
The AAFP urges its members to work with their practice teams and community members to address PDOH and SDOH and urges government, health care systems and public health organizations to develop equitable policies and practices.
(2019 April BOD) (March 2026 BOD)