The EveryONE Project

Education and Practice-Based Resources

The American Academy of Family Physicians (AAFP) is dedicated to providing information and resources grounded in the most up-to-date research about the social determinants of health (SDOH) and interventions that successfully address them. This body of research and information is expanding rapidly.

In response to the pace of information, the AAFP launched The EveryONE Project, which empowers family physicians to address SDOH in their practices and communities. The EveryONE Project will bring a wide variety of information about SDOH to assist AAFP members. It includes AAFP-produced tools, resources, research, and member’s experiences, as well as academic and non-academic literature about SDOH and health equity.

Point-of-Care Social Determinants of Health Resources

As specialists responsible for whole-person care, family physicians understand better than sub-specialists that it is important to identify and address SDOH for individuals and families to achieve optimal health outcomes and whole-person care. The challenge is operationalizing and implementing such a complex task into a busy practice environment in a manner that is actionable and practical.

The AAFP is committed to helping you and your patients. We are developing a series of tools and resources to use at the point of care by the practice team to quickly and efficiently screen your patients, act when needed, and link to community resources. All SDOH do not need to be addressed at one time, nor should this all be done by the family physician alone. However, it is important to be aware of the many SDOH and their interventions available.

AAFP Tools and Resources

As the AAFP’s The EveryONE Project continues to grow, we will be adding new tools and resources as they become available. The AAFP Social Determinants of Health: Guide to Social Needs Screening Tool and Resources is now available for download.

Other tools and resources the AAFP will bring to its members include:

  • An online search tool of social services and community resources;
  • Practice assessments for incorporating social needs screening in to practice; and
  • Tools to help further transform your practice to address health equity.

Success Stories

AAFP member experiences caring for diverse patient populations offer lessons learned and ways to provide equitable health care to all patients.

  • Anita Ravi, MD, MPH, MSHP: Read how Ravi unlearned the traditional ways of providing health care to found a practice dedicated to serving people who have experienced human trafficking and sexual trauma.
  • Scott Nass, MD, MPA, FAAFP: Nass is a leader in the lesbian, gay, bisexual, and transgender (LGBT) health equity movement, and is currently working to ensure that the transgender youth in his community have access to the resources they need.

Educational Resources

Academic Literature

This list of academic literature supports the impact SDOH has on patient populations, and defines opportunities for interventions and change.

Implicit Bias

Social Factors Effect on Health

  • Dwyer-Lindgren L, Bertozzi-villa A, Stubbs RW, et al. Inequalities in life expectancy among US counties, 1980 to 2014: temporal trends and key drivers. JAMA Intern Med. 2017;177(7):1003-1011.
  • Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. Am J Public Health. 2008;98(9 Suppl):S29-37.
  • Galea S, Tracy M, Hoggatt KJ, DiMaggio C, Karpati A. Estimated deaths attributable to social factors in the United States. Am J Public Health. 2011;101(8):1456-1465.

Pathways from Social Factors to Health Outcomes

  • Phelan JC, Link BG, Tehranifar P. Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav. 2010;51 Suppl:S28-S40.
  • McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338(3):171-179.
  • Glass TA, McAtee MJ. Behavioral science at the crossroads in public health: extending horizons, envisioning the future. Soc Sci Med. 2006;62(7):1650-1671.
  • Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129(Suppl 2):19-31.
  • World Health Organization. A conceptual framework for action on the social determinants of health. Accessed March 1, 2018.
  • Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212-1215.

Intervention Strategies

  • Community Preventive Services Task Force. Guide to Community Preventive Services( (The Community Guide).  Accessed March 20, 2018.
  • DeVoe JE, Bazemore AW, Cottrell EK, et al. Perspectives in primary care: a conceptual framework and path for integrating social determinants of health into primary care practice. Ann Fam Med. 2016;14(2):104-108.
  • Bazemore AW, Cottrell EK, Gold R, et al. “Community vital signs”: incorporating geocoded social determinants into electronic records to promote patient and population health. J Am Med Inform Assoc. 2016;23(2):407-412.
  • Page-Reeves J, Kaufman W, Bleecker M, et al. Addressing social determinants of health in a clinic setting: the WellRx pilot in Albuquerque, New Mexico. J Am Board Fam Med. 2016;29(3):414-418.
  • Swain GR, Grande KM, Hood CM, Inzeo PT. Health care professionals: opportunities to address social determinants of health. 2014;113(6):218-223.
  • American Academy of Family Physicians. Cities for life: community health promotion for the management of diabetes in the patient-centered medical home. Accessed March 1, 2018.
  • National Academies of Sciences, Engineering, and Medicine. Communities in action: pathways to health equity. Accessed March 1, 2018.

Non-Academic Literature

Broaden your perspective on what influences health and what the health care system can do to support your patients' needs.

  • Galea S. Healthier: Fifty Thoughts on the Foundations of Population Health. New York, NY: Oxford University Press; 2018.
  • Shilts R. And the Band Played On: Politics, People, and the AIDS Epidemic, 20th Anniversary Edition. New York, NY: St. Martin’s Press; 2007.
  • Klinenberg E. Heat Wave: A Social Autopsy of Disaster in Chicago. Chicago, IL: The University of Chicago Press; 2002.
  • Maternowskia MC, Farmer P (Foreward). Reproducing Inequities: Poverty and the Politics of Population in Haiti. Piscataway, NJ: Rutgers University Press; 2006.
  • Tilly C. Durable Inequality. Berkeley and Los Angeles, CA: University of California Press; 1998.
  • Kristof ND, WuDunn S. Half the Sky: Turning Oppression into Opportunities for Women Worldwide. New York, NY: Vintage Books; 2009.
  • Wilkinson RG, Pickett K. The Spirit Level: Why More Equal Societies Almost Always Do Better. New York, NY: Bloomsbury Press; 2009.
  • Venkatapuram S, Marmot M (Foreward). Health Justice: An Argument from the Capabilities Approach. Cambridge, UK: Polity Press; 2011.
  • Fuchs VR. Who Shall Live? Health, Economics and Social Choice. Hackensack, NJ: World Scientific Publishing Co; 2011.
  • Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth Meg, eds. Challenging Inequities in Health: From Ethics to Action. New York, NY: Oxford University Press; 2001.
  • Desmond M. Evicted. New York, NY: Penguin Random House LLC; 2016.
  • Roberts D. Fatal Invention. New York, NY: The New Press; 2011.
  • Fadiman A. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures, New York, NY: Straus and Giroux; 1997.
  • Vance JD. Hillbilly Elegy: A Memoir of a Family and Culture in Crisis. New York, NY: HarperCollins; 2016.
  • Manchanda R. The Upstream Doctors: Medical Innovators Track Sickness to its Source. New York, NY: Ted Conferences LLC; 2013.
  • Skloot R. The Immortal Life of Henrietta Lacks. New York, NY: Broadway Paperbacks; 2010.