Milbank Quarterly - 2023 - THIMM KAISER - Conceptualizing The Mechanisms of Social Determinants of Health A Heuristic

Original Research
Conceptualizing the Mechanisms of Social

Determinants of Health: A Heuristic
Framework to Inform Future Directions for
Mitigation
M A R C O T H I M M - K A I S E R , ∗,† A D A M B E N Z E K R I , ∗,†
a n d V I N C E N T G U I L A M O - R A M O S ∗,†,‡,§
∗
Center for Latino Adolescent and Family Health, Duke University; † School
of Nursing, Duke University; ‡ School of Medicine, Duke University;
§
Presidential Advisory Council on HIV/AIDS, US Department of Health and
Human Services
Policy Points:
r A large body of scientific work examines the mechanisms through
which social determinants of health (SDOH) shape health in-
equities. However, the nuances described in the literature are in-
frequently reflected in the applied frameworks that inform health
policy and programming.
r We synthesize extant SDOH research into a heuristic framework
that provides policymakers, practitioners, and researchers with a
customizable template for conceptualizing and operationalizing
key mechanisms that represent intervention opportunities for mit-
igating the impact of harmful SDOH.
r In light of scarce existing SDOH mitigation strategies, the frame-
work addresses an important research-to-practice translation gap
and missed opportunity for advancing health equity.
The Milbank Quarterly, Vol. 101, No. 2, 2023 (pp. 486-526)

© 2023 The Authors. The Milbank Quarterly published by Wiley Periodicals LLC on
behalf of The Milbank Memorial Fund.
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original work is properly cited.
486
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The Mechanisms of Social Determinants of Health 487
Context: The reduction of health inequities is a broad and interdisciplinary

endeavor with implications for policy, research, and practice. Health inequities
are most often understood as associated with the social determinants of health
(SDOH). However, policy and programmatic frameworks for mitigation often
rely on broad SDOH domains, without sufficient attention to the operating
mechanisms, and effective SDOH mitigation strategies remain scarce. To ex-
pand the cadre of effective SDOH mitigation strategies, a practical, heuristic
framework for policymakers, practitioners, and researchers is needed that serves
as a roadmap for conceptualizing and targeting the key mechanisms of SDOH
influence.
Methods: We conduct a critical review of the extant conceptual and empirical
SDOH literature to identify unifying principles of SDOH mechanisms and to
synthesize an integrated framework for conceptualizing such mechanisms.
Findings: We highlight eight unifying principles of SDOH mechanisms that
emerge from landmark SDOH research. Building on these principles, we in-
troduce and apply a conceptual model that synthesizes key SDOH mechanisms
into one organizing, heuristic framework that provides policymakers, practi-
tioners, and researchers with a customizable template for conceptualizing and
operationalizing the key SDOH mechanisms that represent intervention oppor-
tunities to maximize potential impact for mitigating a given health inequity.
Conclusions: Our synthesis of the extant SDOH research into a heuristic frame-
work addresses a scarcity of peer-reviewed organizing frameworks of SDOH
mechanisms designed to inform practice. The framework represents a practical
tool to facilitate the translation of scholarly SDOH work into evidence-based
and targeted policy and programming. Such tools designed to close the research-
to-practice translation gap for effective SDOH mitigation are sorely needed,
given that health inequities in the United States and in many other parts of the
world have widened over the past two decades.
Keywords: social determinants of health, health inequities, framework, health
policy, health programs, health system transformation.
T
he reduction of population-level health inequities
has become a broad and interdisciplinary endeavor with impli-
cations for policy, research, and practice in health care,1 public
health, biomedicine,3 criminal justice,4 education,5 business,6 and be-
2
yond (see the definition of “health inequity” and the glossary of other
key terms in Box 1). Increasingly, the scientific literature understands
488 M. Thimm-Kaiser, A. Benzekri, and V. Guilamo-Ramos
and explains chronic and contemporary health inequities, disparities

in health that are assumed to be systematic, unfair, and avoidable (al-
though the terminology for the concept has been inconsistently defined
and used, we use “health inequities”7 ), as being associated with the so-
cial determinants of health (SDOH).5,8 As such, formal frameworks that
operationalize SDOH as the underlying drivers of health inequities are
important tools for decision makers to inform health-related planning
and programming. For example, the Healthy People 2030 plan in the
United States and the Addressing Health Inequalities in the European Union
report draw on frameworks of SDOH to guide programmatic efforts
aimed at reducing health inequities.9,10
Box1. Glossary of Key Terms
Health: Defined by the World Health Organization as “a state of

complete physical, mental, and social well-being and not merely the
absence of disease or infirmity.”93
Health disparity: A difference in health outcomes among segments
of the population, as defined by social, demographic, environmental,
or geographic attributes.142
Health inequity: A health disparity that is assumed to be produced
through systematic, unfair, and avoidable causal mechanisms.7
Social determinants of health: Defined by the World Health Or-
ganization as “the conditions in which people are born, grow, work,
live, and age and the wider set of forces and systems shaping the con-
ditions of daily life [and health outcomes].”143
Social determinants of health capital: Resources and opportu-
nities that are socially allotted to persons or groups and that affect
health outcomes (e.g., income, educational attainment, quality of
housing, accessibility and quality of available health care).
Social determinants of health processes: Social factors shaping the
interactions among persons, groups, institutions, or systems that af-
fect health outcomes (e.g., policies, norms, racism, sexism, classism,
xenophobia, homophobia).
Exposure: Subjection to a health risk or protective factor (exposure
is environmental or behavioral).
Susceptibility: The likelihood of morbidity/mortality given the ex-
posure to a health risk factor (susceptibility is biological).
Resilience: Collective action to reduce the harmful impact of

structural adversity on individuals, institutions, and communi-
ties/populations’ ability to thrive (resilience does not solely rely on
the strengths of individuals and communities and requires societal
investments in the multilevel systems that are responsible for advanc-
ing health equity).
It is important to note that these prominent policy and program-

matic frameworks of SDOH impact frequently rely on broad domains
of SDOH, such as income, educational attainment, quality of hous-
ing, health care access, and racial/ethnic discrimination, which are
conceptualized as predicting a range of health inequity outcomes.9–13
A large body of conceptual and empirical literature highlights the rel-
evance of these domains of SDOH with respect to shaping health out-
comes and inequities along a gradient of stratification based on social
position.14–19 For example, socioeconomic status is widely considered
predictive of a variety of positive and negative health outcomes.14,19
Similarly, the positive correlation between level of education and overall
health is well documented.15 However, applied policy or programmatic
frameworks that rely primarily on broad domains of SDOH (hereinafter
referred to as “domain-focused” frameworks) seldom specify the operat-
ing mechanisms of SDOH in sufficient detail to guide targeted inter-
vention, and rigorously evaluated and effective programmatic strategies
for mitigating the mechanisms of SDOH impact remain scarce.20,21
This is despite a large body of conceptual and empirical work on
SDOH mechanisms in the extant literature. Several influential SDOH
theories have emerged, including the fundamental causes theory, the risk
environment theory, the syndemic theory, the ecosocial theory, and life-
course and biological approaches for understanding the mechanisms of
SDOH, among others.22–30 In addition, numerous frameworks have col-
lectively advanced efforts to integrate the SDOH literature for use in re-
search and applied work, including the widely cited SDOH framework
developed by the World Health Organization Commission on Social De-
terminants of Health, the National Institute on Minority Health and
Health Disparities (NIMHD) research framework, frameworks of health
and health equity drivers reviewed by Givens and colleagues, as well as
others.31–36 Still, to date, the nuances of SDOH mechanisms described
in the literature are too often not reflected in the broad, SDOH domain–
focused frameworks that continue to inform health policy, public health,
and clinical practice, representing a research-to-practice translation gap
and missed opportunity for more effective SDOH mitigation.
Moving Toward a Strength-Based

Paradigm for Addressing Health
Inequities
The increasing prioritization of SDOH in a broad range of disciplines

has motivated a large and growing number of researchers to focus on
the identification of population-level health inequities14,37,38 and the
description of affected groups and communities in terms of sociodemo-
graphic factors, such as race/ethnicity, socioeconomic status, level of ed-
ucation, biological sex, gender identity, sexual orientation, etc., often
characterizing them as “vulnerable.”14,38–40 As a consequence, vulnera-
bility to negative health outcomes has frequently served as a surrogate
explanatory construct for understanding the impact of SDOH on health
inequities. However, characterizations of vulnerability often fail to elu-
cidate the operating mechanisms of SDOH and contribute little to in-
forming applied intervention.39,40
Vulnerability-focused conceptualizations of SDOH impact reflect a
deficiency-focused perspective on health inequities; that is, the ap-
proaches for describing, explaining, and addressing health inequities
tend to be guided by the question What makes communities do poorly?39
Within this paradigm, researchers seek to identify and practitioners seek
to address structural disadvantages (i.e., the harmful SDOH) and medi-
ating risk factors (i.e., vulnerability factors) that are predictive of nega-
tive health outcomes. An alternative but less common question for guid-
ing health inequity research and programming is What makes communities
do well despite significant structural challenges?39 This change of perspective
represents a worthwhile departure from deficiency-focused paradigms of
thought, as it emphasizes the identification of protective levers to mit-
igate health inequities within a context of chronic and persistent social
injustice.
At the same time, it is important to recognize that strength-based in-
terventions focused primarily on offsetting the negative effects of harm-
ful SDOH should not be viewed as a substitute for broader efforts
to eliminate the underlying drivers of health inequities. Effective ap-

proaches to reducing the negative impact of harmful SDOH will require
a simultaneous focus on prioritizing the elimination of the underlying
drivers of chronic health inequities while also identifying programmatic
opportunities in policy, public health, and health care practice that can
be amplified to reduce the health impact of underlying drivers while
they persist, including by investing in strategies for health and wellbe-
ing that are indigenous to communities experiencing harmful SDOH.
Within this paradigm, tools are needed to support translation of schol-
arly SDOH work into effective health policy and programming.
To this end, we propose and apply a practical, heuristic framework
that provides policymakers, practitioners, and researchers with a cus-
tomizable template for conceptualizing and operationalizing the key
SDOH mechanisms that represent leverage points—intervention oppor-
tunities to maximize potential impact in mitigating a given health in-
equity. The framework serves as a tool to facilitate the translation of
scholarly SDOH work into effective health policy, programming, and
clinical care, thereby addressing a scarcity of peer-reviewed organizing
frameworks of SDOH mechanisms that are explicitly designed to inform
practice.36
Unifying Principles for the Mechanisms

of SDOH
As a starting point for the synthesis of an organizing framework of
SDOH mechanisms that is grounded in the extant literature, we con-
ducted a critical review of seminal SDOH research, following guidance
laid out by Grant and Booth41 to identify principles that are reflected
across influential SDOH theories and those that have utility for estab-
lishing linkages between frameworks. For conceptual synthesis, we drew
on approaches for theory construction outlined by Jaccard and Jacoby.42
Specifically, the authors used a process-oriented approach to analyze
the identified literature during open-ended discussions. Our process-
oriented synthesis of the literature sought to posit general rules by which
dynamic systems of SDOH mechanisms tend to behave in shaping health
inequities, as opposed to a variable-oriented approach focused on delin-
eating a more static set of specific causal factors.42 We highlight eight
unifying principles for the mechanisms of SDOH that emerged from the
critical review and conceptual synthesis. Alongside each principle, we

discuss the core elements of an influential SDOH theory that serve to il-
lustrate the central tenets of the respective principle but do not present a
comprehensive discussion of each theory or of all relevant theories, which
is beyond the scope of this paper.
SDOH Are Underlying Causes of Health

Inequities
Most SDOH frameworks and theories approach the explanation of health
inequities by going beyond considering only proximal risk factors.43,44
Instead, these frameworks consider a set of underlying social factors as
most influential in shaping health inequities. Link and Phelan’s fun-
damental causes theory represents an early and influential articulation
of this principle.19,22 The theory posits that health inequities arise as a
consequence of social stratification based on wealth, power, and prestige,
primarily along the lines of socioeconomic status.19,22 In socioeconomic
strata with a lower allotment of health-related capital, these underlying
social causes systematically increase the density of disease risk factors and
reduce access to resources that represent disease protective factors, pro-
ducing inequities across multiple health outcomes.19,22 A large body of
literature empirically supports this principle, showing that these mech-
anisms result in inequitable health outcomes in communities of low so-
cioeconomic status over time.19,45
The growing recognition of underlying “fundamental causes” as prin-
cipal drivers of persistent health inequities in underserved communi-
ties has been an important contributor to the increasing research, pro-
grammatic, and policy focus on SDOH in recent years. The growing
emphasis on SDOH as driving health inequities represents a departure
from prior explanatory frameworks that primarily relied on individual
agency for understanding negative health outcomes (e.g., decisions re-
garding health), underappreciating the absence of equal opportunity for
achieving optimal health. Instead, SDOH emerge as structural drivers,
or fundamental causes, of health inequities, with individuals, commu-
nities, or populations experiencing harmful SDOH being at increased
risk of negative health outcomes, largely owing to scarce health-related
resources and opportunities.19,22,45–48
SDOH Shape Health Inequities Through

Contextual Influences
The recognition of health risk factors that are exogenous to the indi-
vidual, as reflected in the growing focus on the mitigation of SDOH
through structural interventions,49 represents another key principle re-
flected in the SDOH literature. There is a long history of regarding
health risks as a function of the individual, including in biomedical mod-
els of disease that prioritize proximal risk factors at the individual level
(e.g., behavior, genetics) and some social epidemiological models that
prioritize more distal, yet individual-level, risk factors (e.g., income, ed-
ucational attainment). However, the environmental production of risk
has been increasingly adopted as an explanatory concept for health in-
equities and warrants consideration as an independent principle.5 The
risk environment framework advanced by Rhodes and colleagues serves
to effectively illustrate this principle.23,24 The risk environment is con-
ceptualized as the physical, social, economic, and political structures and
influences that exist outside of the individual but which produce or re-
duce individual disease risk given that individuals are shaped by and
interact with their environment in a multitude of ways.23 As underly-
ing drivers of health inequities, SDOH operate in part by shaping these
physical, social, economic, and political conditions across communities.
Importantly, environmental risk cannot always be considered inde-
pendently of behavioral risk because the health risk associated with cer-
tain behaviors is often dependent on the environment where the behavior
occurs (e.g., risk of HIV infection associated with unprotected sex in a
context of high community viral load vs. low community viral load),50
and because environmental influences have been shown to shape behav-
ior itself (e.g., paraphernalia laws shaping drug injection practices).23
Given that individuals from the same community are likely to experi-
ence similar environmental influences and risk environments, negative
health outcomes tend to cluster to produce health inequities.
SDOH Contextual Disadvantage Is Not

Deterministic
Further, the extant SDOH research facilitates understanding of another
particularly important principle of SDOH mechanisms; despite robust
and consistent evidence of the clustering of negative health outcomes in
certain socioeconomic strata or community contexts,43,46,51 the harmful

influences of distal drivers of health inequities, such as low educational
attainment, and of contextual disadvantages, such as low community-
level density of health services, do not immutably cause negative health
outcomes. For example, individuals with the same educational back-
ground frequently have different health outcomes, and communities
with the same density of health services frequently have different base
rates of morbidity and mortality.
Several influential SDOH frameworks emphasize the importance of
complex systems (i.e., nonlinear, multilevel, and dynamic influences
and mechanisms) in shaping both individual health and the emergence
of community-level health inequities.22–31 Although the impact of
harmful SDOH will, on average, result in worse health outcomes, the
mechanisms through which harmful SDOH influence operates and
the degree to which the associated negative health impacts ultimately
manifest can differ among individuals and communities because health
outcomes are shaped by numerous mechanisms across several levels of
influence simultaneously. For example, the risk environment framework
outlines the interplay of influences at three levels that together shape
health risk and outcomes—the micro (individual), meso (institutional),
and macro (community/societal) levels.24 The nature of influences at
each level can either protect from or increase the risk of disease, and
multilevel influences interact to reinforce or weaken the effects of one
another. Therefore, similar macro, meso, or micro contexts of health
risk do not always produce identical health outcomes. For example,
work examining social capital and social cohesion in relation to health
has highlighted the important protective influence of relationships
among actors both within and across levels, including individual net-
works (micro level), institutions (meso level), and community/societal
groups (macro level),31 which is reflected in the growing recognition
of meaningful community engagement as a key opportunity for im-
proving health equity research and programming.52 Altogether, greater
emphasis on understanding the factors that offset the negative impacts
of harmful SDOH can inform optimally effective mitigation efforts.
SDOH Shape Health Over the Life Course

The life-course framework in SDOH research suggests that social, eco-
nomic, psychological, environmental, and other influences accumulate
over the life course to shape health behavior and mental and physical
health.29,53 As such, early-life adverse or protective SDOH affect health
outcomes later in life. Notably, a comprehensive body of research has
examined the various aspects of SDOH influences over the course of life,
including work on the fetal origins of disease,54 sensitive developmental
periods,55 scaffolding theory,56 and the long-term impacts of trauma and
allostatic load.57 Two overarching mechanisms for life course–related
SDOH impact stand out as generalizable.29 First, at any given life stage,
SDOH shape exposure to risk or protective factors. However, the health
consequences attributable to a given risk or protective factor may man-
ifest later in life.29 For example, research conducted by the US Cen-
ters for Disease Control and Prevention suggests that nearly half (44%)
of all cases of depression among adults may be attributable to adverse
experiences during childhood.58 Second, the nature of SDOH influences
that occur early in life predict the nature of SDOH influences later in
life. For example, children who grow up in poverty are more likely to
experience poverty in adulthood.59 The persistence of SDOH influences
over the course of life promotes the accumulation of exposures and asso-
ciated health consequences.29
SDOH Operate Through Biological Embedding

The influence of SDOH on the distribution of various contextual health
risk and protective factors is well documented and is largely accepted
as a core mechanism of SDOH impact. In addition, previous research
conceptually and empirically supports the role of SDOH in shaping bio-
logical processes that contribute to negative health outcomes (biological
embedding).26–30,60 Biological embedding is defined as the process by
which SDOH initiate and sustain biological changes that are associated
with an increased likelihood of negative short- and long-term physi-
cal or mental health outcomes.60 Biological embedding that operates
through epigenetic, neurodevelopmental, immune, endocrine, and mi-
crobiome changes has been described.60–62 Accelerated cardiometabolic
aging, which is associated with residing in contexts of disadvantage, rep-
resents an example of biological embedding.63 In addition, adverse expe-
riences during childhood have been shown to impact neurodevelopment,
including brain structure (e.g., decreased hippocampal volume and gray
matter) and function (e.g., amygdala functional connectivity),64,65 repre-
senting another manifestation of biological embedding. Biological em-

bedding can be understood as the continual, dynamic interactions of
the social and physical environment with biological processes that oc-
cur in the body and brain over the life course.66–69 As such, the life
course–related impact of SDOH should be conceptualized not only as the
accumulation of environmental health risk factors but also of biological
changes that are associated with increased morbidity and mortality.
SDOH Operate Intergenerationally

The impact of SDOH has been described not only as manifesting over
the course of life but also as operating intergenerationally. The prin-
ciple of intergenerational SDOH impact serves to conceptualize mech-
anisms that explain the clustering of negative health outcomes across
generations beyond those that are attributable to genetic predisposition.
The biosocial inheritance framework serves to effectively illustrate this
principle.67,70 Biosocial inheritance is defined as the transmission of so-
cial adversity and advantage across generations.70 It operates through
both the socioenvironmental and biological mechanisms that have been
described in previous sections. There are three types of intergenera-
tional SDOH impacts that warrant consideration. Cross-generational
SDOH impact refers to social influences that lead to exposures at the
parent level, with the resulting health consequences manifesting in the
offspring (e.g., through exposure to environmental toxins or elevated
levels of stress during pregnancy).70–72 Multigenerational SDOH im-
pact refers to social influences that lead to exposures and correspond-
ing health consequences that affect multiple generations simultaneously
(e.g., through stressors such as poverty, food insecurity, or housing in-
stability that affect both children and parents).70,73 Transgenerational
SDOH impact refers to social influences that lead to exposures for which
the resulting health consequences are passed down to multiple gener-
ations (e.g., transmission of trauma through inheritance of epigenetic
tags).70,74
Undoubtedly, the family represents a particularly important health-
related context early in life, with parental influences having an out-
sized effect on child and adolescent health outcomes and trajectories.
Although a context of harmful SDOH influences places a significant
burden on the caregiving environment that can be associated with child
and adolescent stressors,75,76 parents and the family represent powerful
protective buffers against the negative effects of environmental risk on

the health and development of children and adolescents.77–79 For exam-
ple, parental influences have been shown to offset associations of stressful
life events, racial discrimination, and exposure to community violence
with adolescent externalizing problems (e.g., unprotected sex, substance
use) in families experiencing harmful SDOH.80 Thus, the family must
be recognized as an important unit for both understanding and mitigat-
ing the impact of SDOH. This has implications for both research and
practice paradigms, which, to date, have tended to focus on individuals
rather than families.
SDOH Shape Clustering and Synergies of

Health Inequities
The principles of SDOH impact that identify fundamental causes
and contextual influences in shaping health outcomes also help ex-
plain the clustering of health inequities in communities and popu-
lations that experience adverse SDOH. Building on these principles,
the work advanced by Singer and Clair describes another key mecha-
nism of SDOH impact—the synergistic interaction of coexisting health
disparities.25 Syndemic theory focuses on the excess disease burden
that is attributable to the synergistic interactions of two or more epi-
demics within the same community or population (i.e., the extent
to which the combined morbidity attributable to multiple cooccur-
ring epidemics is greater than the summed morbidity had each epi-
demic occurred separately).25 There are both social and biological mech-
anisms that can produce syndemic dynamics.25 For instance, an in-
creased risk of HIV acquisition among people who use substances and
engage in disinhibited sexual behavior is an example of sociocontex-
tual synergism.81 Inflammation of the genital tissue caused by a sex-
ually transmitted infection, which in turn facilitates the transmission
or acquisition of HIV, is an example of biological synergism.82 Given
that the likelihood of epidemiological synergies increases with a greater
number of cooccurring epidemics, the impact of syndemics is the great-
est in communities and populations in which many health dispari-
ties tend to cluster, namely those impacted by adverse SDOH. Am-
plifying clustering mechanisms of SDOH impact across multiple lev-
els and across time also warrant mention. First, harmful and protec-
tive SDOH influences tend to cluster within and across individuals,
families, schools, neighborhoods, communities, etc., with interactions
across levels amplifying the impact of harmful SDOH.83 Second, so-

cial stratification in morbidity and disability contributes to further en-
trenching the existing social hierarchies in terms of wealth, power, and
status,83–85 thereby amplifying SDOH impact and health inequities over
time.
Unjust Social Processes Shape SDOH

Mechanisms to Produce Health Inequities
Last, seminal work on SDOH has examined the mechanisms that pro-
duce health inequities from the perspective of social processes. Krieger’s
ecosocial framework, which conceptualizes health inequities as biologi-
cal expressions of unjust social processes, has been particularly influen-
tial in establishing this principle.26–28 Structural racism, the negative
health impact of which is supported by a growing body of evidence,86
serves to illustrate the central tenets of the principle. Structural racism
as an exploitative and oppressive social process shapes, and is shaped
by, long-standing racial/ethnic social inequality in various domains,87,88
including those that in turn impact health (e.g., income, educational at-
tainment, quality of housing, health care access).14 There is also evidence
of a direct impact of racism on health, for example, through chronic
stress and the associated inflammatory processes89 and through interac-
tions between racism and other SDOH influences (e.g., structural racism
not only reduces access to health care but also impacts the quality of care
when care is accessed).90,91 Therefore, social processes, such as structural
racism, classism, sexism, xenophobia, and homophobia, including as ex-
pressed in policies and regulations, fundamentally shape the mechanisms
through which SDOH affect health inequities,87,88,91 as well as the ways
in which SDOH mechanisms are conceptualized, examined, and targeted
for mitigation.92
Considered together, the eight principles identified here draw on
influential SDOH research to highlight the key mechanisms through
which the influence of SDOH on long-standing and current health in-
equities can be conceptualized. In Figure 1, we illustrate each princi-
ple using applied examples of the mechanisms of SDOH shaping HIV
inequities. In addition, the principles point to future directions for
advancing systems transformation in health policy, public health, and
clinical practice toward greater alignment with stated health equity
Figure 1. Eight Key Principles of Social Determinants of Health

(SDOH) Mechanisms Shaping HIV Inequities.
Case examples for the application of the principles of SDOH mech-

anisms to HIV inequities. (A) SDOH act as underlying drivers of
HIV transmission by shaping the distribution of HIV risk and pro-
tective factors.22,44 (B) SDOH influence manifests in the policy, eco-
nomic, social, and physical dimensions of the HIV risk environment.23,24
(C) Adverse SDOH influences at the macro level (macro) are not de-
terministic in shaping HIV outcomes but interact with meso level
(meso) and micro level (micro) influences.24 (D) SDOH influence in
early life and over the life course shapes HIV treatment outcomes and
disease progression.29,125,126 (E) The impact of SDOH on HIV out-

comes includes biological mechanisms of influence,60,67–69 including
inflammatory127–133 and neural69,131–133 mechanisms. (F) SDOH shape
HIV outcomes for several generations through three types of intergenera-
tional influence.67,69,134–137 (G) SDOH shape the clustering of multiple
cooccurring epidemics, which amplifies exposures and susceptibilities
associated with increased HIV transmission.25,138,139 (H) Social injustice
shapes HIV inequities directly and in interaction with systematic differ-
ences in other SDOH.26–28,47,139. Abbreviations: CCR5, C-C chemokine
receptor type 5; CD4, cluster of differentiation 4; HPA, hypothalamic-
pituitary-adrenal; IFG, inferior frontal gyrus; PrEP, HIV preexposure
prophylaxis; STI, sexually transmitted infection; TPJ, temporo-parietal
junction.
goals.1–6,9–13,31,93 Table 1 highlights priorities for health equity–focused

systems transformation that emerge from the eight principles of SDOH
mechanisms, each contrasted against the current status quo.
An Organizing Framework of SDOH

Mechanisms
Building on the eight unifying principles outlined above, we propose
a conceptual model that synthesizes the eight key SDOH mechanisms
into one organizing framework (Figure 2), which is designed to serve as
a roadmap for policymakers and applied researchers in conceptualizing
leverage points for mitigating a given health inequity. The goal of our
synthesis was to (1) distill clearly defined concepts that hold meaning for
the future users of the framework (see the glossary of key terms in Box
1) and (2) put them into relationships with each other so as to capture
the dynamic processes of SDOH mechanisms that are reflected in the
eight principles.42 The resulting conceptual model incorporates SDOH
as underlying causes that shape health inequities through nonlinear, me-
diated, and moderated relationships (Principle 1). More specifically, the
model distinguishes between SDOH capital, the resources and opportu-
nities that affect health outcomes and are socially allotted to individuals
and groups (e.g., educational attainment, quality of housing, income),
and SDOH processes, the often unjust social processes shaping the inter-
actions and relationships among persons, groups, institutions, or systems
Figure 2. The Center for Latino Adolescent and Family Health Frame-
work of SDOH Mechanisms.
Abbreviations: macro, macro level; meso, meso level; micro, micro level;
SDOH, social determinants of health.
that affect health outcomes (e.g., racism, policies, norms) (Principle 8).
The influence of SDOH is mediated by exposure, which is conceptual-
ized as context-specific environmental and behavioral risk (Principle 2),
and biologically embedded susceptibility (Principle 5). The depicted
SDOH mechanisms are not deterministic given that the model in-
corporates the moderating influence of multilevel resilience factors
(Principle 3). At the outcome level depicted at the right end of the fig-
ure, the model accounts for the clustering of multiple cooccurring health
inequities and corresponding synergisms that reinforce the impact of
SDOH (dotted arrows) (Principle 7). In addition, the model assumes
that the influence of the outlined SDOH mechanisms accumulates over
the course of life (Principle 4) and recognizes the family as a primary
context for understanding and mitigating the intergenerational impact
of SDOH (Principle 6). Last, the model considers the depicted constructs
and relationships as operating across multiple levels and encourages op-
erationalizing them as such.
The proposed framework of SDOH mechanisms offers a rich, yet
generalizable, template for conceptual, empirical, and applied work de-
signed to develop and implement comprehensive and multilevel inter-
ventions, programs, and policies to prevent and mitigate the harmful
impact of SDOH. Specifically, our framework serves as a heuristic for

conceptualizing four key elements of SDOH mechanisms: underlying
causal factors, mediating factors, moderating factors, and health inequity
outcomes.
Underlying Factors
Our proposed framework conceptualizes SDOH—the distal causal fac-
tors that shape health inequities—as two distinct classes of social in-
fluence. Specifically, we distinguish between SDOH capital and SDOH
processes. We conceptualize SDOH capital as quantifiable resources and
opportunities that affect health outcomes, for which allotment to in-
dividuals or groups is primarily determined by social factors. For ex-
ample, educational attainment can be measured at the level of the
individual or the community, is important for shaping health out-
comes, and is largely distributed along a social gradient. In contrast, we
conceptualize SDOH processes as social factors shaping the interactions
among persons, groups, institutions, or systems that impact health. The
SDOH processes—many of which are unjust—do not pertain to a given
individual or group in isolation but are inherently relational in nature.
They include policies, norms, and unjust social processes, such as racism,
sexism, classism, xenophobia, and homophobia.5
We posit a reciprocal relationship between SDOH processes and
SDOH capital. For example, it is well documented that structural
racism contributes to persistent socioeconomic inequality experienced
by communities of color, which includes differences in access to qual-
ity housing.94 At the same time, persistent socioeconomic inequality in
communities of color in the United States has reinforced racist beliefs
and attitudes that perpetuate structural racism.95 Evidence substanti-
ates the impact of both social processes such as structural racism and a
wide range of socioeconomic factors in shaping health inequities.14,48,91
Given that SDOH capital and SDOH processes shape health inequities
together but also independently, they offer different opportunities for
mitigation if conceptualized separately.
Mediating Factors
We expand on the conceptualization of vulnerability as a primary proxi-
mal mediator of SDOH impact. Our organizing framework of SDOH
mechanisms conceptually substitutes vulnerability with (1) environ-

mental and behavioral exposure and (2) biological susceptibility (Box 1).
The framework recognizes that health inequities emerge in communi-
ties in which either adverse exposure or susceptibility is elevated or in
which both are elevated (the presence of proximal risk factors or the
absence of proximal protective factors can increase adverse exposure).
The work of Krieger as well as Chae and colleagues has contributed
to this operationalization of exposure and susceptibility as substitutes
for vulnerability.26,27,39 Notably, within this conceptual model, exam-
ining exposures without considering susceptibility and examining sus-
ceptibility without considering exposure each incompletely explains the
emergence of population-level health inequities, and application of the
framework relies on the operationalization of both constructs.
Moderating Factors
The proposed framework includes resilience as a moderator of the pre-
sumed mechanisms of SDOH. We conceptualize resilience as collective
action that supports the ability of communities to thrive when con-
fronted with structural challenges. Importantly, resilience represents a
multilevel construct that does not solely rely on the strengths of indi-
viduals and communities and requires societal investments in the mul-
tilevel systems that are responsible for advancing health equity.26,27,39
SDOH mitigation efforts must not be limited to interventions designed
to foster individual- or community-level resilience. Application of the
framework to explore any given health inequity therefore warrants op-
erationalization of the micro-, meso-, and macrolevel resilience factors.
Outcomes
Within the proposed framework, a given health inequity does not ex-
ist in isolation. In contrast to traditional, reductionist approaches, we
conceptualize the impact of SDOH mechanisms on health inequities as
dependent on the broader patterns of morbidity within the community
of interest. As such, the framework calls for considering community and
population health wholistically, taking cooccurring health inequities for
which synergistic effects are hypothesized or empirically supported into
account.
As a whole, the proposed heuristic framework is designed for ap-

plication to a broad range of different health inequities. Therefore, the
model accommodates broad classes of SDOH-related causal factors,
which can be operationalized more narrowly when the framework is
applied to a specific health inequity of interest. Application of the
framework includes the use of theory, empirical data, and the pub-
lished literature to operationalize each depicted construct and evaluate
the relevance of each depicted relationship (represented by arrows) in
relation to a specified health inequity, place, and time.96 For exam-
ple, the specific SDOH-related causal mechanisms most relevant for
explaining COVID-19 inequities in an urban context in the United
States may differ considerably from those most relevant for explaining
stroke inequities in rural Australia. Nevertheless, in both scenarios,
the proposed heuristic framework offers an aid to conceptualizing and
operationalizing the key constructs and relationships to be considered.
To illustrate, we discuss an exemplary application of the framework.
An Example Application: Mitigating the

Impact of COVID-19 in the Bronx
The utility of the proposed framework as a heuristic for conceptualizing
and operationalizing SDOH mechanisms becomes most apparent when
an application to a specific health inequity is considered. To illustrate,
we discuss an application of the framework to COVID-19 mortality in-
equities in New York City’s South Bronx. This example highlights a
subset of well-established SDOH influences and mechanisms that are
important for understanding the selected health inequity. Additional
factors undoubtedly contribute to COVID-19 mortality inequities in
the South Bronx but are omitted in our discussion because they would
distract from the intended purpose of the example application, namely
to illustrate the practical utility of our framework for conceptualizing
and identifying specific SDOH mechanisms that can be targeted for in-
tervention.
Since the beginning of the pandemic, more residents of Bronx County
have died from COVID-19 than in 99% of other counties in the United
States,97 and the rate of COVID-19 deaths in the Bronx is nearly twice
the national average.98,99 The South Bronx lies in the poorest congres-
sional district in the continental United States and is designated as a
medically underserved area with a shortage of health professionals.100,101
The meaningful contribution of SDOH to elevated COVID-19–related

morbidity and mortality in similar socioeconomically and medically un-
derserved contexts has been documented.102 In Figure 3, we apply our
framework to illustrate operationalized mechanisms of influence for a
well-established SDOH health capital factor, namely a lack of culturally
and linguistically appropriate health services,103 and well-established
SDOH processes, namely the health care and public health systems’ low
trustworthiness among South Bronx residents.104
In the South Bronx, 97% of all residents are Latino or Black, and 30%
are foreign born.105 Notably, the scarce health services in the medically
underserved community are often inadequately aligned with the needs
of its culturally and linguistically diverse residents, representing a major
barrier to accessing health services and information103 (SDOH of health
capital). At the same time, experiences with long-standing, systemic bar-
riers and unresponsiveness have rendered the extant systems for delivery
of health care and public health services untrustworthy for communi-
ties experiencing structural racism and socioeconomic disadvantage104
(SDOH health process). Together, the two distal SDOH influences shape
access to and meaningful engagement with health services among resi-
dents of the South Bronx.
In our example, the impact of SDOH on community-level COVID-19
mortality inequities is mediated by (1) reduced exposure to an important
protective factor (i.e., inadequate reach of COVID-19 testing services)
and (2) increased biological susceptibility (i.e., lack of vaccine-induced im-
munity to COVID-19), each manifesting as a function of both less access
to services and greater hesitancy to use available services.106,107 The ex-
posure (inadequate testing) influences the outcome (COVID-19 mortal-
ity) through delayed COVID-19 diagnosis and advanced disease progres-
sion before receipt of medical care.108 Lack of vaccine-induced immu-
nity represents increased susceptibility to severe COVID-19 and risk of
death. In this example, we consider the emergence of the primary health
inequity of interest within the broader context of cooccurring health
inequities in the South Bronx. Cooccurring, synergistic health inequities,
such as elevated rates of disability, which reduces mobility and presents
a barrier to accessing testing services,109,110 and prevalent cardiovascu-
lar disease, which is associated with increased COVID-19 severity,111
further exacerbate exposure and susceptibility.
Last, the example application operationalizes resilience factors at the
individual/family, institutional, and system levels, which moderate the
impact of SDOH on COVID-19 mortality. For instance, household ca-
Figure 3. Exemplar Application of the Framework for Operationaliz-

ing SDOH Mechanisms that Shape COVID-19 Mortality Inequities in
the South Bronx, New York City.
We illustrate how the framework introduced in Figure 2 can be ap-

plied to a specific health inequity. Here, we show example opera-
tionalizations for each construct depicted in Figure 3 for an applica-
tion to COVID-19 mortality inequities in the South Bronx, New York
City. In addition, we show the conceptualized causal relationships (ar-
rows). Notably, a causal effect of exposure on susceptibility, as included
in Figure 2, is not supported by theory or data for the current ex-
ample and is therefore omitted, but inclusion of the relational form
should be considered (based on theory, empirical data, and the pub-
lished literature) when the framework is applied to a different health
inequity. We emphasize that the family context should be recognized
as important for shaping the depicted constructs and relational forms
(e.g., past experiences with health services among family members are
associated with an individual’s trust in health care providers140 ; health
system literacy among parents can shape the receipt of health services for
their children).141 The possibility of operationalizing framework con-
structs at multiple levels is illustrated here for resilience but can also be
adopted for other constructs. Life-course implications for COVID-19 are
not yet fully understood and are therefore not applicable for the current
example, but the importance of a life-course perspective for understand-
ing the impact of SDOH on other health inequities is well established.29
Abbreviations: macro, macro level; meso, meso level; micro, micro level;
SDOH, social determinants of health.
pacity for COVID-19 mitigation, such as knowledge regarding the im-

portance of COVID-19 testing and vaccination and proficiency in navi-
gating culturally misaligned health services, can moderate the effect of
the distal SDOH factors on exposure and susceptibility. Operationaliza-
tion of multilevel resilience factors is particularly important, given that
they can significantly expand the number of leverage points for inter-
vention that intuitively emerge from the application of the framework
(e.g., in our example, family-based interventions, institutional commu-
nity engagement, and increased investments in public health infrastruc-
ture and the workforce).
We wish to highlight that the design and implementation of targeted
SDOH mitigation programs based on the example discussed here is not
only theoretically possible but that a real-world application is currently
in the field. The Nurse–Community–Family Partnership (NCFP)
program, which is currently being evaluated in a community-based,
randomized controlled trial in the South Bronx as part of the National
Institutes of Health (NIH)’s Rapid Acceleration of Diagnostics in
Underserved Populations initiative,112,113 is a family-based interven-
tion designed to increase COVID-19 testing and vaccine uptake using
a multilevel approach. In Table 2, we highlight several key NCFP
program elements that target intervention opportunities for SDOH
mitigation emerging from the example application of the framework in
Figure 3. In addition, annotated photographs that provide impressions
from NCFP implementation in the field are available online in the
Supplementary Materials to this article.
Conclusion
Despite increasing recognition of SDOH as the underlying drivers of
historic and contemporary health inequities, a 2021 evidence review
commissioned by the US Department of Health and Human Services
found that the available set of rigorously evaluated and effective inter-
ventions to mitigate the impact of SDOH remains inadequate.20 The
importance of a strong conceptual understanding of the precise mecha-
nisms of SDOH influence for developing targeted and effective mitiga-
tion strategies has been argued by the World Health Organization and
others.31,44,114,115 Nonetheless, the SDOH frameworks that are most fre-
quently applied in health care and public health planning and program-
Table 1. Priorities for Health Equity–Focused Systems Transformation

(versus Status Quo) that Emerge from the Eight Unifying Principles of
SDOH Mechanisms
Principle of SDOH Priority for Health Equity–Focused
Mechanisms Systems Transformation (vs. Status Quo)
SDOH are Meaningful community engagement in data
underlying causes generation and interpretation for
of health understanding and mitigating underlying
inequities health inequity drivers and multilevel
resilience factors (vs. an exclusively
data-driven focus on identifying community
risk factors)
SDOH shape health Development, evaluation, and scale up of
inequities multilevel interventions that address the
through mechanisms of SDOH at the structural,
contextual psychosocial, and clinical/biomedical levels
influences (vs. primarily biomedical approaches
combined with screening for individual
social needs [e.g., housing, food,
transportation] and subsequent referrals to
psychosocial services)
SDOH contextual Adoption of individualized/differentiated,
disadvantage is decentralized, and community-based service
not deterministic delivery models (vs. centralized
one-size-fits-all models)
SDOH shape health Proactive intervention focused on prevention
over the life and health promotion as well as restorative
course care to maintain and improve physical,
mental, and psychosocial functioning and
quality of life (vs. focus on treatment within
a system built for sick care)
SDOH operate Greater prioritization of harmful SDOH
through mechanisms and mitigation of their
biological biological impact in clinical education and
embedding practice, including investment in
biomarkers for early detection of and
intervention on emerging disease
trajectories (vs. focus on diagnosis after
disease onset and subsequent disease
management)
Continued
Table 1. (Continued)
Principle of SDOH Priority for Health Equity–Focused

Mechanisms Systems Transformation (vs. Status Quo)
SDOH operate in- Prioritization of family-based approaches to
tergenerationally restorative health care, prevention, and
health promotion (vs. primarily
individual-focused intervention approaches)
SDOH shape Greater integration of comprehensive,
clustering and interdisciplinary, team-based health services
synergies of delivered within a value-based framework
health inequities and at the top of providers’ licenses (vs.
fragmented and siloed fee-for-service
systems with practice restrictions for
nonphysician providers)
Unjust social Departure from vulnerability- and
processes shape deficiency-focused paradigms for
SDOH understanding health inequities toward
mechanisms to multilevel resilience-focused paradigms for
produce health reducing health inequities (i.e., “What
inequities makes communities do well despite
significant structural challenges?” vs. sole
focus on “What makes communities do
poorly?”)
Abbreviations: SDOH, social determinants of health.
ming tend to rely on broad SDOH domains that are operationalized as

being associated with a wide range of health inequities without ade-
quate attention to the operating mechanisms. We propose an organiz-
ing framework that synthesizes and integrates eight unifying principles
relating to the mechanisms of SDOH.
Our synthesis of the extant SDOH research is designed as a heuris-
tic and customizable template for conceptualizing and operationaliz-
ing the specific SDOH mechanisms that represent potential leverage
points for mitigating a given health inequity and serves as a tool to
advance the translation of scholarly SDOH work into effective policy
and programming (a continuously updated online tool to guide applica-
tion of the framework is available at www.DUSONtrailblazer.com). As
such, the framework aligns with calls for greater attention to the operat-
510
Table 2. NCFP Program Elements Emerging from Applying the Heuristic Framework of SDOH Mechanisms in Figure 3
Intervention Opportunity Corresponding NCFP Program

a
for SDOH Mitigation Element
SDOH capital
Lack of Regular home visits by bilingual (English/Spanish) and bicultural
linguistically/culturally nurse-community health worker (CHW) intervention teams familiar with
appropriate health the community context; bilingual and culturally/contextually tailored
services printed NCFP intervention materials; bilingual nurse hotline
SDOH processes
Health care and public Development of the NCFP Trustworthiness Agreement: a formal commitment
health systems’ low of NCFP intervention teams to adhere to expectations in four dimensions of
trustworthiness trustworthiness (transparency, respect, reliability, and benefit) that are
collaboratively established with participating families at the beginning of
the program
Exposure
Continued
M. Thimm-Kaiser, A. Benzekri, and V. Guilamo-Ramos

a
Inadequate reach of Offer of at-home COVID-19 testing to participating families for:
COVID-19 testing Routine testing: monthly offer of at-home polymerase chain reaction (PCR)
services test
Indicated testing: same-day at-home rapid antigen test offered if COVID-19
symptoms or exposure are reported
Susceptibility
The Mechanisms of Social Determinants of Health
Lack of vaccine-induced Theory-based and culturally, linguistically, and contextually tailored

immunity to COVID-19 intervention content designed to shape vaccine decision making; navigation
to at-home or community-based COVID-19 vaccination services
Resilience factors
Household capacity for Technical, knowledge, and skill components delivered by nurses (e.g., offer of
COVID-19 mitigation COVID-19 testing, training on household infection control skills, safe and
correct use of PPE, etc.); theory-based behavioral intervention components
delivered by CHWs that address decision-making factors (e.g., expectancies,
norms, emotions, etc.)
Continued
511
512

a
Strength of organizational Outreach to and engagement of key community partners to obtain buy-in and
ties with the community establish a predictable relationship with the community (e.g., Tenants
Associations)
Strength of public health Development of sustainable COVID-19 mitigation capacity through
emergency response engagement and inclusion of community members in the NCFP
infrastructure and implementation team and NCFP project team across all levels
workforce
Synergistic health inequities
Elevated rates of disability Screening for comorbidities, behavioral health, and social service needs among
and cardiovascular disease all family members; navigation to services when needed
Abbreviations:
a
NCFP, The Nurse–Community–Family Partnership; PPE, personal protective equipment; SDOH, social determinants of health.
NCFP is a community-based, nurse and CHW-delivered program designed to increase COVID-19 testing, vaccine uptake, and overall household capacity
for COVID-19 mitigation. We highlight how several NCFP program elements directly address intervention opportunities for SDOH mitigation that emerge
from the application of the heuristic framework of SDOH mechanisms in Figure 3. The NCFP evaluation study received funding from the National Institutes
of Health (3P30 DA011041-25S), ClinicalTrials.gov identifier NCT04832919.
M. Thimm-Kaiser, A. Benzekri, and V. Guilamo-Ramos
ing mechanisms shaping health inequities by NIMHD and other NIH

institutes and offices.116–118 Further research should apply, empirically
evaluate, and conceptually iterate on the framework of SDOH mecha-
nisms proposed here, including by drawing on systems science perspec-
tives that emphasize the dynamic processes shaping health inequities119
and through integration with other comprehensive, multilevel, but
more static SDOH frameworks (e.g., the widely used NIMHD re-
search framework).32 Moreover, work to develop, implement, and scale
up programmatic applications for comprehensive SDOH mitigation is
warranted, today more than ever. Over the past two decades, social
inequality and health inequity have widened in the United States and
in many other parts of the world.120–123 Most recently, the ongoing
COVID-19 pandemic has disproportionately impacted communities ex-
periencing preexisting social and health inequities worldwide.102,124
These data suggest that new approaches to mitigate the impact of SDOH
are needed. Frameworks that help target the mechanisms of SDOH more
precisely and effectively will be indispensable if the increasingly broad
and interdisciplinary initiatives designed to reverse the signs of deteri-
orating health equity are to be successful.
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Funding/Support: This work was supported by the William T. Grant Foundation,

Reducing Inequality Initiative, Grant 189030 (V.G.-R.).
Conflict of Interest Disclosures V.G.-R. reports grants and personal fees from
ViiV Healthcare outside the submitted work, and he serves as a member of
the US Presidential Advisory Council on HIV/AIDS and as a member of the
CDC/HRSA Advisory Committee on HIV, Viral Hepatitis and STD Prevention
and Treatment. The other authors declare they have no competing interests.
Address correspondence to: Vincent Guilamo-Ramos, School of Nursing, Duke

University, DUMC 3322, 307 Trent Dr, Durham, NC 27710 (email: vin-
cent.ramos@duke.edu).
Supplementary Material
Additional supporting information may be found in the online ver-
sion of this article at http://onlinelibrary.wiley.com/journal/10.1111/
(ISSN)1468-0009:

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Original Research

Conceptualizing the Mechanisms of Social

The Milbank Quarterly, Vol. 101, No. 2, 2023 (pp. 486-526)

Context: The reduction of health inequities is a broad and interdisciplinary

and explains chronic and contemporary health inequities, disparities

Box1. Glossary of Key Terms

Health: Defined by the World Health Organization as “a state of

Resilience: Collective action to reduce the harmful impact of

It is important to note that these prominent policy and program-

Moving Toward a Strength-Based

The increasing prioritization of SDOH in a broad range of disciplines

to eliminate the underlying drivers of health inequities. Effective ap-

Unifying Principles for the Mechanisms

critical review and conceptual synthesis. Alongside each principle, we

SDOH Are Underlying Causes of Health

SDOH Shape Health Inequities Through

SDOH Contextual Disadvantage Is Not

certain socioeconomic strata or community contexts,43,46,51 the harmful

SDOH Shape Health Over the Life Course

SDOH Operate Through Biological Embedding

senting another manifestation of biological embedding. Biological em-

SDOH Operate Intergenerationally

protective buffers against the negative effects of environmental risk on

SDOH Shape Clustering and Synergies of

across levels amplifying the impact of harmful SDOH.83 Second, so-

Unjust Social Processes Shape SDOH

Figure 1. Eight Key Principles of Social Determinants of Health

Case examples for the application of the principles of SDOH mech-

disease progression.29,125,126 (E) The impact of SDOH on HIV out-

goals.1–6,9–13,31,93 Table 1 highlights priorities for health equity–focused

An Organizing Framework of SDOH

impact of SDOH. Specifically, our framework serves as a heuristic for

mechanisms conceptually substitutes vulnerability with (1) environ-

As a whole, the proposed heuristic framework is designed for ap-

An Example Application: Mitigating the

The meaningful contribution of SDOH to elevated COVID-19–related

Figure 3. Exemplar Application of the Framework for Operationaliz-

We illustrate how the framework introduced in Figure 2 can be ap-

pacity for COVID-19 mitigation, such as knowledge regarding the im-

Table 1. Priorities for Health Equity–Focused Systems Transformation

Principle of SDOH Priority for Health Equity–Focused

ming tend to rely on broad SDOH domains that are operationalized as

Intervention Opportunity Corresponding NCFP Program

Intervention Opportunity Corresponding NCFP Program

Lack of vaccine-induced Theory-based and culturally, linguistically, and contextually tailored

Intervention Opportunity Corresponding NCFP Program

ing mechanisms shaping health inequities by NIMHD and other NIH

6. Marmot M, Alexander M, Allen J, Munro A. The Busi-

15. Marmot M, Friel S, Bell R, Houwelling TAJ, Taylor S. Closing

26. Krieger N. Theories for social epidemiology in the 21st century:

cessed February 27, 2023. https://www.healthaffairs.org/do/10.

49. Brown AF, Ma GX, Miranda J, et al. Structural interventions

72. Coussons-Read ME. Effects of prenatal stress on pregnancy and

83. Brazil N. The multidimensional clustering of health and its eco-

27, 2023. https://www.aspe.hhs.gov/sites/default/files/2021-

119. Fink DS, Keyes KM, Cerdá M. Social determinants of popu-

physicians. BMC Health Serv Res. 2021;21(1):1122. doi:10.1186/

Funding/Support: This work was supported by the William T. Grant Foundation,

Address correspondence to: Vincent Guilamo-Ramos, School of Nursing, Duke

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