Solving for Gaps in Health Equity

By: Unite Us

The recognition that community conditions and social needs significantly influence health
outcomes is not new. The pandemic has underscored this point and highlighted the known
health disparities and structural inequities existing between communities.

Effectively addressing social determinants of health (SDoH) requires dynamic sets of data
providing insight into local community needs and opportunities. We must address SDoH by
gaining a deeper understanding of individuals’ lived experiences and health outcomes—not by
disassociating them from the systems in which they exist, but by contextualizing them within the
inequities those systems create. At Unite Us, we’ve identified five principles for advancing
health equity through the use of SDoH data.

Five Principles for Using SDoH Data to Improve Health Equity

1. Ensure communities and individuals most impacted have power to make decisions.

CBOs can gain agency through shared decision making driven by the data they produce. This is
an important strategy for dismantling structural and institutional barriers to health equity and
unifying how we reach community investment decisions.

2. Leverage the power of referral data to improve access to social care.

We need to be clear on what we should measure, how often, and why. Data collection practices,
such as client interview questions, should be person centered and avoid asking clients to retell
traumatic stories across different providers. Data analysis should account for biases that lead to
inaccuracies, uninformed conclusions, or exacerbated disparities. It’s critical that outcomes data
indicate whether organizations connect a client to services and address their social needs.
Without it, their story is not complete.

3. Measure and evaluate data.

Health-equity-oriented evaluations should be designed to understand what works, for whom,
and under what conditions. They should reveal whether health inequities have changed over
time. Achieving this level of understanding can be challenging. A good first step is incorporating
health equity activities, goals, and expected outcomes into a program or intiative’s conceptual
framework or logic model to clarify the intended effects of the initiative or program on health
equity outcomes.

4. Remove barriers to data sharing.

Appropriately addressing SDoH requires removing barriers to data sharing across the systems
individuals interact with regularly. The health, social needs, and situations of clients served by
healthcare and community organizations continuously change. As clients move across sectors
and through referral pathways, their changing situations must accurately reflect wherever and
whenever an individual accesses social care. They should receive person-centered and
trauma-informed care, eliminating the need to recount traumatic experiences each time they
access services.

5. Use data to drive action.

The complexity and persistence of health disparities requires an approach grounded in public
and political will for change combined with cross-system collaboration. Across sectors,
stakeholders should consider how enhanced technology and data infrastructure can help
advance health-related policies. Doing so, stakeholders can prioritize meeting community
members’ social needs and developing policies that redistribute resources equitably to prevent
those needs from occurring at all.

At Unite Us, we believe evaluating social care data at scale meaningfully contributes to health
equity, and analyzing the relationship between health and social care data leads to valuable
insights about how to improve overall health. For a deeper discussion on bridging gaps in health
equity, download this white paper to learn more