Social Determinants of Health (SDoH) are social and environmental factors that contribute toward overall health and quality of life. They are typically divided into five areas: 

  • Healthcare Access and Quality
  • Education Access and Quality
  • Social and Community Context
  • Economic Stability
  • Neighborhood Environment

In a meta-analysis of nearly 50 studies, researchers at the Kaiser Family Foundation found that disparities in SDoH factors accounted for over a third of total deaths in the United States in a year. [1] Furthermore, health inequities and disparities have resulted in excess medical costs amounting to approximately $93 billion. [2,3]

Identifying and understanding high-risk populations can greatly impact the public health, medical, and community initiatives in place to improve life outcomes and reduce healthcare-associated costs.  

So, what are high-risk populations and how can we identify them? 

High-risk populations are defined as vulnerable groups that are most at risk of outcome disparities because of barriers to resources in the five areas listed above. Increasing the quality and use of data collection on SDoH factors is essential in identifying which populations are at high-risk and developing informed interventions to target each disparity. 

For example, a public health initiative to educate the public on reducing infant sudden death syndrome was initially seen as highly successful. However, when analyzed, it was found that the effort was far less effective among Black mothers because the messaging was not written in a way that resonated with them. [4] 

If SDoH factors had been considered, the campaign could have been tailored to each of the various groups that are at high-risk for experiencing sudden infant death syndrome. By measuring and analyzing data on SDoH, organizations can begin uncovering and addressing disparities impacting their patient or client population.  

It has become increasingly clear that we need to look at the whole picture when it comes to identifying and addressing high-risk populations. Identifying high-risk populations using SDoH data, and incorporating that data into hospitals and community programs, can provide better life outcomes for all individuals while also reducing costs associated with social risk factors.  


[1] [2]