Health Equity Resources

This page provides an introduction to the concepts of health equity, health disparities, and the social determinants of health (SDOH), and contains tools, articles, and guides on implementing health equity initiatives. These resources have been designed and selected to help Community Health Centers and Primary Care Associations pursue health equity and address health disparities by affecting the social determinants of health in their communities. Please contact the CHAMPS Programs Coordinator, Population Health if you have any questions about these materials or would like to share any other useful resources.

For a compilation of educational resources, please visit the CHAMPS Social Determinants of Health Resources webpage.

Please scroll down or use the links below to explore the following topics:


Action Resources for Community Health Centers and Primary Care Associations

Action Resources for Patients and Communities


The Health Equity Institute defines the pursuit of health equity as “efforts to ensure that all people have full and equal access to opportunities that enable them to lead healthy lives.” The World Health Organization (WHO) explains that many groups that experience health inequities – including many poor and marginalized people – lack political, social, or economic power. For this reason, effective and sustainable health interventions must go beyond addressing a particular health inequality and also help to empower the group or groups in question through systemic change.

WHO defines the social determinants of health as “the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels.” The social determinants of health are primarily responsible for health disparities, which WHO defines as “unfair and avoidable differences in health status.”

To learn more about the foundations of health equity, health disparities, and the social determinants of health, please see the resources below.

Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity
The Henry J. Kaiser Family Foundation (2015)
Provides a comprehensive introduction to social determinants of health and various approaches to addressing them at multiple levels.

Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health
World Health Organization (2008)
Final report of WHO’s Commission on social determinants of health.

Defining Health Equity
Health Equity Institute
Video that offers definitions of and approaches to achieving health equity.

Public Health, Environmental and Social Determinants of Health
World Health Organization
A clearinghouse of international news and resources related to addressing the social determinants of health.

Social Determinants of Health
Healthy People 2020
Explains the social determinants of health and how they are integrated into the Healthy People 2020 approach.

Unnatural Causes
National Association of County and City Health Officials
Seven-part documentary series exploring racial and socioeconomic health inequities through individual case studies. Includes a discussion guide and action toolkit.



Accountable Health Communities (AHC) Model Fact Sheet
Centers for Medicare and Medicaid Services (CMS)
Explains the AHC model, including its background, purpose, funding impact, and eligibility requirements.

Adolescent and School Health – Health Disparities
Centers for Disease Control and Prevention (CDC)
Provides data and resources related to health disparities among youth.

Building Clinical Trial and Health Research Access
This white paper presents the findings of studies that examined community health center workers’ feedback on being involved in clinical studies to increase the amount of racially and ethnically diverse populations represented. (2024)

Capturing Social and Behavioral Domains and Measures in Electronic Health Records
Institute of Medicine
Phase 1: (2014)
Phase 2: (2015)
These reports identify social and behavioral domains that are best to be considered in all EHRs, specify criteria for deciding which domains to include, and identify domains that should be included for specific populations.

Children’s HealthWatch Hunger Vital Sign
Feeding America
Two-question screening tool to identify children and households experiencing food insecurity.

Coding Social Determinants of Health for Optimizing Value Infographic
Health Information Technology, Evaluation, and Quality (HITEQ) Center
Infographic for providers explaining how SDOH coding data can be used to benefit not only individual patients but also the broader population being served.

County Health Rankings and Roadmaps
Robert Wood Johnson Foundation
Provides county rankings by state for health factors and outcomes, as well as community health resources by state.

Disparities in Oral Health
Centers for Disease Control and Prevention (CDC)
Provides data and resources related to oral health disparities.

Health Disparities Data Widget
Office of Disease Prevention and Health Promotion
Widget that allows users to view selected health disparities data related to the Healthy People 2020 Objectives for the Leading Health Indicators (LHIs).

Health Disparities in Cancer
National Cancer Institute
Provides data and resources on cancer and cancer screening disparities across population groups.

Health Equity Report 2019-2020
U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA)
Presents a current picture of and progress made to date in addressing health equity issues affecting the nation’s diverse, vulnerable, and socially disadvantaged populations.

Patient Centered Assessment Method (PCAM)
A tool for medical practitioners to use to identify the social determinants of health affecting their patients.

PRAPARE (Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences)
National Association of Community Health Centers (NACHC)
PREPARE is a national effort to help CHCs and other providers collect the data needed to understand and act on their patients’ social determinants of health. Includes an assessment tool, an implementation and action toolkit, webinars, and PowerPoint slides on how to use PREPARE resources like the Electronic Health Record templates, and more.

Social Determinants of Health Maps
Centers for Disease Control and Prevention
Generates U.S. maps illustrating health disparities across counties and states related to poverty, unemployment, high school education, and health insurance coverage.

Veterans Homelessness Screening Tool
U.S. Veterans Administration
Brief screening questionnaire used by VA healthcare professionals to screen for homelessness and housing instability among patients who are veterans.

What are Cancer Disparities?
National Cancer Institute
Infographic illustrating what cancer disparities are, factors that cause them, population-based examples, and how NCI is addressing them.

Youth Screening for Social Determinants of Health
American Academy of Pediatrics
Provides tools for identifying and addressing social determinants of health concerns in children.


Addressing Social Determinants of Health in a Clinic Setting: The WellRx Pilot in Albuquerque, New Mexico
Journal of the American Board of Family Medicine
Janet Page-Reeves, PhD, et al. (2016)
Describes the WellRx pilot program, in which primary care providers identified and addressed nonmedical social needs experiences by patients seen in a clinical setting.

The Adolescent “Expanded Medical Home”: School-Based Health Centers Partner with a Primary Care Clinic to Improve Population Health and Mitigate Social Determinants of Health
Journal of the American Board of Family Medicine
Margaret Riley, MD, Anna R. Laurie, MD, Melissa A. Plegue, MA, and Caroline R. Richardson, MD (2016)
Explores how a partnership between a primary care practice and several school-based health centers impacted rates of compliance among high-risk adolescent patients.

Advancing Equity in Health Systems by Addressing Racial Justice
Stanford Social Innovation Review
Amy Reid, Santiago Nariño, Hema Magge, and Angelina Sassi (2019)
Addresses lessons on racial equity that underscore the need to set explicit aims, build coalitions, and flatten hierarchies in order to strengthen healthcare’s role in undoing systems of oppression.

Building a Foundation to Reduce Health Inequities: Routine Collection of Sociodemographic Data in Primary Care
Journal of the American Board of Family Medicine
Andrew D. Pinto, MD, CCFP, MSc, et al. (2016)
Describes the methods and results of a program at four health organizations in Toronto that utilized a brief survey to gather data on patients’ social determinants of health and add it to their EHRS.

Community Vital Signs: Taking the Pulse of the Community While Caring for Patients
Journal of the American Board of Family Medicine
Lauren S. Hughes, MD, MPH, MSc, Robert L. Phillips Jr., MD, MSPH, Jennifer E. DeVoe, MD, DPhil and Andrew W. Bazemore, MD, MPH (2016)
Explores how aggregated community-level information about the neighborhoods in which patients live, work, learn, and play can be integrated with patient-level data available through EHRs.

Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth
Journal of the American Board of Family Medicine
Katy B. Kozhimannil, PhD, MPA, Carrie A. Vogelsang, MPH, Rachel R. Hardeman, PhD, MPH and Shailendra Prasad, MD, MPH (2016)
Explores how doulas influence pregnancy and birth outcomes for low-income, racially, and ethnically diverse women by addressing health literacy and improving communication among care team members.

Financial Incentives and Vulnerable Populations – Will Alternative Payment Models Help or Hurt?
The New England Journal of Medicine
Karen E. Joynt Maddox, MD, MPH (2018)
Examines the ways that alternative payment models may affect vulnerable populations, including their impact on care coordination, integration, and provider motivation.

A Glossary for Health Inequities
Journal of Epidemiology and Community Health
I Kawachi, S V Subramanian, N Almeida-Filho (2002)
Article addressing eight key questions related to health inequities.

How Can Health Orgs Address the Social Determinants of Health?
Patient Engagement HIT: Patient Care Access News
Sara Heath (2017)
Article describing how healthcare organizations should lean on community health partnerships to address the social determinants of health.

The Impact of Community Engagement on Health, Social, and Utilization Outcomes in Depressed, Impoverished Populations: Secondary Findings from a Randomized Trial
Journal of the American Board of Family Medicine
Christine A. Lam, MD, MBA, et al. (2016)
Explores the processes by which low-income patients with depression engage in their care and the benefits offered by different resource enhancement approaches.

Improving Access and Utilization of Data to Support Research and Programs Intended to Eliminate Disparities and Promote Health Equity
Journal of Health Disparities Research and Practice
Rosaly Correa-de-Araujo (2016)
Discusses barriers to the effective use of population health data to address health disparities, and suggests new resources and strategies for maximizing the integration of data science into health systems.

Integrating Social and Medical Data to Improve Population Health: Opportunities and Barriers
Health Affairs
Laura Gottlieb, Rachel Tobey, Jeremy Cantor, Danielle Hessler, Nancy E. Adler (2016)
Describes the rationale for extracting EHR data on social determinants of health, including the influence of this data on quality improvement initiatives and health care payment reform.

Patient-Provider Communication Disparities by Limited English Proficiency (LEP): Trends for the US Medical Expenditure Panel Survey, 2006-2015
Journal of General Internal Medicine
Terceira A. Berdahl and James B. Kirby (2018)
Reviews the health and care disparities experienced by those with limited English proficiency (LEP) and discusses policy efforts to improve patient-provider communication.

Social Determinants of Health and Primary Care: Intentionality is Key to the Data We Collect and the Interventions We Pursue
Journal of the American Board of Family Medicine
Lauren S. Hughes, MD, MPH, MSc (2016)
Discusses the ways that social determinants of health (SDOH) data collection and analysis may inform patient care, population health, and policy interventions and establishes the foundation for a robust SDOH research agenda in primary care.

The Social Determinants of Health: It’s Time to Consider the Causes of the Causes
Public Health Reports
Paula Braveman, MD, MPH, and Laura Gottlieb, MD, MPH (2014)
Provides a detailed overview of research linking various social determinants of health to health disparities and discusses the challenges of conducting such research and proving causality.


Caring with Compassion Curriculum
University of Michigan Medical School
A training curriculum comprised of online modules, learning games, and implementation resources designed to support health care professionals who care for socioeconomically disadvantaged populations. Introduces the bio-psychosocial model for the provision of personalized care for at-risk patients.

Colorado Equity Action Guide
Colorado Department of Public Health & Environment
Tools that examine root causes of inequity across Colorado through an in-depth review of community characteristics, stories, and data.

Disparities Leadership Program
The Disparities Solutions Center
A year-long, hands-on executive education program designed to help health care leaders translate the latest understanding of health disparities into realistic solutions that can be adopted by their organizations.

Ground Work: Racial Justice and Cultural Humility Training for Health Centers
National Association of Community Health Centers (NACHC)
A training designed to help the health center field level-set on the concepts of racial identity, privilege, bias, and structural and institutional racism. The training provides information and tools for health center staff to engage in health equity and anti-racism work in the community.

Health Equity and Prevention Primer
Prevention Institute
Web-based training series for public health practitioners and advocates interested in achieving health, safety, and health equity through policy advocacy, community change, and multi-sector engagement.

Health Equity Resources
Institute for Healthcare Improvement (IHI)
Tools, videos, publications, and other resources that tie together health equity and quality improvement efforts.

Health Equity Starter Kit
Health Outreach Partners
Contains resources related to health equity, designed to support efforts to better understand health equity as a broader framework to explain and address structural factors, social determinants of health, and health disparities.

Resources for States to Address Health Equity Disparities
National Academy for State Health Policy (NASHP)
Resources showcasing effective state efforts to achieve health equity, improve care, and prioritize the social determinants of health.

Roots of Health Inequity
National Association of County and City Health Officials
Online learning collaborative that introduces participants to social processes that produce health inequities, and then helps them strategize ways to act on the root causes of these inequities.

The SDOH Academy
National Center for Medical-Legal Partnership
A HRSA-funded six-month virtual training series designed to help health centers and primary care associations develop, implement, and sustain social determinants of health interventions in their clinics and communities.

Vibrant and Healthy Kids: Aligning Science, Practice, and POlicy to Advance Health Equity
National Academy of Medicine (NAM)
Report which outlines steps needed to move all children toward positive health paths, reducing health gaps.

Unnatural Causes
National Association of County and City Health Officials
Seven-part documentary series exploring racial and socioeconomic health inequities through individual case studies. Includes a discussion guide and action toolkit.

Visualizing Health Equity: One Size Does Not Fit All Infographic
Robert Wood Johnson Foundation
Infographic demonstrating the need for diverse approaches to health equity.


Accounting for Social Risk Factors in Medicare Payment
The National Academies of Sciences, Engineering, and Medicine
Series of five brief consensus reports exploring ways to identify social risk factors that affect the health outcomes of Medicare beneficiaries and methods to account for these factors in payment programs.

Achieving Health Equity: A Guide for Health Care Organizations
Institute for Healthcare Improvement (IHI) (2016)
Provides guidance on how health care organizations can reduce health disparities related to racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

Building an Inclusive Organization Toolkit
Association of Clinicians for the Underserved (ACU)
This toolkit responds to common questions and needs of health center staff engaged in efforts to build a more inclusive organization.

Community-Driven Health Equity Action Plans
National Academy of Medicine (NAM) (2020)
Model for developing Community-Driven Health Equity Action Plans which was piloted in collaboration with five diverse communities across the U.S. Contains links to each pilot community’s completed plan, as well as lessons learned from the pilot project.

Community Health Centers Leveraging the Social Determinants of Health
Institute for Alternative Futures (2012)
This collaborative project includes a report on patterns of activity, lessons, and recommendations for CHCs to effectively leverage social determinants of health (SDOH); a database of CHC SDOH efforts; and 10 CHC SDOH case studies.

Evidence Library
Social Interventions Research and Evaluation Network
Contains research articles, issue briefs, reports, and commentaries that either focus on or are relevant to evaluating health care-based interventions that address patients’ social and economic needs.

Guidance for Health Care Entities Partnering with Community-Based Organizations
Health Care Payment Learning and Action Network (2023)
Recommendations of health policy and payment mechanisms utilized to address health-related social needs (HRSNs) with a focus on collaboration between community-based
organizations (CBOs) and health care entities involved in alternative payment model (APM) design and delivery. This helps advance health equity through APMs.

Health Leads
HealthLeads USA

Works with healthcare organizations to create sustainable, high-impact and cost-effective social needs interventions that connect patients to community-based resources.

Healthy Places: Designing an Active Colorado
Colorado Health Foundation
This initiative fosters community-led processes that help Colorado communities become healthier places to live, work, and play by increasing physical activity through the construction of safer and more appealing built environments.

Justice, Equity, Diversity, and Inclusion (JEDI): Essential Steps for Health Centers
Association of Clinicians for the Underserved (ACU)
List of essential practices for health centers to incorporate JEDI principles to actively address and understand the intersections with broader structural and systemic racism in policies and procedures and address interpersonal institutional racism.

Leading State Approaches and Communication Strategies to Support Health Equity
National Governors Association (NGA) (2023)
This brief includes the best strategies and practices states and territories are using to communicate and address health equity.

Linking Clinical Care with Community Supports (Linkages) Program
Michigan Primary Care Association, Michigan Health Endowment Fund
This project hires, trains, and integrates Community Health Workers (CHWs) into primary care teams in 16 health centers throughout Michigan. THE CHWs directly support patients by sharing of information and resources for accessing food, housing, social services, and counseling; monitoring patients’ health; and helping increase accountability through individualized patient care plans. This page includes more information about the program as well as a toolkit for CHWs.

Opportunities to Enhance Community-Based Medication Management Strategies for People with Complex Health and Social Needs
Center for Health Care Strategies, Inc.
Explores promising practices for medication management to optimize care and outcomes for high-need complex patients.

Prioritizing Social Determinants of Health in Medicaid ACO Programs
Center for Health Care Strategies, Inc.
Interview discussing Minnesota and Rhode Island’s approaches to using Medicaid accountable care organizations (ACOs) to address social determinants of health as a means of both improving health outcomes and lowering healthcare costs.

Rural Innovation Profile: Medical-Legal Partnership Addresses Social Determinants of Health
FirstHealth of the Carolinas
This nonprofit health care network integrated a medical-legal partnership, as one of the clinical and community support services, into its chronic care management for low-income chronically-ill patients to reduce the non-medical factors that affect their health outcomes.

Screening for Social Determinants of Health in Populations with Complex Needs: Implementation Considerations
Center for Health Care Strategies, Inc.
Examines how several organizations are assessing and addressing social determinants of health for populations with complex needs, and provides assessment tools created by these organizations to better capture patients’ social needs and barriers to care.


Advancing Health Equity: A Critical Thinking Tool for Organizations, Programs, and Individuals Committed to Equity
Colorado School of Public Health
Flexible online tool that walks users through eight topics of public health processes, each including questions that motivate teams to enhance collaboration and consider how to improve health equity and reduce health disparities via community programs, projects, or policies.

Checking Assumptions to Advance Equity
Office of Health Equity, Colorado Department of Public Health and Environment
Series of questions and additional resources designed to help government, non-profit, and community-based organizations review how an action or decision might impact the health of groups that are most likely to suffer preventable adverse consequences.

Communities in Action: Pathways to Health Equity
The National Academies of Sciences, Engineering, and Medicine (2017)
Describes origins of and solutions to health inequities in the U.S., with an emphasis on how communities can promote health equity by addressing root causes and structural barriers. Available as a free PDF download or for purchase as a physical or electronic book.

Creating the Healthiest Nation: Health and Housing Equity
American Public Health Association (APHA) (2020)
Report that examines how structural racism and discriminatory policies led to housing and health inequality in America for low-income communities and people of color. To equip public health professionals with the tools to address these inequities in their communities, the report outlines numerous ways to advance equitable change in housing equity through policy and advocacy, cross-sector partnerships, and community engagement and education.

Engaging Allies in the Culture of Health Movement: Information from Stakeholder Meeting #4 (Role of Anchor Institutions)
National Academy of Medicine (NAM)
Includes key takeaways and session readings and resources from stakeholder meeting event.

Health Impact Assessment
World Health Organization
Tool for assessing the health impacts of policies, plans, and projects in diverse economic sectors using quantitative, qualitative, and participatory techniques.

Health In All Policies: A Guide for State and Local Governments
American Public Health Association, Public Health Institute, California Department of Public Health (2013)
Provides information on using collaborative approaches to improve population health by embedding health considerations into decision-making processes across a broad range of sectors.

A Practitioner’s Guide for Advancing Health Equity: Community Strategies for Preventing Chronic Disease
Centers for Disease Control and Prevention (2013)
Guide designed to assist public health practitioners in local, state, and tribal organizations promote health equity through policy, systems, and environmental improvement strategies, including best practices for strategic organizational capacity building, community engagement, and partnership development.

Purpose in Practice Podcast
Association of Clinicians for the Underserved (ACU)
A podcast that features interviews from health care providers and experts to discuss ways to advance health equity and improve the quality of healthcare for underserved communities.

Rhode Island’s Health Equity Zones: Addressing Local Problems with Local Solutions
Journal of Health Disparities Research and Practice
Nicole Alexander-Scott et al. (2015)
Describes the strategies and infrastructure developed by the Rhode Island Department of Health to coordinate place-based, community-led initiatives that address the social determinants of health.

A Road Map to Address the Social Determinants of Health Through Community Collaboration
American Academy of Pediatrics
Offers a step-by-step method for developing collaborations between primary care facilities and community organizations to address social determinants for children and families.

Solving the Medication Complexity Conundrum through Community-Based Solutions
Center for Health Care Strategies, Inc.
Report discussing opportunities to enhance medication management at the community level.

Unnatural Causes
National Association of County and City Health Officials
Seven-part documentary series exploring racial and socioeconomic health inequities through individual case studies. Includes a discussion guide and action toolkit.

Visit the CHAMPS Offsetting Patient Costs webpage to access resources on making healthcare costs more affordable for low-income patients.