Social Determinants of Health 101 for Health Care: Five Plus Five - National Academy of Medicine (2022)

By Sanne Magnan

October 9, 2017 | Discussion Paper

Social Determinants of Health 101 for Health Care: Five Plus Five - National Academy of Medicine (1)

Introduction

Social determinants of health (SDoH) is a relatively new term in health care. As defined by the World Health Organization (WHO), SDoH are “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” [1]. The social determinants of health also determine access and quality of medical care—sometimes referred to as medical social determinants of health (see Figure 1 for the County Health Rankings model of factors shaping health). Future opportunities may exist in genetics and biological determinants; however, whether modifying these will be as feasible as modifying the social determinants of health is unknown.

Although the SDoH easily resonate for clinicians, given their intuitive recognition that health outcomes are affected by patients’ conditions outside the clinical walls, clinicians may raise several concerns about involvement in the SDoH. First, they realize that this is not their domain of expertise or current accountability. Second, some are worried that health care systems already have enough to address and should not play a role in efforts to mitigate or improve the SDoH. Third, they express concern about the limited evidence of effectiveness of interventions by health care on the SDoH [2]. There is a viewpoint, however, for health care to find its role in population health [3], and some providers believe there is enough science to support integration of SDoH into health care and are pursuing evidence-informed interventions with community partners [4,5].

Lest we think SDoH are the next panacea in health care, let us consider what we know and what we need to learn about SDoH to achieve the national quality strategy of better care, healthy people/healthy communities, and affordable care [6].

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Five Things We Know About (Social) Determinants of Health in Health Care

1. As a determinant of health, medical care is insufficient for ensuring better health outcomes.

Medical care is estimated to account for only 10-20 percent of the modifiable contributors to healthy outcomes for a population [7]. The other 80 to 90 percent are sometimes broadly called the SDoH: health-related behaviors, socioeconomic factors, and environmental factors. Although we as a country spend a higher percentage of our gross domestic product on medical care expenditures than other developed countries, it is more difficult to compare spending on the SDoH. We do know that many developed countries proportionately spend more on social services than the United States [8]. Although social services do not correspond directly to the SDoH, this comparison gives one view of proportional expenditures in our country.

Corollary: Despite our significant spending, our outcomes are among the lowest for developed countries, including significant inequities [9]. For health care, the hope is that addressing the more upstream social determinants will improve health outcomes, reduce inequities, and lower costs. What can we learn from other nations’ medical and nonmedical system efforts that are achieving better health outcomes?

Figure 1 | County Health Rankings & Roadmaps | Source: Reprinted with permission from County Health Rankings & Roadmaps, http://www.countyhealthrankings.org/our-approach (accessed July 18, 2017).

2. SDoH Are Influenced by Policies and Programs, and Associated with Better Health Outcomes.

SDoH are greatly influenced by policies, systems, and environments (PSE). A diagram used by County Based Health Rankings and Roadmaps (Figure 1) shows the interaction between health outcomes, the SDoH, and policies and programs. For example, tobacco is a leading determinant of many health outcomes (e.g., mortality, quality of life), and decreasing tobacco use is more influenced by the price of cigarettes and smoke-free environments in the community than by the availability of cessation clinics or quitlines.

Corollary: Community partnerships that synergize medical interventions and PSE changes produce a more comprehensive approach to behavior change. For example, walking prescriptions for patients can be complemented by community changes to increase availability of safe walking spaces. Such partnerships can also allay providers’ concerns about being held responsible for problems outside their clinical domain, and the partnerships can bring expertise, allies, and resources to address complex issues such as tobacco use, physical activity, alcohol use, housing, and so on.

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3. New Payment Models Are Prompting Interest in the SDoH.

New value-based payment models such as alternative payment models, accountable care models such as accountable care organizations (ACOs) and patient-centered medical homes, and Medicare Shared Savings are moving toward payment for outcomes rather than process measures, as well as benchmarks for “total cost of care.” Since better results on the SDoH are associated with better health outcomes, will payment models evolve to jointly reward health care organizations and communities for outcomes such as lower tobacco, obesity and/or diabetes prevalence, or improved high school graduation rates?

Corollary: The Population-based Payment Model Workgroup of the Health Care Learning and Action Network (LAN) recently recommended that “Big(ger) Dot” measures increasingly be used in new payment models. For example, measures of cardiac care are ideally outcome measures (e.g., 30-day mortality, health-related quality of life or well-being), not individual process measures (e.g., aspirin at arrival (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/downloads/HospitalOverviewOfSpecs200512.pdf)) [10]. However, process measures continue to be important for quality improvement and for some payment programs. New summary measures for population health and well-being for use by health plans and accountable care organizations have been proposed [11,12], and frameworks for rewarding health outcomes are being developed.

4. Frameworks for Integrating SDoH Are Emerging.

Data frameworks have been proposed for integrating SDoH into primary care and capturing SDoH domains in electronic health records (EHRs). One framework includes community-driven and individual data for use in primary care, recognizing that there are still questions about the effect on outcomes [13]. The framework, however, does not include how the data might be used with community partnerships to expand the effect of collecting the data.

Screening tools have been developed, e.g., for an accountable health community initiative [14], and one for a pediatric emergency department with a low-income population [15]. Models are emerging for how to follow up screening data, e.g., “clinic-to-community treatment models” for children living in food-insecure households [16].

For the EHR, the Institute of Medicine (IOM) has recommended that social and behavioral health domains be captured [17]. The incentive, training, and privacy barriers for feasibility of incorporating SDoH into EHRs have been discussed [18]. Interestingly, electronic screening produced higher rates of self-disclosure of some sensitive determinants (violence and substance abuse) than in-person screening [15]. Most recently, the feasibility, reliability, and validity of the IOM-recommended domains (except for income) were evaluated, and clinical trials were recommended [19, 20].

Corollary: Integrating the SDoH into health care should not fall primarily on primary care clinicians. Although front-line clinicians can see patterns of key determinants for populations, leadership within health care organizations must advance this work by alignment with strategic directions, board support for community partnerships, adopting a culture that values the SDoH in addition to quality and affordable health care, measurement/evaluation, role clarification, creation of new skill sets, and realignment of resources [21], i.e., building a system approach to integration. These leadership actions allow front-line clinicians to be natural champions for the SDoH within the organization and the community without being responsible for all the necessary components of a systems approach.

5. Experiments Are Occurring at the Local and Federal Level.

State innovation models are exploring connections among health care, social services, and some SDoH [22]. ACOs are responding to nonmedical needs of patients such as transportation, housing, and food with the assumption that outcomes and cost will improve [4]. One randomized pediatric intervention of in-person navigation services in two safety-net hospitals to address families’ social needs demonstrated a decrease in the families’ report of social needs and better reported children’s overall health status [23], and the authors recommend more experiments to determine investments in interventions. The Centers for Medicare & Medicaid Services (CMS) launched accountable health communities (ACH)—the first innovation-center model to test matching the needs of a population (i.e., CMS beneficiaries) with community resources [24,25]. With a robust evaluation plan, the five-year ACH model tests two tracks: assistance track – provide community service navigation assistance, and alignment track – encourage partner alignment to ensure services are available and responsive. These experiments will provide more evidence about effectiveness in achieving better outcomes, better experience, and lower costs.

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Five Things We Need to Learn about Social Determinants of Health in Health Care

1. How do we prioritize SDoH for individual patients and for communities?

Prioritization requires an assessment of readiness to address proven or testable interventions, and return on investment. Which patients will benefit the most from addressing their SDoH, and which SDoH? Which patients are most ready for these interventions? Which interventions will decrease per capita spending? From a community perspective, which SDoH are of most concern to community stakeholders, and which SDoH will have the greatest effect on total population health and well-being, health equity, and health care expenditures?

2. How do we intervene without medicalizing SDoH?

There is a danger that a medical approach to these nonmedical factors will lead to more health care versus more cost-effective and community-based interventions. For example, a social worker sees a patient with schizophrenia once a week in northern Minnesota, but she says, “What this patient needs is a friend.” How do we avoid “re-creating the wheel” inside health care and increasing costs? How do we listen to communities, identify and delineate health care’s role, and collaborate appropriately with existing community resources and increase capacity? As health care professionals, we need huge doses of humility and openness to authentically address SDoH and form or join community partnerships. A recent infographic illustrates an emerging path for community collaboration—from the “aha moments” to feedback and course correction to new dialogue with the community [34].

Corollary: We often speak of the SDoH, but what are the “social determinants of well-being”? Well-being is “the sense of life satisfaction of the individual” as introduced by Evans and Stoddart in their classic paper on the determinants of health, in which they postulate that well-being is the ultimate objective of health policy [35]. Advancing “social determinants of well-being” versus health does not have the automatic association with hospitals, clinics, visits, tests, procedures, and medication that the term health has. This concept is promoted by Kottke, Stiefel, and Pronk who suggest we engage others and avoid medicalizing by focusing on “well-being in all policies” rather than health in all policies [36,37].

3. What (new) data are needed?

A third question is what SDoH data should be collected—for what purpose, and by whom? Recently, HealthDoers, a Robert Wood Johnson Foundation–funded network with the Network for Regional Healthcare Improvement, held a Peer-to-Peer (P2P) event focused on the intersection of clinical, multisector, and SDoH data. Nial Brennan, former Chief Data Officer at CMS, asked how SDoH data fared on four key questions he says he always asks about collecting new data [27]:

  1. “How much will it cost to collect? Is the juice worth the squeeze?
  2. “How good [are] the data? Is it standardized?
  3. “How comprehensive [are] the data? Are we getting it for 5%, 10%, 50%, 100%of people?
  4. “What level of granularity does the data need to be at?”

These questions lead us back to issues of prioritization, the opportunity index, and effective interventions.

With so many unknowns about the use of SDoH in clinical care, having data for measurement and evaluation of interventions is essential. Monitoring for unintended consequences of well-designed and/or well-intentioned programs and policies is important, especially to ensure that disparities do not worsen.

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4. How do we build multisector partnerships?

What partnerships should be built to address the SDoH for individuals and for communities? What sectors need to be involved to achieve the desired outcomes? What are the roles of people and organizations in these different partnerships? Building these multisector partnerships requires trust for not only sharing data but also for sharing resources and money. What factors are most important for building trust between health care organizations and community partners, where there is often a power differential? A recent workshop from the National Academies of Sciences, Engineering, and Medicine (NASEM) explores the infrastructure of successful multisector partnerships, including examples of health sector and community collaboration [38]. For example, a leader from Bellin Health identified five “domains of transformation”: (1) understand the system, (2) social change, (3) critical conversations, (4) co-creation, and (5) spread and scale.

Corollary: What level of integration (e.g., in continuity of care, responsibility for quality and costs for a population, hospital affiliation, etc.) between health care organizations and service organizations is needed or not needed to successfully address SDoH with community partners? Does it depend on the SDoH being addressed? Fraze and colleagues [4] describe a typology of ACOs regarding the integration of patients’ non-medical needs with medical care—from noncoordinated to fully integrated—with most ACOs being in the noncoordinated quadrant (“neither services nor organizations were integrated”). More importantly, what specific system components (e.g., global budgets, board leadership, quality improvement culture, data systems, care managers or community health workers, experience with community partnerships) are needed to create effective interventions?

5. What else?

The last question is “What else?” For example, discussions about population health and its measurement often center on the leading causes of death and not well-being or the “leading causes of life,” such as purpose, connection, agency, blessing, and hope [39]. In addition, health care mental models are frequently built from a deficit perspective—addressing what is wrong with an individual and/or a community. How do we focus on assets, starting with what is right with patients, families, and/or communities so we can build on strengths? Building on strengths and working with multisector collaborations are two ways to minimize any unintended consequences of screening for the SDoH in clinical settings [40].

Conclusion

This paper articulates five things we know and five things health care organizations need to learn to address SDoH for the national quality strategy [6]. Critics are right to question how we address yet another issue in health care. However, organizations can define (and circumscribe) their roles [41], and join or form new community partnerships to prioritize, develop, and implement proven and/or testable interventions. With the failure of our current health care system to deliver better health and well-being at an affordable cost, exploring opportunities in the other determinants of health seems wise, if not imperative.

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FAQs

What are social determinants of health care? ›

Social determinants of health (SDOH) are conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes.

What are the 5 social determinants of health quizlet? ›

Social determinants of health such as poverty, unequal access to health care, lack of education, stigma, and racism are underlying, contributing factors of health inequities. The Centers for Disease Control and Prevention (CDC) is committed to achieving improvements in people's lives by reducing health inequities.

What is a social determinant of health example? ›

This includes topics like quality of housing, access to transportation, availability of healthy foods, air and water quality, and neighborhood crime and violence. The World Health Organization also provides a definition of social determinants of health.

What are determinants of health PDF? ›

Determinants of health: Nutrition, lifestyle, environment, and genetics are considered as core determinants and four pillars of health. When any one or more of these is compromised, health is at risk and medical care is required as a support system.

What are the 11 determinants of health? ›

Determinants Of Health
  • Income and social status.
  • Social support networks.
  • Education and literacy.
  • Employment/working conditions.
  • Social environments.
  • Physical environments.
  • Personal health practices and coping skills.
  • Healthy child development.

What are social determinants of health PPT? ›

Determinants of Health Definition Conditions in the social, physical and economic environment in which people are born, live, work and age, including the access to the health care.

What is the most important social determinant of health? ›

Income is perhaps the most important social determinant of health. Level of income shapes overall living conditions, affects psychological functioning and influences health-related behaviours such as quality of diet, extent of physical activity, smoking and excessive alcohol use.

Why is social determinants of health important? ›

Social determinants have a major impact on health outcomes – especially for the most vulnerable populations. Factors such as education, income level, and environment must be considered when providing treatment to achieve better health outcomes in these populations.

What are social determinants of health and why are they important? ›

Social determinants have a major impact on health outcomes—especially for the most vulnerable populations. Factors such as a patient's education, income level and environment must be considered when providing treatment and care.

Who created social determinants of health? ›

In 2003, the World Health Organization (WHO) Europe suggested that the social determinants of health included: the social gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transportation.

What are social determinants of health quizlet? ›

"Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

Which of the following is an example of a social determinant of health quizlet? ›

Some examples of social determinants include: SES, work and unemployment, social exclusion, stress, food security, early life experiences and access to health care/services.

What are the 3 social determinants of health quizlet? ›

  • income.
  • occupation.
  • education status.

How much of health is determined by social determinants? ›

the U.S. Studies estimate that clinical care impacts only 20 percent of county-level variation in health outcomes, while social determinants of health (SDOH) affect as much as 50 percent.

Is mental illness a social determinant of health? ›

Although less frequently discussed than the converse pathway, mental illness can also impact social determinants, including homelessness, school dropout, marital instability, and economic insecurity [52–54].

How do doctors address the social determinants of health? ›

KEY TAKEAWAYS

Healthcare providers can address social determinants of health through five approaches—awareness, adjustment, assistance, alignment, and advocacy, according to a report from the National Academies of Sciences, Engineering, and Medicine.

What are the 3 main factors that affect your health? ›

The determinants of health include: the social and economic environment, the physical environment, and. the person's individual characteristics and behaviours.

Is stress a social determinant? ›

Stress is an important pathway through which the social and physical environments affect health. Stress can directly affect biological processes integral to the development of disease and drive the use of maladaptive health behaviors that can put individuals at risk for poor health outcomes.

How is lifestyle a determinant of health? ›

Thus, individual lifestyle determinants have a strong effect on a person's well-being. Determinants such as unbalanced diet, a lack of physical activity and substance abuse can be linked to a number of major health problems (European Commission 2007).

What are the 9 social determinants of health? ›

Social determinants of health are the conditions in which people are born, grow, live, work and age. They include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care (Figure 1).

What are 10 factors that affect health status? ›

  • Ten Factors that. Affect. Your Health Status.
  • Heredity.
  • Quality of the Environment.
  • Random Events.
  • Health Care.
  • Behaviors You Choose.
  • Quality of your Relationships.
  • Decisions You Make.

What is the single most important determinant of health? ›

Income and Social Status

These two factors may be the most important determinants of health. The greater the gap between the richest and the poorest people in an area, the greater the disparities in their health.

How does social factors affect health? ›

In addition to genetics and lifestyle choices, many social factors interact to determine the health of an individual and community. Together, social factors that influence our health (income, education, social connections, and housing) account for up to 40% of what keeps us healthy.

What are environmental determinants of health? ›

Social and environmental determinants of health are the full set of social and physical conditions in which people live and work, including socioeconomic, demographic, environmental and cultural factors, along with the health system.

What are the 6 factors that influence your health? ›

There are many different factors that can affect your health. These include things like housing, financial security, community safety, employment, education and the environment. These are known as the wider determinants of health.

What are examples of social factors? ›

Socially factors are things that affect someone's lifestyle. These could include wealth, religion, buying habits, education level, family size and structure and population density.

What are four important influences on your health? ›

Our health is largely determined by the social, economic, cultural, and physical environments we live in — everything from where we work and live to our level of education and our access to healthy food and water.

How can we prevent social determinants of health? ›

Healthcare experts are turning to housing security, food access, and transportation interventions to address social determinants of health.
  1. Working to address food security.
  2. Creating affordable housing.
  3. Driving care access through medical transportation.
26 Feb 2019

What is the difference between determinants of health and social determinants of health? ›

Social determinants of health refer to a specific group of social and economic factors within the broader determinants of health. These relate to an individual's place in society, such as income, education or employment.

How do determinants of health impact health? ›

Determinants of health are factors that influence how likely we are to stay healthy or to become ill or injured. This chapter examines three key determinants of health: social determinants, biomedical risk factors and behavioural risk factors.

Why are social determinants of health important to nurses? ›

The ability to assess a patient's social determinants of health is one of the best ways to predict the chance of developing conditions like asthma, COPD, and diabetes, as well as determine the risk of heart attack, stroke, and cancer.

Is poverty a social determinant of health? ›

No matter where you reside, your socioeconomic status likely plays a major role in regards to your overall health, and that of your family. Factors such as food insecurity, suboptimal housing, and a lack of access to healthcare can reduce both your lifespan and quality of life.

What are the 5 socioeconomic factors? ›

Social and economic factors, such as income, education, employment, community safety, and social supports can significantly affect how well and how long we live.

What is the social model of health? ›

The social model of health examines all the factors which contribute to health such as social, cultural, political and the environment. An example is poor housing: see diagram It is well documented that both stress and low self esteem can have a negative impact on health.

What is considered to be the most important determinant of health quizlet? ›

'Income and social status' is the single most important determinant of health. People with higher incomes generally live longer, healthier lives than people with lower incomes. Health status improves at each step up the income and social hierarchy.

What are the primary determinants of health quizlet? ›

Determinants can be classified in many ways such as biological, behavioural, physical environment and social. Factors relating to the body that impact on health. Examples include genetics, hormones, body weight, blood pressure, cholesterol levels, birth weight etc...

What are the principle determinants of health quizlet? ›

Determinants of health can be classified in many ways such as physical environment, biological, behavioural, and social.

What is an example of individual lifestyle factors as determinants of health quizlet? ›

An individual's lifestyle or behavior includes diet, exercise, sexual activity, and stressful jobs, which are types of determinants of health.

What are health disparities? ›

Health disparities are preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.

Which topic is a key issue in economic stability as a social determinant of health quizlet? ›

Food security is a key issue in economic stability as a social determinant of health.

Why are the social determinants of health considered to be so important quizlet? ›

Social determinants are in part responsible for the unequal and avoidable differences in health status within and between communities. The selection of Social Determinants as a Leading Health Topic recognizes the critical role of home, school, workplace, neighborhood, and community in improving health.

What are three determinants of public health quizlet? ›

Range of economic, social, and environmental factors that influence health status.

What is the best source of information for the nurse who wants to find data on population size? ›

Census documents are the best source of information for the nurse who wants to find data on population size. The local health department provides information on water, sewage, housing, and other environmental factors may influence health.

What is the most important social determinant of health? ›

Income is perhaps the most important social determinant of health. Level of income shapes overall living conditions, affects psychological functioning and influences health-related behaviours such as quality of diet, extent of physical activity, smoking and excessive alcohol use.

What are the 6 social factors? ›

Some of the most important factors of social change are as under:
  • Physical Environment:
  • Demographic (biological) Factor:
  • Cultural Factor:
  • Ideational Factor:
  • Economic Factor:
  • Political Factor:

What are the 6 factors that influence your health? ›

There are many different factors that can affect your health. These include things like housing, financial security, community safety, employment, education and the environment. These are known as the wider determinants of health.

What are social determinants of health and why are they important? ›

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

What is the single most important determinant of health? ›

Income and Social Status

These two factors may be the most important determinants of health. The greater the gap between the richest and the poorest people in an area, the greater the disparities in their health.

What are the 3 main factors that affect your health? ›

The determinants of health include: the social and economic environment, the physical environment, and. the person's individual characteristics and behaviours.

Is mental illness a social determinant of health? ›

Although less frequently discussed than the converse pathway, mental illness can also impact social determinants, including homelessness, school dropout, marital instability, and economic insecurity [52–54].

What are the 5 types of social change? ›

Type of Social Change:
  • (1) Evolutionary Social Changes: ...
  • (2) Revolutionary Changes: ...
  • (i) Social Movement and Social Revolution: ...
  • (ii) Common Motivation: ...
  • (iii) Common Need: ...
  • (iv) Long Standing Suffering due to Suppression and Oppression: ...
  • (v) Impact of Communication: ...
  • (vi) Education:

What are the 5 environmental factors? ›

Air, water, climate, soil, natural vegetation and landforms are all environmental factors. By definition, the environmental factors affect everyday living, and play a key role in bringing health differences across the geographic areas.

What are the four key sources of social? ›

Major sources of social change include population growth and composition, culture and technology, the natural environment, and social conflict.

What are the 9 Social determinants of health? ›

Social determinants of health are the conditions in which people are born, grow, live, work and age. They include factors like socioeconomic status, education, neighborhood and physical environment, employment, and social support networks, as well as access to health care (Figure 1).

What are the 10 factors that affect health status? ›

  • Ten Factors that. Affect. Your Health Status.
  • Heredity.
  • Quality of the Environment.
  • Random Events.
  • Health Care.
  • Behaviors You Choose.
  • Quality of your Relationships.
  • Decisions You Make.

What are the 4 major factors affecting community health? ›

The four factors are physical factors, social and cultural factors, community organizing, and individual behaviors.

What is the impact of social determinants of health? ›

Negative social determinants of health can impact both an individual's knowledge about healthcare and resources, and limit access to them. A growing body of research indicated: Children born to parents who haven't completed high school are more likely to live in environments that contain barriers to health.

What are social determinants of health PPT? ›

Determinants of Health Definition Conditions in the social, physical and economic environment in which people are born, live, work and age, including the access to the health care.

When did social determinants of health begin? ›

The groundwork for how we approach SDOH today can be traced to the early 19th century as a response to the Industrial Revolution when society saw significant increases in disease and poverty.

Videos

1. From Public Health Genomics to Precision Public Health, A 20-Year Journey
(UNC Eshelman School of Pharmacy)
2. Immigration Policy and Social Determinants of Health
(LLUH IHPL)
3. Collecting Data on Patient Social Determinants of Health and Interventions that Address Them
(SDOH Academy Resources)
4. Healthy Society Series: Health Equity 101. Transforming the Health of our Nation
(Commonwealth Club of California)
5. Emerging Evidence on Social and Behavioral Factors in Health Outcomes
(Teachers College, Columbia University)
6. 15th NIH Matilda White Riley Behavioral and Social Sciences Honors: 2022
(Office of Behavioral and Social Sciences Research)

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