When Do We Know Enough to Recommend Action on the Social Determinants of Health? Paula A. Braveman, MD, MPH, Susan A. Egerter, PhD, Steven H. Woolf, MD, MPH, James S. Marks, MD, MPH Abstract: The Robert Wood Johnson Foundation Commission to Build a Healthier America was charged to identify strategies beyond medical care to address health disparities in the U.S. related to social and economic disadvantage. Based on insights gained while providing scientifıc support for the commis- sion’s efforts, this paper presents an overview of major issues that arise when assessing evidence to inform policies and programs to address the social determinants of health. While many of the insights are not new, they have not been widely assimilated within medicine and public health. They have particular relevance now, given growing awareness of the important health influences of social factors. The discus- sion presented here is intended to highlight key considerations for researchers who study social determi- nants of health and policymakers whose decisions are shaped by research fındings. Policies should be based on the best available knowledge, derived from diverse sources and methods. An array of tools and guidelines is now available to guide the assessment of evidence on the social determinants of health, building on—and going beyond—principles fırst articulated in the “Evidence- Based Medicine” movement. The central thesis of the current paper is that the standards for evidence to guide social policies must be equally rigorous but also more comprehensive than those traditionally used to inform clinical interventions, because social policies must deal with upstream factors that affect health through complex causal pathways over potentially long time periods. (Am J Prev Med 2011;40(1S1):S58 –S66) © 2011 American Journal of Preventive Medicine Introduction T his paper critically examines several challenging methodologic issues that arose in the context of providing scientifıc support to the Robert Wood Johnson Foundation’s Commission to Build a Healthier America (the commission). Other papers in this supple- ment to the American Journal of Preventive Medicine describe the commission and its charge, 1 the rationale and conceptual framework for its efforts, 2 and its fındings and recommendations. 3–5 Stated briefly, the commis- sion’s primary focus was on the social factors that funda- mentally shape health; its charge was to identify and recommend policies beyond the realm of clinical medi- cine that would improve health for all Americans while narrowing health disparities among socioeconomic and racial or ethnic groups. A multidisciplinary research group (based at the University of California, San Fran- cisco with collaborators at George Washington, Harvard, and Virginia Commonwealth Universities, and at the University of Texas, University of Michigan, and two independent research consulting organizations) pro- vided scientifıc support to the commission. (The reports and issue briefs produced to inform the commission ef- fort are available at www.commissiononhealth.org/ Publications.aspx.) In its work to synthesize existing knowledge about both the social factors influencing health and health dis- parities, and potential interventions, the research group faced a variety of analytic challenges. For example, the criteria for evidence to be used in this effort clearly needed to extend beyond the prevailing hierarchy of evi- dence, with its “gold standard” of RCTs for studies to inform medical practices. In this paper, a summary is presented of the development of our thinking about ap- propriate criteria for evaluating evidence on health effects of social policies. The goal is to affırm the scientifıc prin- ciples of the “evidence-based medicine” (EBM) move- ment, while at the same time recognizing the limitations of its hierarchy of evidence, particularly when applied outside selected categories of clinical interventions. Many of the insights included here have been noted in the literature, but have not been adequately promulgated From the Department of Family and Community Medicine, University of California San Francisco (Braveman, Egerter), San Francisco, California; the Department of Family Medicine, Virginia Commonwealth University (Woolf), Richmond, Virginia; and the Robert Wood Johnson Foundation (Marks), Princeton, New Jersey Address correspondence to: Paula A. Braveman, MD, MPH, Center on Social Disparities in Health, Department of Family and Community Med- icine, University of California San Francisco, Box 0943, 3333 California Street, Suite 365, San Francisco CA 94118-0943. E-mail: braveman@fcm. ucsf.edu. 0749-3797/$17.00 doi: 10.1016/j.amepre.2010.09.026 S58 Am J Prev Med 2011;40(1S1):S58 –S66 © 2011 American Journal of Preventive Medicine • Published by Elsevier Inc.