Social determinants of health are the social, economic, and environmental factors that contribute to a person’s health and well-being.
These factors include access to quality education, employment, safe housing, healthy food, transportation, and healthcare services. In clinical settings, social determinants of health and health-related social needs are often used interchangeably for individual adverse conditions or requirements. But identifying that social determinants of health relate to community conditions and that health-related social needs relate to individuals helps differentiate between actions targeting individuals’ risks, needs, and preferences and policy actions to address the real underlying conditions.
Addressing social determinants of health is essential for achieving health equity in the US. Health equity means everyone can reach their full health potential, regardless of race, ethnicity, income, or other factors. By addressing these factors, we can improve health outcomes for marginalized and underserved populations, ultimately creating a more just and equitable society.
Let’s take a closer look at social determinants of health to understand their role in pursuing greater health equity.
The Importance of Screening for Social Determinants of Health
Screening patients for social determinants of health and related social needs is crucial for achieving health equity. Identifying non-medical challenges that negatively affect patients’ health outcomes allows healthcare providers to tailor treatment plans to address these factors, such as referring them to resources or community programs. Additionally, screening for social determinants of health helps providers understand patients’ social and economic contexts, informing clinical decision-making and improving the quality of care. Addressing these factors can reduce health disparities among marginalized communities and those with limited access to healthcare services, ultimately improving outcomes for all patients.
How Social Determinants of Health Influence Health Outcomes
Social determinants of health influence health outcomes in many ways, but here are a few of the big-picture elements we must address.
Access to healthcare: Individuals with limited access to healthcare services may delay seeking medical care or forgo preventative care, leading to more advanced disease states and poorer health outcomes. For example, a study published in the Journal of General Internal Medicine found that individuals without health insurance are less likely to receive recommended preventative screenings such as mammograms and colonoscopies.
Education: Education level is a strong predictor of health outcomes, with individuals with higher levels of education experiencing better health outcomes. This may be due to increased access to job opportunities, higher income, and better access to health information and resources.
Housing: Poor housing conditions, such as inadequate ventilation, mold, and pests, can lead to respiratory problems and exacerbate asthma and other chronic diseases. In addition, individuals experiencing homelessness are more likely to experience chronic health conditions and have higher mortality rates.
Employment and income: Individuals with lower incomes or unstable employment may have limited access to healthy food options, safe housing, and healthcare services, contributing to chronic disease and poor health outcomes. For example, a study published in the Journal of Health Economics found that income inequality is associated with higher rates of cardiovascular disease.
Neighborhood conditions: Living in neighborhoods with high pollution levels, crime, and limited access to healthy food options and safe public spaces can increase stress levels and negatively impact mental health, leading to chronic disease and other health problems.
How Technology Helps Healthcare Organizations Screen for Social Determinants of Health
Advancements in data gathering, analytics, communication, and collaboration technologies and methodologies have opened the doors to addressing social determinants of health more efficiently and effectively among individuals and the broader patient populations.
Recent research supports the idea that despite having screening tools within the EHR, information on SDoH is not always captured, and at-risk patients are not always flagged appropriately. In a study of related medical literature, 79% of studies integrated SDoH information from external data sources into EHRs, while the rest reported extracting it from unstructured clinical notes in the EHRs. All but one study used external area-level SDoH data reported minimum contribution to performance improvement in the predictive models, while those that incorporated individual-level SDoH data reported improved predictive performance of service referrals, medication adherence, risk of 30-day readmission, and other outcomes.1
Purpose-built platforms, focused exclusively on reducing disparities in care and improving the patient experience, can help providers identify trends and patterns in health outcomes by allowing them to identify and address health-related social needs. Healthcare providers can use tools that enable patients to voice non-medical challenges such as financial stress, food security, or housing status to target interventions that address them proactively. These platforms help caregivers identify issues that would be unlikely to ever come up during a visit or screening where time is limited. They offer patients a safe platform to share their needs honestly when they may hesitate to mention them in person. Once patients are identified as at risk or lacking specific support, healthcare providers can work to address these factors and provide resources that ultimately help improve health outcomes.
These tools can also help healthcare providers identify gaps in care and opportunities for improvement among their broader patient populations, such as identifying communities most at risk for poor health outcomes and tailoring their offerings and interventions to address those needs.
To learn more about how technology helps healthcare organizations identify and address social determinants of health, check out the Patient Discovery equitable care platform – an actionable technology and data analytics solution designed to help reduce disparities in care.
1. Chen, M., Tan, X., & Padman, R. (2020). Social determinants of health in electronic health records and their impact on analysis and risk prediction: A systematic review. Journal of the American Medical Informatics Association, 27(11), 1764–1773. doi: 10.1093/jamia/ocaa143