Over the years, I tried to keep track of the health statistics for the county where I practiced. I knew that 11% of adults smoked, 18% had excessive alcohol consumption and 24% were obese. My medical assistants were pretty good at documenting smoking, alcohol and exercise habits when they roomed my patients. I gave the usual advice and occasionally a smoker would quit, a patient would exercise more and occasionally even a drinker would stop before there was a medical reason to do so. I tended to focus my advice on choices my patients made that affected their health, but in fact, those choices may play a very small role in the health of our communities.
There were many things I didn’t ask my patients: How far did they go in school? What was it like for them growing up? How hard was it for them to get in to see me that day? Do they have trouble paying for food or handling their house payment? What is their neighborhood like? If I had thought to ask those questions, I am not sure I would have known what to do with the answer. But, I might have had better understanding of the stresses and challenges my patients face each day.
Social determinants of health are “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies and politics.” (WHO)
There are five main areas of SDOH:
- Economic: wages, food insecurity, housing insecurity
- Education: literacy, education level and job training
- Socio-economic condition: concentrated poverty, racism, adverse childhood experiences, crime
- Health and health care: access to care, health literacy
- Neighborhood: access to healthy living, work and play, transportation
When I did take closer look at my community, I found that there are neighborhoods in my city where 50% of the children live in poverty. There are sections where less than 70% of adults have a high school education. There are neighborhoods where no one over 14 can speak English. In my community, 25% of residents have severe housing problems. The health issues for these people are significantly impacted by their social conditions and the options they have for nutrition, activity, and healthy habits are severely limited.
Screening for SDOH
There are many validated screening tools for SDOH. Several of our FQHCs use a survey tool to ask about transportation, housing, food resources, stress, education and violence. There are standardized tools available such as PRAPARE (http://www.nachc.org/research-and-data/prapare/) and YOUR CURRENT LIFE SITUATION (Kaiser Permanente). Other tools include Roots to Health Survey (http://www.surveygizmo.com/s3/2096658/Health-Roots-v0-2 ), Health Leads Screening Toolkit (https://healthleadsusa.org/tools-item/health-leads-screening-toolkit/), Safe Environment for Every Kid (SEEK: www.nciom.org) and many more. Whatever tool you choose, screening your patients for housing and food security, access to transportation, level of education, a history of trauma, and adverse childhood experiences will help you understand your patient’s health status and the limits on the choices they are able to make.
There has been some controversy on screening; screening in absence of an intervention has been labeled as unethical as identifying a social need without being able to offer any help to meet that need (see http://jamanetwork.com/journals/jama/fullarticle/2593561). Screening, of course, is best integrated with referral and linkage with community based resources. One idea that is very practical is to screen for one need, such as food insecurity, for which you have an identified and linked community resource. Start with one need and community resource and develop more linkages over time.
Developing sustainable strategies with your community partners is the long term goal to meet our patients’ and community’s needs. PHC has funded several implementation grants in the last year to do just that. It is hoped that what is learned in one community will help us develop comprehensive, integrated and patient-centered programs across our region to help patients get the resources and support they need.
What can we doctors do? Most of our communities have housing coalitions, county public health sponsored work groups, medical society community health committees and more. We can be catalysts. We can be community leaders. We can be advocates in our communities and in organized medicine. It is important for us to work to establish policies to improve the social and economic conditions in our communities at every level.
James Cotter, MD MPH