Social Determinants of Health: Principles
Victor Cueto, MD, MS; Baraka D. Floyd, MD, MSc, FAAP; and Fernando S. Mendoza, MD, MPH, FAAP
John is a 12-year-old boy who is at your clinic for a sports physical. He is with his older sister because his mother is working and could not bring him in for the visit. He has 3 younger siblings at home. John says he is getting “mostly Cs” in school. When asked why he might be struggling in school, he responds by saying, “I’m trying my best.” He plans on playing football this fall and is excited about the possibility of a “scholarship someday.” His older sister remarks, “You can’t be getting to school late if you want to get good grades.”
1. What is the value of information about a patient’s school and school performance? What is the best approach to learning about a patient’s school performance?
2. How would you solicit information about a family’s nonmedical needs and concerns?
3. What is the relevance of information about a family’s structure and resources?
4. What role can a pediatrician play in assisting a family’s access to necessary resources?
Children are born, live, grow, develop, and learn within an ecosystem that determines and influences their health, well-being, and overall life course; the factors comprising this ecosystem are known as the social determinants of health (SDoH). These factors are rooted in history, institutions, communities, and culture but are continually shaped by changes in the surrounding socioeconomic environment. The SDoH exist either in concert with health and well-being (ie, strengths or assets) or in opposition to health and well-being (ie, risks or needs). The combination of risks and strengths are not static; rather, they act in a dynamic fashion to uniquely shape and influence a child’s life at any given time.
The SDoH have been conceptualized and categorized in myriad ways. The World Health Organization Commission on Social Determinants of Health formulated a comprehensive framework that conceptualizes the intersections of and relationships between the structural and intermediary determinants that affect health and well-being (Figure 141.1). This construct highlights the dynamic connections between the factors at play in patients’ lives. On a national level in the United States, the public health initiative Healthy People 2020 has distilled the large constellation of the SDoH into overarching themes identified by 5 key domains that provide for actionable areas of focus: neighborhood and built environment, social and community context, health and health care, education, and economic stability (Figure 141.2).
The duality of individuals existing within the broader context of a population is an important point for the physician to consider. At a population level, it has been proposed that social factors and the social ecosystem account for more than one-half of the influence on health (Figure 141.3). The other significant contributors are health behaviors and medical care. In sharp contrast, the contribution of genes and biology are rather small. At the individual level, these findings underscore the immense importance and influence of social determinants on individual health.
The recognition that the health of individuals and populations hinges on much more than the underpinnings of physiology is of central importance to understanding the role of health professionals in the larger context of patients’ lives. In fact, as SDoH themselves, health professionals play an integral role as mediators of other influential factors in their patients’ lives. In the role of mediator, the individual physician has the ability to support favorable situations and mitigate adverse conditions and consequences in the lives of that physician’s patients.
Pediatricians in particular have the unique potential to optimize the healthy development and life-course trajectory of the children and adolescents under their care. This presents both a challenge and an opportunity to recognize and address the SDoH that influence the lives of individual patients, the population served in the clinical setting, and the community in which the pediatrician practices.
Role of the Pediatrician
From its inception, the specialty of pediatrics has had a rich tradition of recognizing and working to ameliorate SDoH. As witnesses to the effect of social, political, and economic policies on children, pediatricians have expertise that necessarily extends beyond the diagnosis and management of disease. The combination of pediatricians’ expertise of the growth and development of children as well as their status as trusted voices and advisors in society on behalf of children allows pediatricians to serve as both advocates for children and active agents of change in children’s lives. In practice, however, balancing the demands of providing medical care with the task of recognizing, assessing, and addressing the circumstances that can hinder or optimize the health and well-being of children is challenging. However, an organized process is available that can and should be applied to address SDoH. Moreover, the thoughtful approach and concerted effort required of pediatricians concerning these circumstances is not unlike that applied to identifying, assessing, diagnosing, and managing medical conditions. Similar to the traditional clinical approach to care, this process is characterized by actionable items, including screening, triage, identification, assessment, and intervention or referral. Most important, the skills and tools involved in this process also serve to augment and complement medical care, with the shared benefits of improving physical and mental health and promoting healthy growth and development.
Figure 141.1. World Health Organization Commission on Social Determinants of Health conceptual framework for social determinants of health.
Reprinted with permission from Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health: Health Discussion Paper 2 (Policy and Practice). Geneva, Switzerland: World Health Organization; 2010. apps.who.int/iris/bitstream/10665/44489/1/9789241500852_eng.pdf.
Screening for Needs
Various screening procedures, tools, and questionnaires are commonly used in pediatrics. Most medical visits involve a patient intake process, which usually includes the use of questionnaires, triage, and assessment of vital signs. The primary reason for presentation is assessed, and measurements such as weight, height, temperature, and blood pressure are recorded. Similarly, well-child and health supervision visits usually include targeted age-based screening and assessment of developmental milestones. Additionally, new patients or patients who have not been seen recently often are asked to report on known health conditions and recent changes in health status. Patients and families are less commonly screened for the components and domains of the SDoH.
As a result of recommendations from the American Academy of Pediatrics and other trusted sources, however, screening for mental health symptoms, psychosocial stressors, and food insecurity have recently become more commonplace in some practice settings. Dedicated screening for the social determinants particular to any given patient should be included as part of usual protocol for all patients. Such screening is akin to obtaining vital signs in that it allows the physician to identify risks to health that may be as important to well-being as height or weight, if not more so. For example, knowing from height and weight measurements that a child has obesity is less beneficial than also knowing that the child has a parent who is unemployed and whose family is experiencing food insecurity. The information drawn from both screenings is of vital importance both during the clinical encounter and in the approach to management.
Screening requires a balanced approach involving integration of the clinical workflow, existing and emerging needs in the community, and knowledge of available resources. Furthermore, relying on clinical judgment alone for the existence of SDoH needs or risks in each family is problematic. Like the ability of pediatricians to recognize anemia, obesity, maternal depression, and developmental risk, pediatricians may recognize risk factors for negative SDoH in a patient’s history, but identification of opportunities to support families requires a systematic approach and goes beyond recognition. Negative SDoH are often stigmatizing and linked to a family’s past trauma, and as a result a family may be less likely to volunteer any needs to the pediatrician. This requires health professionals to rely on their own unconscious biases along with their clinical experience to judge which families may have additional needs in an already busy, short encounter and can lead to over-detection or under-detection of SDoH risks and strengths.
Figure 141.2. Healthy People 2020 focus areas for social determinants of health (SDOH) in the United States.
Reprinted from Office of Disease Prevention and Health Promotion. Social determinants of health. HealthyPeople.gov website. www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health.
Screening for SDoH affords pediatricians the opportunity to affect long-lasting change in patients’ lives, but effecting meaningful change requires purposeful preparation. Understanding the needs and assets of the population and community served in a given clinical setting is essential. To begin this process, a needs assessment is conducted to understand what needs are most prevalent in the community served. The information gathered through the needs assessment is paired with an asset map to help the physician and staff match identified needs to available resources. This pairing is important to ensure that a physician does not develop a screening protocol that will identify risks that cannot be addressed using existing local resources. This process provides an opportunity to leverage knowledge of community stakeholders (Box 141.1) to augment information gleaned in the needs assessment. In the clinic with limited time and resources for undertaking a formal needs assessment and creating an asset map, the knowledge and experience of key stakeholders with positive relationships with the community can be leveraged to increase feasibility.
Many validated tools exist to screen for SDoH needs, but no standard tool has yet been identified. Few tools exist to assess SDoH assets. Single-domain screening tools (eg, the 2-item Food Insecurity Screener) focus on 1 specific domain, whereas comprehensive screening tools (eg, the 12-item Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education [WE CARE]) focus on multiple domains of risk. In this ever-evolving landscape, many practices choose questions from validated screening tools to create their own tailored screening tools based on their own needs assessment and local asset map. Screening modality, whether verbal, paper, or electronic, is also tailored to the workflow of each clinical setting. Personnel performing the screening usually depend on the screening modality. For example, in clinical settings in which families complete previsit questionnaires electronically, SDoH screening may be performed as part of that questionnaire, but in settings in which other screenings are paper based and delivered by ancillary staff, SDoH screening may be included with those other paper-based workflows.
Figure 141.3. Determinants of population health. The dashed lines convey estimates of the various influences. The absence of a line separating total ecology from social/societal characteristics reflects the lack of quantitative knowledge at this time.
Reprinted with permission from Tarlov AR. Public policy frameworks for improving population health. Ann N Y Acad Sci. 1999;896(1):281–293.
Most SDoH needs are not identifiable via growth parameters, laboratory studies, or physical examination; thus, specific screening for SDoH has been recommended as part of routine well-child care. Additional consideration should be given to SDoH related to the disease process or the presenting symptom, or as otherwise indicated. Food insecurity screening at follow-up visits for obesity and weight checks for failure to thrive are excellent examples of situations in which additional consideration should be given to SDoH. Likewise, standard questions about habitability and smoking at an asthma visit might be enhanced by asking additional questions about financial needs and resulting parental stress should the parent mention the recent loss of a job. In the clinical setting in which formal screening is not conducted or in which a validated screening tool or individual to perform such a screening are not available, the physician can use the IHELLP (income, habitability, education, legal status, literacy, personal safety) mnemonic to guide discussions with families to identify needs.
Although each clinical setting and family situation is unique, certain best practices can be followed when performing SDoH screening. Universal screening, or screening all families, decreases the likelihood that implicit bias will negatively affect screening and increases sensitivity of the instrument. Screening for risks and strengths identifies assets of which families may not have been aware, and these assets can be used to counterbalance challenges the family is experiencing and build parental confidence and self-efficacy. To elicit strengths, the physician can either engage the family in problem solving for a particular risk to help them identify their strengths or highlight strengths noted during the clinical encounter. Screening tools should be linguistically appropriate with attention to literacy level such that respondents with limited English proficiency or low literacy in any language can use them. If screening is delivered verbally, interpreters should be used to communicate with families with limited English proficiency. Because families may feel shame, guilt, or frustration about having SDoH needs or fear being reported as neglectful if they disclose needs, the physician should pose clear questions and remain nonjudgmental.
Box 141.1. Social Determinants of Health: Risks and Strengths
•Intimate partner violence
•Parental mental health
•Parental obligations/time constraints
•Lack of financial or social resources
•Lack of knowledge about services (eg, social support, educational)
•Family/community connectedness (ie, social capital)
— Growth mindset
— Family structure (ie, supportive, caring adults to nurture child)
— Family role models
— Safe neighborhoods
— Safe, high-quality schools
— Stable and habitable housing
— Access to nutritious food
— Access to job opportunities
— Access to reliable transportation
— Access to medical care, including behavioral health and wellness care
— Social customs, practices, norms
•Strengthening Families Protective Factorsa
— Parental resilience
— Concrete supports
— Social connections
— Knowledge of parenting and child development
— Social and emotional competence of children
•Centers for Disease Control and Prevention protective factorsb
— Supplemental Nutrition Assistance Program (SNAP)
— Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
— Temporary Assistance for Needy Families (TANF)
— Earned-Income Tax Credit (EITC)
— Anti-poverty agencies
— Specific advocacy agencies (eg, intimate partner violence)
— Food banks
•Early childhood systems
— Parenting supports
— Developmental supports (eg, Early Head Start, Head Start)
— Home visiting
— United Way, YMCA
— Churches/Religious institutions