The phrase “social determinants of health” (SDOH) is defined by the Centers for Disease Control and Prevention (CDC) as “The circumstances in which people are born, grow up, live, work, and age, as well as the systems put in place to deal with illness…”. The Institute of Medicine of the National Academies of Sciences published a report titled “A Framework for Educating Health Professionals to Address the Social Determinants of Health” in March of 2016 which stimulated much of the growing interest in the medical literature. The number of published scientific articles indexed in the National Library of Medicine MEDLINE database with Medical Subject Heading (MeSH) term “social determinants of health” has grown from 158 in 2013 to 466 in 2018 with another 5 times those numbers with the phrase “social determinants of health” or abbreviation SDOH in the title or abstract. A search of MEDLINE (https://www.ncbi.nlm.nih.gov/pubmed/) with “primary care” and “social determinants” now finds over 300 articles mostly published in the past two years.
One of the most controversial issues in this literature is screening for SDOH in primary care practice. Much of the call for SDOH screening comes from organizations that deal with population health rather than individual health. However, as clinicians we are obligated to consider the evidence of benefit to our individual patients by any actions we take. Recommendation from public health authorities to screen primary care patients for factors which neither we nor our patients can alter on the premises that gathering that information might be useful in epidemiologic research or shaping public policy often has the implicit assumption that there is no cost or risk associated with that action.
A systematic review of the pros and cons of SDOH screening in clinical care concludes: “This first summary of literature on the subject found many published reasons for why patients’ social and economic circumstances should be enquired about in healthcare settings. These reasons include potential benefits at the levels of individuals, health service provision, and population, as well as the potential to improve healthcare equity. Cautions and caveats include concerns about the clinician’s role in responding to patients’ social problems; the perceived importance of social health determinants compared with biomedical factors; and the use of average population data from geographic areas to infer the socioeconomic experience of individuals. Actual evidence of outcomes is lacking: our review suggests hypotheses that can be tested in future research.”1
I believe that primary care practitioners (PCPs) have a unique opportunity to make a connection between population healthcare and individual healthcare. As PCPs, we are most likely to know our patients and their circumstances as well as the communities where they live and where we practice. When we find that patients miss appointments and didn’t buy the medications we prescribed, we ask and discover transportation issues, financial problems, lack of social support, job insecurity, etc. Knowledge of our community’s resources and risks, described in a 2017 American Family Physician editorial as “community vital signs”2, is helpful both in determining individual health risks and options for obtaining healthy food, exercise, and lifestyle options.
The American Academy of Family Physicians (AAFP) has, in my opinion, done an excellent job of educating the primary care community over the past few years in a pragmatic approach to integrating SDOH into practice. The AAFP’s The EveryONE project developed screening tools specifically for PCPs and guidance to when and how to use them. These screening tools are designed to address the Institute of Medicine report categories and are available free of charge in multiple languages for both the short and long form as fillable PDF files.
Other freely available screening tools include:
- The Centers for Medicare & Medicaid Services: Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool – intended for self-administration
- National Association of Community Health Centers: Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences tool (PRAPARE) – a clinical or non-clinical staff member to administer the questionnaire
- Moscrop A, Ziebland S, Roberts N, Papanikitas A. A systematic review of reasons for and against asking patients about their socioeconomic contexts. Int J Equity Health. 2019 Jul 23;18(1):112. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6652018/
- Hughes LS, Likumahuwa-Ackman S. Acting on Social Determinants of Health: A Primer for Family Physicians. Am Fam Physician. 2017 Jun 1;95(11):695-696. https://www.aafp.org/afp/2017/0601/p695.html
Charles A. Sneiderman, MD, PhD, DABFM
Medical Director, Culmore Clinic
Bailey’s Crossroads, VA
Published on 10/16/19