Residency · Residency · Preventive Medicine

Social Determinants of Health: Measurement and Intervention

Introduction

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work, and age that shape health outcomes. SDOH account for an estimated 30-55% of health outcomes, compared to approximately 10-20% attributed to clinical care. The WHO Commission on Social Determinants of Health (2008) declared that social injustice is "killing people on a grand scale" and called for action on the causes of the causes of disease. Healthy People 2030 elevated SDOH to a foundational principle, organizing them into five domains: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context.

Theoretical Frameworks

WHO Conceptual Framework

Structural determinants (socioeconomic and political context): Governance, macroeconomic policies, social policies, public policies, culture and societal values. Socioeconomic position: Social class, income, education, occupation, gender, race/ethnicity -- these determine differential exposure and vulnerability. Intermediary determinants: Material circumstances (housing, food, working conditions), behavioral and biological factors, psychosocial factors, and the health system itself. The framework emphasizes that health inequities are driven by unequal distribution of power, money, and resources.

Healthy People 2030 Domains

Economic stability: Poverty, employment, food security, housing stability. Education access and quality: High school graduation, enrollment in higher education, early childhood education, language and literacy. Healthcare access and quality: Insurance coverage, provider availability, health literacy, quality of care. Neighborhood and built environment: Housing quality, transportation, walkability, environmental conditions, access to healthy food, crime and violence. Social and community context: Social cohesion, civic participation, discrimination, incarceration, community engagement.

<image>Nested concentric circles diagram showing the layers of social determinants of health, from individual characteristics at the center (age, sex, genetics) outward through individual behaviors, social and community networks, living and working conditions (housing, education, employment, healthcare), and broad socioeconomic, cultural, and environmental conditions at the outermost layer, with specific examples labeled at each level</image>

Measuring Social Determinants

Individual-Level Screening

Screening tools for SDOH in clinical settings have proliferated; commonly used instruments include: PRAPARE (Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences): 21-item tool covering 15 SDOH domains. AHC HRSN (Accountable Health Communities Health-Related Social Needs): 10-item CMS-developed screening tool for 5 core domains. SDOH screening questions: Food insecurity (Hunger Vital Sign 2-item screen), housing instability, transportation, utility needs, interpersonal safety. CMS now requires SDOH screening with Z-codes (ICD-10) for documentation: Z59 (housing), Z55 (education), Z56 (employment), Z57 (occupational exposure), Z60 (social environment)

Area-Level Measures

Area Deprivation Index (ADI): Composite measure of neighborhood socioeconomic disadvantage using Census data; ranks neighborhoods at national and state levels. Social Vulnerability Index (SVI): CDC/ATSDR tool identifying communities most vulnerable during public health emergencies; includes 16 Census variables across 4 themes. Community Need Index (CNI): Dignity Health-developed index scoring zip codes on income barriers, cultural barriers, education barriers, insurance barriers, and housing barriers. Child Opportunity Index: Composite measure of neighborhood conditions affecting child well-being across education, health/environment, and social/economic domains.

Population-Level Data Sources

Behavioral Risk Factor Surveillance System (BRFSS): State-level telephone survey including SDOH-related questions. American Community Survey (ACS): Census Bureau annual survey providing detailed sociodemographic data at community levels. National Health Interview Survey (NHIS): National survey including household income, education, employment, insurance, and healthcare access. County Health Rankings: Robert Wood Johnson Foundation model combining health outcomes with health factors (health behaviors, clinical care, social and economic factors, physical environment)

<image>Side-by-side comparison of two SDOH measurement approaches: individual-level clinical screening (showing a patient encounter with PRAPARE questionnaire, Z-code documentation in EHR, and referral to community resources) versus area-level population measurement (showing a community map color-coded by Area Deprivation Index with health outcome data overlaid), with annotations explaining when each approach is most appropriate</image>

Evidence-Based Interventions

Healthcare System Interventions

Social needs screening and referral: Identifying unmet social needs in clinical settings and connecting patients to community resources. Closed-loop referral platforms: Technology platforms (Unite Us, Aunt Bertha/findhelp) that enable bidirectional referral tracking between healthcare and social services. Community health workers (CHWs): Bridge healthcare and social services; evidence supports CHW effectiveness in improving chronic disease outcomes, reducing ED utilization, and addressing social needs. Medical-legal partnerships: Embedding attorneys in healthcare settings to address legal needs affecting health (housing, benefits, immigration, family law) Accountable Health Communities (AHC) Model: CMS Innovation Center model testing systematic SDOH screening, referral, and community-clinical alignment.

Policy Interventions

Income support: Earned Income Tax Credit (EITC) expansion is associated with reduced low birth weight, improved maternal mental health, and reduced infant mortality. Housing policies: Housing First approaches reduce homelessness and improve health outcomes; housing vouchers reduce exposure to neighborhood poverty. Early childhood education: Head Start and pre-kindergarten programs improve long-term health, educational, and economic outcomes. Minimum wage increases: Associated with reduced suicide rates, improved birth outcomes, and reduced food insecurity. Supplemental Nutrition Assistance Program (SNAP): Reduces food insecurity, improves dietary quality, and is associated with reduced healthcare utilization and expenditures.

Community-Level Interventions

Healthy food access: Farmers' markets, mobile markets, produce prescription programs, and healthy corner store initiatives. Built environment: Complete streets policies, mixed-use zoning, park and greenspace development, and public transit investment. Violence prevention: Community violence intervention programs, trauma-informed community building. Social cohesion: Community organizing, faith-based health programs, intergenerational programs.

Challenges in SDOH Implementation

Screening without resources: Screening for social needs without capacity to address them may cause harm through frustration and erosion of trust. Medicalization of social problems: Healthcare systems alone cannot solve poverty, racism, and structural inequality; partnering with non-health sectors is essential. Data standardization: Lack of standardized SDOH data elements in EHRs limits interoperability and population-level analysis. Privacy concerns: SDOH data collection raises questions about confidentiality, stigma, and potential discrimination. Sustainability: Social needs interventions require sustained funding and community infrastructure, not just grant-funded pilot programs. Workforce: The healthcare workforce is not adequately trained to screen for, address, or refer for social needs.

<image>Logic model for an SDOH intervention program showing inputs (funding, partnerships, technology platform, trained staff), activities (universal screening, navigation, referral, community resource development), outputs (patients screened, referrals made, services received), short-term outcomes (reduced unmet social needs, improved care engagement), intermediate outcomes (improved chronic disease control, reduced ED visits), and long-term outcomes (reduced health disparities, improved population health), with evaluation measures at each stage</image>

Key Clinical Pearls

Screening for social determinants is only ethical and effective when coupled with the infrastructure to respond; "screen and intervene" rather than "screen and abandon". Area-level SDOH measures (ADI, SVI) are valuable for population health management, resource allocation, and risk adjustment, but they do not capture individual-level variation within neighborhoods. Policy interventions addressing structural determinants (income, education, housing) have far greater population health impact than clinical interventions targeting individual social needs. Preventive medicine physicians should be trained in both SDOH screening and policy advocacy, recognizing that clinical practice alone cannot address the root causes of health inequity.

References

1. Commission on Social Determinants of Health. Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. Geneva: WHO; 2008.
2. Braveman P, Gottlieb L. The social determinants of health: it's time to consider the causes of the causes. Public Health Rep. 2014;129(Suppl 2):19-31.
3. Gottlieb LM, Wing H, Adler NE. A systematic review of interventions on patients' social and economic needs. Am J Prev Med. 2017;53(5):719-729.
4. Billioux A, Verlander K, Anthony S, Alley D. Standardized screening for health-related social needs in clinical settings: the Accountable Health Communities screening tool. NAM Perspectives. 2017.

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