Understanding the Social Determinants of Health

Nurse practitioner and mature woman discussing health over coffee
Nurse practitioner and mature woman discussing health over coffee

As medical research continues to explore the biology of adversity, both chronic mental and physical stress have been established to take a severe toll on an individual's health.

Many of these stresses can be defined as "social determinants of health." These are health-related social circumstances that include inadequate housing, poor nutrition, unreliable transportation, a lack of mental health services, poor education, unstable employment and lack of healthy interpersonal relationships.

In fact, such social and environmental factors make up half of the "modifiable factors" thought to improve health — another modifiable factor would be personal behavior patterns, whereas a genetic predisposition would be an example of an unmodifiable factor.

Social determinants of health are by definition a complex set of interdependent issues that must be looked at holistically rather than as separate pieces. For example, while a nurse practitioner may encounter a patient in ill health with poor nutrition as a major contributing factor, said poor nutrition may be caused by food insecurity due to unemployment.

Furthermore, a vicious cycle may occur where the health problems exacerbated by poor nutrition contribute to the inability to find secure employment. For such patients, simply providing nutritional guidelines is not enough.

Screening for Social Determinants of Health

The Centers for Medicare & Medicaid Services recently began a $157 million initiative to create accountable health communities, a novel model of healthcare that includes identifying and addressing patients' personal social determinants of health.

As part of the initiative, researchers screened Medicare and Medicaid beneficiaries to identify unmet social needs and give extra assistance to high-risk individuals (defined by the study as greater than two recent emergency department visits combined with an unmet social need) in finding community-based services. Although many programs exist to aid these at-risk individuals, a large percentage of low-income patients do not realize that they are available.

An effective way of combating this is a combination of better education to promote existing government programs and cross-sector collaboration between clinicians and non-medical social services. In fact, to properly coordinate care for such individuals, doctors, nurses, social workers and therapists must all work in tandem; clear and consistent communication across disciplines is crucial.

For clinicians, issues arise because of just how different screening for social determinants of health compared to screening for traditional medical problems. Directly screening for these issues often detects adverse conditions facing patients are typically outside the scope of normal clinical care, creating a dilemma for healthcare personnel. Some even consider screening for specific social conditions without the adequate means of referring patients for relevant help to be ineffective and possibly unethical.

Without receiving regular specialized training, health professionals can have difficulty screening patients for sensitive social determinants like unemployment and interpersonal violence. Healthcare workers may be afraid of offending or may not know how to speak about the issues tactfully and respectfully. Due to screening questions and methods, patients may also perceive judgment or callousness in the health professional, resulting in distrust, less honest responses and lower compliance rates.

Addressing the cause of these issues may lead to better health outcomes, improve healthcare delivery, and reduce associated costs. Consequently, it's becoming more and more apparent that treatment modalities that seek to identify and address these social determinants should be integrated into healthcare training, including the nursing curriculum.

What can be done?

One recent commentary article in The Journal of the American Medical Association outlined the following specific action items for healthcare professionals to follow when screening for social determinants of health:

Screening should be patient-centric and include family members when possible.

Always remember that the screening process is for the patient. While this advice may appear to be common sense, it is all too often overlooked. Be attentive to your patients' needs and include relevant questions related to personal preferences. For example, avoid risk-stratification models that automatically refer patients who meet certain criteria to applicable social services programs. Instead, explain what you know about the program and ask the patient if help is wanted.

Additionally, to remain respectful, healthcare professionals should maintain an open dialog with the patient, answering questions directly without patronizing. Patients, and the at-risk populations especially, frequently feel infantilized by the medical community. Keeping your patients informed and self-directed will go a long way in establishing trust and positive outcomes.

As social determinants like food scarcity are often a household-wide problem, it's important to ask your patients whether they would prefer to include relevant family members — those with whom they live or share finances — in the screening and referral processes.

Referral to community-based resources must be integrated into the screening process.

Learning that your patient is facing a medically relevant hardship ultimately does not improve the patient's health status if you as a clinician can do nothing to solve the issue. Without these resources, screening can also elicit unmet expectations and subsequent frustration for the patient, causing unintended harm to the very people the resources seek to help.

However, remember that you are not expected to take on duties outside the scope of your training! Instead, have a list of contacts, such as local case managers, tailored to fit different screening outcomes. Additionally, maintaining personal contact with key players within these community services may ultimately prevent some of your patients from going unnoticed.

Again, this may seem like a daunting task for nurse practitioners and other clinicians without direct social work experience. This is why more and more public health researchers are advocating for the addition of dedicated support staff to facilitate the partnership between medical practices with vital non-medical services. If possible, try to broach the subject with management if you feel your practice would enjoy such an addition to the staff.

Screening must take place as part of a comprehensive systems approach.

Just as a community-based referral model should be part of the screening process, so too should clinicians keep informed about local system-building efforts that seek to integrate medical and nonmedical services. While such a task can be daunting for smaller private practices, it is a model strongly encouraged by the Centers for Medicare & Medicaid Services.

A strength-based approach should be used to support patients and families.

Healthcare professionals should attempt to focus on the strengths of the populations they serve. While engaged in these screening processes, take special care to avoid stripping at-risk individuals of their agency. Instead, place a strong focus on patient empowerment.

Because many social determinants of health are governed by outside forces, it's important to strengthen protective factors wherever possible. Therefore, while screening for negative social determinants, it is also important to screen for and highlight positive ones, such as healthy social connections, that may bolster your patient's well-being.

Perceived social class should not limit screening practices.

The old idiom "you can't judge a book by its cover" could not be more appropriate here.

Although the poor state of the economy may seem to be common knowledge, clinicians often overlook related widespread societal trends like the volatile job market and the shrinking of the middle class. Instead, many individuals continue to rely on stereotypes regarding age, race, sex, education and apparent social class, only screening certain subsets of the population and ignoring those who may otherwise benefit. Nurse practitioners can avoid these mistakes by applying screening techniques across the entire practice, regardless of whether a patient appears to be in need.

Going forward

Adhering to these guidelines — many of which overlap or otherwise complement the medical home model of primary care — will improve the effectiveness of screening while also minimizing unintended consequences. As you complete your nursing education, consider incorporating this philosophy into your clinical practice.