Outlook: Newsletter of the Society of Behavorial Medicine

Summer 2022

Social Determinants of Health, Social Risks, and Social Needs: What’s the Difference and How Do You Measure Them?

Stephanie L. Fitzpatrick, PhD‚úČ; SBM Member Delegate and 2023 Annual Meeting Program Chair


Despite advances in medicine, racial, ethnic, and socioeconomic disparities in chronic disease prevention and management persist. In the health care sector, social determinants of health have increasingly become part of the conversation around reducing health disparities. This makes sense given that social determinants account for 50% of health outcomes whereas medical care only accounts for 20% (health behaviors account for 30%).1 Multi-level, multi-sector, and multi-system efforts are needed to address health inequities. Behavioral medicine can help inform these efforts. However, as behavioral medicine researchers and practitioners, we must: 1) understand the nuances in the different terminology that is used related to social health as it has implications for study design and level of impact; and 2) do a better job at incorporating social health-related measures in behavioral medicine research. The goals of this article are to explain the difference between social determinants of health, social risk factors, and social needs as well as provide a brief overview of available measures that can be used to assess these constructs in future research.
 

Social Determinants of Health

The Office of Disease Prevention and Health Promotion defines social determinants of health as “conditions in which people are born, live, learn, work, play, worship, and age that affect health [physical and mental], functioning, and quality of life.2 Social determinants can impact health positively or negatively and are shaped by policies, systems, and social norms that determine the distribution of money, power, and resources.3,4 Unfortunately, these policies and systems are marred by historical injustices and racism leading to subpar education, poor access to health care, and unacceptable living conditions for certain groups of society and an overabundance of resources for others, for example. Thus, social determinants are upstream factors such as policies and systems that play a role in health and health inequities.
 

Social Risks and Social Needs

Social determinants affect everyone, not just the socially and economically disadvantaged. On the other hand, social risk factors are specific adverse conditions at the individual or family level that are associated with poor health and can exacerbate health inequities.4 Examples of social risk factors include:

  • Food insecurity
  • Housing instability
  • Social isolation
  • Intimate partner violence
  • Lack of transportation
  • Financial strain

Social needs (also sometimes referred to as health-related social needs, non-medical factors, material need insecurities, or unmet needs) are the social risks an individual seeks assistance with immediately.4 Although a person may indicate the presence of several social risk factors, they may only need help with one of those at the time of screening. In other words, social needs take into account the individual and/or family’s preferences and priorities, and thus requires a person-centered approach when intervening.
 

Social Health Measures

Because social determinants of health are shaped by policies, systems, and social norms, it is in fact these upstream factors that need to be assessed in future behavioral medicine studies. Here are just a few ideas:

  • Conducting a community environmental scan
  • Qualitative interviews with various political, community, and other systems level stakeholders to understand the history of certain policies and the impact on certain communities
  • Examining zoning laws and other built environment agendas and the impact on health
  • Utilizing geographic information systems (GIS) to understand the impact of certain policies at the neighborhood, city, county, or state level and linking with electronic health record or other available public health databases

There are numerous social risk factor measures available for use in behavioral medicine research. Some commonly used tools include the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) assessment tool,5 the Centers for Medicare & Medicaid Services Accountable Health Communities Health-Related Social Needs Screening Tool,6 and the 2-item Hunger Vital Sign.7 Refer to Henrikson et al. 2019 for a systematic review of the psychometric and pragmatic properties of 21 unique social risk screening tools.8
 

In summary, social determinants of health, social risk factors, and social needs are related, but distinct concepts. As behavioral medicine researchers and practitioners, it is important to understand this distinction to appropriately design our studies and interventions as well as incorporate measurement of these concepts to advance health equity.   

 

Suggested readings:

  1. Green K, Zook M. "When Talking About Social Determinants, Precision Matters", Health Affairs Blog, October 29, 2019. DOI: 10.1377/hblog20191025.776011
  2. Bailey ZD, Krieger N, Agenor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. 2017;389(10077):1453-1463.
  3. Bailey ZD, Feldman JM, Bassett MT. How Structural Racism Works - Racist Policies as a Root Cause of U.S. Racial Health Inequities. N Engl J Med. 2021;384(8):768-773.

 

References

  1. Magnan, S. 2017. Social Determinants of Health 101 for Health Care: Five Plus Five. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/201710c
  2. Office of Disease Prevention and Health Promotion. Healthy People 2030: Social Determinants of Health. https://health.gov/healthypeople/priority-areas/social-determinants-health. Accessed May 31, 2022.
  3. World Health Organization. Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1. Last Updated 2022. Accessed May 31, 2022.
  4. Alderwick H, Gottlieb LM. Meanings and Misunderstandings: A Social Determinants of Health Lexicon for Health Care Systems. Milbank Q. 2019;97(2):407-419.
  5. National Association of Community Health Centers. Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE). https://www.nachc.org/research-and-data/prapare/prapare_one_pager_sept_2016-2/. Published 2020. Accessed March 31, 2022.
  6. Alley DE, Asomugha CN, Conway PH, Sanghavi DM. Accountable Health Communities--Addressing Social Needs through Medicare and Medicaid. N Engl J Med. 2016;374(1):8-11.
  7. Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1):e26-32.
  8. Henrikson NB, Blasi PR, Dorsey CN, et al. Psychometric and Pragmatic Properties of Social Risk Screening Tools: A Systematic Review. Am J Prev Med. 2019;57(6 Suppl 1):S13-S24.