This blog post was first published on The Medical Care Blog on April 12, 2021.
The World Health Organization (WHO) defines social determinants of health (SDOH) as the non-medical factors that influence health outcomes. They are the “conditions in which people are born, grow, work, live, and age.” Currently, SDOH is a hot topic as stakeholders try new ways to improve individual and population health, achieve health equity, and reduce health care costs. SDOH became an even more important topic during the COVID-19 pandemic when issues related to health equity, health disparities, and silos between healthcare, public health and social care became much more visible. More and more, stakeholders are exploring how to improve people’s health by addressing challenges in their social circumstances. These efforts vary in nature and scale, and in general require collaboration across very different disciplines and settings.
A common understanding of SDOH and related terms – in particular, social risk factors and social needs - should guide SDOH-related efforts. However, that is not exactly the case. Researchers, practitioners, and policymakers may misunderstand and use these terms interchangeably. Yet, they are beginning to tease out the differences between these terms, and to understand the implications of doing so.
In this post, we define and differentiate between key terms, and make the case for why getting these terms right is important.
Social determinants of health shape health for better or worse.
“The distribution of money, power, and resources at global, national and local levels” shape the conditions or circumstances within which individuals live. Some examples of SDOH include income, education, employment, and housing. When people experience poor social circumstances, the SDOH at play may shape their health outcomes for the worse. For instance, higher income is associated with better health, while lower income is associated with worse health outcomes.
Social risk factors place individuals and groups at risk for poor health outcomes.
SDOH and social risk factors are connected but are not the same. We discussed earlier that SDOH shape health for better or worse depending on social circumstances. When social circumstances are adverse, they leave some people at greater risk for poor health. Adverse social circumstances associated with poor health, like economic insecurity or housing instability, are social risk factors.
These risk factors can disadvantage individuals and specific population groups and can be more prominent for some groups than for others. Some groups face greater social risk due to systemic discrimination based on race, ethnicity, gender, gender identity, and sexual orientation. Some groups have greater social risk due to wealth and income inequality.
Housing instability is a clear example of a social risk factor. Individuals facing housing instability frequently move, fall behind on rent, or experience homelessness. They are also more likely to have poor health in comparison to people with stable housing. LGBTQ youth make up 40% of the homeless youth population, despite only being 7% of the general youth population. Similarly, Black Americans represent 13% of the general population but are 40% of the homeless population and more than 50% of homeless families with children. Systemic factors place these populations at much greater risk than others.
Social needs are best addressed through person-centered care.
Social needs, distinct from SDOH and social risk factors, refer to an individual's immediate non-medical needs (e.g., food and housing needs). They also depend on individual preferences and priorities, underscoring the importance of person-centered care. For example, a grandmother may have transportation challenges (a social risk factor) but may tell a community health worker that she most needs a cellphone to regularly talk to her granddaughter. Engaging individuals in conversations about what unmet social needs are most important to them is crucial.
Social determinants of health, social risk factors, and social needs may seem similar but are distinct.
From 2017-2019, U.S. health systems invested approximately $2.5 billion towards SDOH such as housing, food security, and job training. However, this number is likely lower in reality. Often, efforts are categorized as addressing SDOH, when really, they target social needs.
For example, some of these health systems’ food security programs provide fresh produce to community members who otherwise have limited access to fresh produce. This addresses individual social needs but does not address systemic inequities in food access. One example of a systems-level solution would be robust federal and state nutrition programs. Another example would be providing incentives and resources for independent grocers to locate in underserved areas or, if already there, to offer healthier foods.
The graphic below neatly untangles the terms of SDOH, social risk factors, and social needs.