Study Calls for Clarity on SDOH, Related Terminology

Misunderstanding, Misuse of Language Can Have Negative Policy Effects

June 10, 2019 02:08 pm News Staff

It likely comes as no surprise that people often ascribe different meanings to the same words. This is especially true for terms that are relatively new to the lexicon. Arguably, the term "social determinants of health" falls into this category.

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The AAFP has spent considerable time developing resources family physicians can use to identify and address SDOH in their patients based on how it has defined the term. The Academy's definition of SDOH, although similar to that of the CDC(www.cdc.gov) and of the World Health Organization,(www.who.int) differs somewhat -- in emphasis, if nothing else -- based on the unique lens of family medicine.

As the authors of a Milbank Quarterly paper(www.milbank.org) published last month suggest, misunderstandings about what SDOH and associated terms mean could have significant consequences in the areas of health care policy, practice and payment, where administrators and policymakers are apt to confuse or conflate one term with another. They attempt to bring clarity to the chaos by proposing a set of definitions for SDOH and related terms while drawing distinctions between the various ways these expressions are interpreted.

Reviewing the Terminology

SDOH and population health. The authors note that the WHO defines SDOH as "the conditions in which people are born, grow, live, work and age" and those conditions, in turn, are "shaped by the distribution of money, power and resources." Yet despite frequent association of the term with health inequities experienced by people near the bottom of the socioeconomic ladder, social determinants "are not just about the haves and have nots," they contend. Rather, people in the middle of the socioeconomic scale typically have worse health than those at the top, and those lower on the scale have worse health than those in the middle. SDOHs therefore pertain to an entire population, not just the poorest or most vulnerable.

Story Highlights
  • Researchers have found considerable differences in the way individual health care professionals, organizations and other stakeholders define and use terms such as social determinants of health and related phrases.
  • Improper use or misunderstanding of these terms could have serious implications for health care practice, payment and policy.
  • Having greater clarity on what these terms mean could benefit family physicians and their patients and help advance SDOH-related policies and practices.

The authors also point out that "population health" is not synonymous with SDOH. Population health is "the health outcomes of a group of individuals, including the distribution of such outcomes within the group," whereas social determinants are just one group of factors (along with genetics, behaviors and other nonmedical factors) that shape population health.

Population health improvement and population health management. Just as interpretations of population health differ, so, too, do those of its derivatives. Health care professionals may use the term "population health improvement" when describing their efforts to improve the health of their patient population, but among public health officials, it more often is used to refer to efforts that involve the population of a larger geographic area, such as a county or region.

Moreover, the authors call for clear distinctions between population health improvement and "population health management," noting that the latter term may be used to describe approaches to improving health that focus on defined groups of patients, such as those served by specific health plans or organizations, rather than approaches that focus on improving the health of an entire community in a particular geographic area.

SDOH and social risk factors. Although social determinants can positively or negatively affect one's health, the term "social risk factors" refers to "specific adverse social conditions that are associated with poor health," such as homelessness or social isolation. The authors note that social risk factors have also been referred to as social determinants, "health-related social problems," "social needs" or similar terms, and they propose that any individual-level SDOH that increases one's likelihood of poor health be referred to as a social risk factor.

The authors suggest this distinction for two reasons. First, it makes clear that SDOH are neither positive nor negative. Second, by identifying individual-level social risk factors, health systems could devise interventions to address them specifically or collect data to understand where community-level interventions might improve a population's health.

Social and behavioral risk factors. Although the authors acknowledge a connection between these terms in that social factors and individual behaviors can influence each other, they emphasized that these terms are not synonymous and cautioned against conflating them. They also note that in the United States, the term "behavioral risk factors" often is used as a catch-all phrase for mental health risks, even though the terms do not mean the same thing.

Moreover, say the authors, a distinction exists between social risks and social needs, with the latter emphasizing the patient's role in identifying and prioritizing social interventions. This concept is at the heart of efforts that involve shared decision-making; understanding what patients value, along with the physician's clinical expertise, enables physicians to make well-informed decisions about the right course of care.

Social needs-informed care and social needs-targeted care. According to the authors, "social needs-informed care" refers to activities that involve modifying traditional concepts of medical care to account for patients' social circumstances (e.g., providing transportation to health care appointments or translators for patients who face language barriers).

"Social needs-targeted care," on the other hand, refers to activities in the clinical setting that aim to directly address patients' social needs (e.g., helping patients who lack financial resources get access to income assistance or linking them with services that provide food or housing assistance).

Although both care approaches are important, say the authors, neither is sufficient if the goal is to improve population health for the entire community. Achieving that goal requires that health care organizations work together and in conjunction with other groups, such as housing agencies and local governments, to reshape the socioeconomic conditions that impact the health of those living in the community. Policy interventions at the state and/or federal levels also will be required to fundamentally change the structural social and economic conditions that shape the health of individuals within those communities.

Stressing the Importance of Clarity

Danielle Jones, M.P.H., manager of the AAFP's Center for Diversity and Health Equity, told AAFP News that having greater clarity on SDOH terminology and associated concepts could directly benefit both family physicians and the Academy.

"Having clear definitions for SDOH helps family physicians by providing them with a common language they can use to engage public health officials, social service organizations and policymakers to address a need in their community," Jones explained. "Having clear definitions helps the AAFP in developing shared goals with collaborative partners to bridge practice gaps and contribute to evidence-based knowledge."

Furthermore, standardizing SDOH terminology among the people who most frequently use these terms could lead to standardization throughout the health care field, resulting in positive outcomes for all stakeholders.

"Having a common language to use when discussing SDOH among physicians, payers and policymakers is perhaps the first step toward standardization across an intricate and complex health care system," said Jones. "Standardization would mean that SDOH data is defined and collected the same way across institutions, providing the ability to conduct comparative analysis of outcomes to help determine the effectiveness of SDOH interventions such as screening and referral.

"Effectiveness is the piece of the puzzle that is missing when it comes to supporting the development of robust policy, guidelines and payment methods, and the way we get there is by starting with a common language."

Related AAFP News Coverage
AAFP Lends Expertise on Social Determinants to Inform HHS
(11/20/2018)

More from AAFP
American Family Physician: Editorial: Social Determinants of Health: Family Physicians' Leadership Role
(4/15/2019)

Addressing Social Determinants of Health in Primary Care: Team-Based Approach for Advancing Health Equity(952 KB PDF)

Media Kit: AAFP Committed to Addressing the Social Determinants of Health, Striving for Health Equity