Written by: Cheryl Reifsnyder, PhD
The U.S. Department of Health and Human Services defines social determinants of health (SDoH) as “the conditions in the environment where people are born, live, work, play, worship, and age.” These environmental conditions have a significant impact on our health and well-being. In fact, research shows that SDoH can have a greater influence on health than either health care or lifestyle choices. Research suggests that SDoH are responsible for between 30% and 55% of all health outcomes.
SDoH also contribute to health inequities between different social and economic groups, affecting the rate at which people deal with diseases; the quality of their healthcare; and their expected lifespan.
These factors make SDoH data vitally important when conducting clinical research. Under-representation of patient populations affected by different SDoH greatly reduces the generalizability of research findings—but despite its importance, SDoH data is frequently not collected. As a result, many research studies have significant gaps in diversity.
Healthy People 2030, the nation’s longest-running disease prevention and health promotion initiative, has created a framework for thinking about SDoH across 5 domains. This article introduces the 5 domains and some of the ways they can affect patient health outcomes.
The first SDoH domain is economic stability. This is because people with steady employment are less likely to live in poverty and—as a result—more likely to be healthy. Unfortunately, many people have difficulty finding and keeping a job. This is especially true for those with:
Even among those with steady employment, many don’t earn enough to afford the basic necessities they need to stay healthy.
In the U.S., 1 in 10 people live in poverty. This lack of economic stability can significantly impact patients’ health outcomes because it means basic requirements for health are not affordable, such as healthy foods, health care, and housing. This can lead to problems such as poor nutrition or the inability to see a healthcare provider (HCP) when sick—which can worsen existing medical conditions or make patients more likely to contract new medical conditions.
The second SDoH domain is education access and quality. A solid educational background sets children up for a higher income (and better healthcare as a result) later in life. Research shows that people with higher education levels are likely to be healthier and live longer.
However, numerous factors can interfere with children’s education. Economic instability frequently makes it more difficult for children to obtain a quality education. The stress created simply by living in poverty can affect children’s brain development, making it more difficult to do well in school. Children living in poverty are also more likely to live in areas with poorly performing schools.
Children are more likely to struggle with math and reading when:
As a result, these children are also less likely to graduate from high school; less likely to go to college; and less likely to ultimately get safe, high-paying jobs. These factors, in turn, make it more likely for them to have health problems such as heart disease, diabetes, and depression, as well as the effects of economic instability, discussed earlier.
Many people in the U.S. do not have access to quality health care, the third SDoH. This type of barrier can have numerous causes, such as lack of transportation or uninsurance.
About 1 in 10 people in the U.S. do not have health insurance; people without health insurance are often unable to afford the health care and medications they require. People without health insurance are less likely to have a primary care physician (PCP), which means they may not receive recommended health services such as cancer screenings.
Many people face other barriers to having a PCP, such as living too far from the HCPs who provide recommended health services. Many Millennials fail to establish a relationship with a PCP; without a strong relationship with a PCP who includes basic behavioral healthcare in their services, a Millennial may not realize they have a behavioral health issue. Even if they recognize they have a problem, they may not know how to obtain treatment. Others live in areas with PCP shortages, which can force them to delay treatment, do without care entirely, or visit an emergency department for non-emergency medical needs.
Individuals’ “neighborhood and built environment” forms the fourth SDoH. This domain includes factors such as:
The neighborhoods in which people live have a major impact on their health, well-being, and quality of life. For instance, some neighborhoods lack safe areas for physical exercise and expose residents to high levels of air pollution, secondhand smoke, or high noise levels, which can negatively affect their sleep and health. People may lack safe access to grocery stores with healthy foods, making them less likely to eat a nutritious diet. Individuals living in poor neighborhoods have a higher risk of health conditions such as heart disease, diabetes, and obesity. They also have lower life expectancies than those without this SDoH risk factor.
This SDoH domain is often associated with others because racial and ethnic minorities and lower-income people are more likely to live in higher-risk neighborhoods.
Look at the relationship between health and socioeconomic status, and you’ll see the final SDoH domain, social and community context. Health and illness unmistakably follow a social gradient: Those with lower socioeconomic positions have worse health and a higher rate of illness.
This domain includes social discrimination, such as bullying. Regularly exposing children to social discrimination influences their educational progress, making them less likely to graduate high school or attend college; and less likely to get a good-paying job. It also makes them more likely to suffer from heart disease, diabetes, depression, and other health problems.
This domain covers peoples’ relationships and interactions with family, friends, coworkers, and community members as well. People often face social challenges beyond their control, such as:
These challenges make it more difficult to get support from loved ones, coworkers, and so on, which can have a negative impact on individuals’ health and safety.
However, positive relationships—whether at home, at work, or in the community—can help counter these negative impacts. Increasing relationships and interactions with the people in their lives provide social support that is beneficial to individuals’ health and well-being.
Today’s clinical research continues to have significant gaps in diversity, in terms of social risk factors as well as in race and ethnicity. As a result, many currently approved medications, products, and devices have not been tested with a truly diverse population. Under-representation of these patient populations limits the generalizability of research findings.
There’s a growing awareness that SDoH must be considered when setting up clinical trials. However, social risk information is not always available in traditional data sources. Social risk information is often recorded in unstructured electronic health record (EHR) fields that are not generally accessible for real-world clinical research.
Veradigm can help researchers mitigate some of these issues by using innovative technology to improve diversity in clinical research. Veradigm uses Natural Language Processing (NLP) to mine data from unstructured, narrative clinical notes to generate information that can be integrated with datasets. For instance, Veradigm was able to use NLP to extract data on intimate partner abuse, increasing available data points from 13.5 thousand to over 300,000.
Veradigm’s access to source data, via our direct access to the Veradigm Network of EHRs, means we have access to unstructured data such as clinical notes, attachments, and images. This enables us to customize datasets to fit specific research goals, including information that can improve research diversity, such as SDoH data.
Contact us to learn more about how Veradigm can help you improve diversity in SDoH in your research.