Research Study: Accounting for Social Determinants of Health in Clinical Care
There’s increasing attention being paid to social determinants of health (SDOH) and non-medical health-related social needs. Clinicians are collecting data on social determinants of health, but they often lack the capacity and understanding to address them. Perspectives and input from patients most impacted by SDOH have been largely absent from current efforts to address SDOH in medicine. Because structural racism is a principal driver of SDOH, it’s critical that healthcare policy research attempt to control for its overreaching influence.
Tubman Health conducted a preliminary study examining: 1) what people feel comfortable sharing with primary care providers; and 2) what primary care providers feel equipped to address in their patient encounters. The following study offers a people-centered vs systems-centered inquiry into how social determinants of health could best be addressed in patient visits with their PCP.
Given the void of research regarding how clinicians use collected SDOH data for patient benefit, the Tubman Center for Health & Freedom piloted two exploratory surveys that began to examine perceptions of healthcare consumers and Primary Care Providers while also analyzing the role of racism and lived experience in the research process.
Over the summer months, we conducted two informal community surveys to collect preliminary data on the topic of sharing SDOH/“non-medical” health needs with their primary care providers. The survey piloted questions for a formal research study in the future. As we are designing a community health clinic that center the needs of marginalized people, we are seeking to better understand how to address patient’s social determinants of health both in and out of clinical settings.
The study’s guiding questions and assumptions include:
Providers are asking patients about their “non-medical” health related needs. Are patients comfortable disclosing to their Providers? Are providers prepared to hold the conversations and address the needs?
Providers are documenting data collected from patients. If data are not used to treat patient needs (e.g. providing aid vs. a referral), what are they for? How can the data be used to best benefit patients? Large data banks hold non-medical health related data. Do patients trust that their healthcare data are safe?
Survey I. The Health Care Consumer Survey
The health care consumer survey “Trusted Talk,” was offered to all community members over the age of 18. The survey was intended to reach recipients of healthcare. Data collection occurred as part of Tubman Health’s summer outreach efforts, which included canvassing and tabling at community events in well attended public spaces over the month of August, 2022. This outreach strategy offered a convenience sampling of community members across the Puget Sound region over the age of 18. There were 60 unique respondents that completed the survey. Generally, people reported that they did not feel comfortable unreservedly sharing their non-medical health related social needs with their PCP’s offices/clinics. Additional preliminary findings include:
There are some subject areas that people are far less likely to share with their providers. This includes employment discrimination, involvement with the criminal justice system and struggling to afford or maintain housing. This was particularly the case for respondents that identified as Black, or Multi-race Black. 48% of Black, Multi-race Black respondents reported that they would not share information about involvement with the criminal justice system with their provider; this is compared to 20% of White respondents
Most respondents said that they would share information regarding their difficulty securing housing with a Primary Care Provider “only if I was really comfortable,” and 39% of Black/Multi-race Black reported that they would not tell their Primary Care Provider that they were having difficulty affording or maintaining housing compared to only 13% of White respondents
Most survey respondents reported being concerned that sensitive non-medical health related social needs information would be used against them somehow. There was difference of perspective between People of Color and White respondents. 60% of White respondents did not report concern, while 56% of People of Color did report feeling concern.
When asked if people would feel “more” or “less” comfortable sharing personal information with a Primary Care Provider that has a shared identity background or life experience as them, there was overwhelming support for Primary Care Providers with a shared identity among People of Color (96%) and Black/Multi-raced Black respondents (97%) compared to 47% of White respondents. White respondents were much more likely to report neutrality regarding a Providers background (53% compared to <5%). No one reported feeling less comfortable with a provider who shared an identity, background, or life experience with them.
Survey II. The Primary Care Provider Survey
The Primary Care Provider (PCP) survey was circulated online for one week prior to the very preliminary analysis offered below. The Tubman Center for Health & Freedom sent the survey via email to PCPs and asked that providers help circulate it among their networks. This convenience sample yielded 17 Primary Care Provider respondents. We are still actively collecting survey responses from Primary Care Providers regarding their clinical experiences with SDOH. This preliminary analysis occurred in August, when the convenience sample had just 17 respondents with a range of years of experience, licensing, racial identities and grew up under different economic circumstances. A larger sample size will be used in a more thorough analysis of the data. Survey responses will continue to be collected until a small (more) representative convenience sample is reached, at which point the data will be disaggregated by race and licensure. The questions used in this study will be further developed and used in a rigorous research study that further investigates the issue.
Out of the 17 respondents 9 were able to provide an accurate definition of SDOH.
Overall, PCP believe they are moderately well trained in how to hold sensitive conversations with their patients regarding SDOH.
Generally, PCPs believe they received the most training on how to talk to patients about their employment status/types of work, followed by patient’s housing. Respondents believe they were least trained to hold sensitive conversations with patients regarding “impact of racial discrimination” but much more prepared to hold conversation regarding the “impact of homophobia.”
When asked if PCP believed they and their colleagues “have access to resources that would allow them to address SDOH [their] patients disclose in their treatment plans,” 12 of the 17 believed that they do have access to resources to address their patients SDOH.
16 of the 17 indicated that they believe it is part of their clinical responsibility to respond to their patient’s SDOH, while 1 participant was unsure.
The survey asked which tools PCPs are most likely to use/rely upon from their toolbox: 1.) insights from your professional training 2.) resources from community groups you are in relationship with 3.) hospital or social work services 4.) insights from personal lived experience. The most indicated answer was “resources from community groups that you are in relationship with.” This was followed by “insights from personal lived experience.” The least indicated response was “Hospital or Social Work Services.”
Further Exploration
Providers may believe that they have adequate resources (and training) to address their patient’s SDOH needs; however, overwhelming public health data shows otherwise. Providers are relying upon their personal relationships and lived experience to inform the care they are offering to patients with SDOH. Yet, most primary care providers do not have a lived experience of managing “non-medical” health related social needs and SDOH. Do PCP who have a lived experience of being affected by SDOH have more success addressing/treating SDOH among their patients? Without the means to track the clinical interventions that PCP are suggesting to their patients, there may be a false belief among Providers that they have the necessary resources to address SDOH in their patient populations
Preliminary Recommendations
Addressing SDOH in clinical care should not be left to the determination of healthcare Payors. Health care consumers and patients most impacted should be determining how SDOH are incorporated into clinical care (de Freitas, 2015). Data collection should not be occurring for the sake of collecting data, without a tangible intervention the provider can offer (beyond a referral). The “Principle of Beneficence” in health care, where a provider must always act in the patients’ best interest to bring about a positive outcome (Verkey, 2021), must extend to the collection of patient SDOH information.
Public health data is useless if not used to drive population-level change. Therefore, healthcare spending investments should target policy-level change with investments into community groups that have advocated to address SDOH for years. Simultaneously, Payors should prioritize investments to cover the true costs of tangible investments for “non-medical” health-related social services. This might include providing free, safe housing until a patient and their family can get back on their feet or paying court fees for a patient who is unable to otherwise and threatened with removal from their family.
Solutions to addressing SDOH and non-medical health needs currently exist outside of health systems. Community-based organizations (CBOs) that have been working for decades to provide these services should not be overlooked or counter-invested in by Payors or healthcare systems. CBOs should be receiving healthcare and public health revenue for the services and advocacy they provide. Any return on investment related to addressing SDOH in a patient population should be reinvested into the model, thereby increasing services to patients.
Accounting for systemic racism in research related to SDOH is essential. Research led by researchers and community groups who are among communities most impacted by SDOH offers a methodology that will likely examine refreshing queries, yield more accurate community data, and challenge the status quo of structural racism in healthcare policy and research.
Tubman Center for Health & Freedom will be conducting further research to determine how patients can best have their “non-medical” health related social needs addressed in a visit with their Primary Care Provider.