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.
“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.
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, 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.
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.
SOURCE: Adapted from the Health Care Transformation Task Force’s (HCTTF) conceptual graphic, as seen in, “When Talking About Social Determinants, Precision Matters”, October 2020.
To summarize, SDOH—such as housing availability—present health benefits to some people while causing harm to others. When SDOH negatively impact a person’s well-being, opportunity, safety, or health, it is considered a social risk factor. Social risk factors place individuals and specific population groups at a disadvantage for good health. Individuals may have many social risk factors but fewer immediate social needs that can best be addressed through person-centered attention.
We cannot fully address SDOH, social risk factors, or social needs without first understanding and using more precise language. We can use more refined and intentional language to answer questions like these:
What kinds of efforts can target SDOH, social risk factors, or social needs?
Efforts to address one person’s social needs, such as finding immediate housing for someone experiencing homelessness, will not directly affect SDOH. But upstream policy changes to target SDOH can help many downstream individuals. For example, raising the federal minimum wage could address the SDOH of economic stability and help individuals access numerous resources and opportunities that improve their health and well-being. So the policy lessens the downstream social risk factors and social needs.
Who can and cannot help with each level?
Ideally, policymakers can best address upstream SDOH. However, without political will, we are less likely to see the creation of upstream solutions.
Community-level advocates, public officials, and health and social workers can identify shared social risk factors and bring them to the attention of policymakers. They can even model individual or community-level social risk factors. This can predict who will need preventive efforts before a serious social need – like a housing or food crisis – even arises. All of these stakeholders, together, can identify and link multiple individuals to existing resources that address shared social risk factors. Communities - with state, federal or private support - can also develop new resources, such as affordable housing or a food pantry.
Only individuals truly know their most important social needs. Those closest to them, such as family members or friends, or professionals who really listen to the individuals and take a person-centered approach, can help tease out these needs and find ways they can be met.
Most importantly, we need to get this language right to make the biggest impact on the health and well-being of the most disadvantaged and vulnerable people. In this post, we aimed to elevate this important conversation and bring it to a wider audience. We look forward to seeing how it continues and evolves.
We’d like to thank Ye Pogue and Judy Rayner for their generous and helpful guidance and feedback on this blog.
