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How Understanding and Acting on Social Determinants of Health Improves Outcomes

By Dr. Sydney Heimbrock and Chris Schott

In a previous GovLoop piece, we shared the importance of modernizing public health infrastructure and centralizing data collection to drive faster time to action and a more holistic view of individuals and communities. 

This holistic view demands harnessing data beyond traditional health metrics to encompass the human experiences that drive health outcomes. First-person, social determinants of health (SDOH) data is essential to holistically improve health outcomes for your community — because SDOH answers the “why” behind the “what” of health KPIs. For example: Why are certain population centers more susceptible to obesity and diabetes (think food deserts, lack of public transportation, higher unemployment rates)?

But leveraging SDOH means harnessing data that we don’t yet have, or that exists in fragments. Even in fully interoperable datasets, key information on SDOH beyond race and gender is often missing — preventing a whole-person view of individuals and communities. Complete demographic, medical and social services histories can’t presuppose other determinants like nutrition or transportation access. Understanding these factors requires first-person data. 

Public health policies, programs and services exist to influence and optimize the health of community members. And by “health” we mean the lived experience that goes far beyond public, medical or social services records.

Health and Human Services need a whole-person view of individuals and communities

The New England Journal of Medicine recently published a “Whole Person Health Score” for understanding nonmedical health determinants, which are crucial to any holistic health risk profile. This report lists Physical Health, Emotional Health, Resource Utilization, Socioeconomics, Ownership, Nutrition and Lifestyle as key pillars. 

The report focused on a particular study that tracked 7,926 unique patients in Riverside County, CA for a 14-month period and assessed their need for intervention in the factors listed above. When asked to choose between these factors, the greatest need was in the Nutrition and Lifestyle domain (15.22% of patients), followed by Emotional Health (10.59% of patients) and Socioeconomics (9.35% of patients). Surprisingly, a mere 1.35% of patients required help in the Physical Health domain, yet the vast majority of Health & Human Services resourcing at the federal, state and local level are directed at Physical Health.

Generalizing these findings on the primacy of SDOH factors leads us to important conclusions regarding the need for first-person SDOH data:

  1. First-person social determinants of health data are required to contextualize decision-making

SDOH factors can’t be captured through existing medical or social service enrollment records. Understanding them requires direct engagement with community members to process their lived experiences. Even the most complete picture of a resident’s demographic, medical and social service enrollment history misses key social determinants beyond simple demographic labels. SDOH factors including transportation access, food access or safety can only be understood through direct community engagement. 

  1. Understanding social determinants requires ongoing listening through scalable digital channels

Traditionally, understanding social determinants in a community involves dozens or even hundreds of volunteers drawn from non-profits, community-based organizations and other partners recruited as part of annual or biennial community needs assessments. While these assessments provide a comprehensive picture of social determinants, they are frozen in time. Since full reporting on Community Health Needs Assessments (CHNAs) can take many months, even the most thoughtful CHNAs can produce insights that are outdated by the time they are reported — not to mention when they are used to inform decision-making.

No community is frozen in time. A true understanding of social determinants must be constantly evolving and scalable. Evolving, because the makeup and needs of the community are constantly changing regardless of any cadence set by public health authorities for CHNAs. Scalable, to maximize the reach and representativeness of the community members.

Digital engagement and reporting tools enable ongoing listening of community members, presenting public health as community partners who don’t show up only during a crisis (like during COVID), but are always there to provide preventative strategies (by understanding and acting on key drivers of issues such as food insecurity or violence). 

Digital tools also increase scale and equity. Contrary to some assumptions, smartphones have proliferated even into impoverished and homeless communities. A recent assessment by a State Department of Social Services found that over 92% of beneficiaries used smartphones, and studies of cellphone use among homeless populations dating back to 2017 found cell phone ownership rates over 90%. The proportion of individuals who can be reached via SMS texting is even higher. As it turns out, the use of digital technology unites more than it divides. Younger demographics in particular prefer engaging via texting, apps or other digital channels. Digital tools also enable partnerships with community-based organizations through simple methods like sharing links or QR codes, ensuring that the entities leading the frontline engagement forge community trust.

  1. Disparate experiences with public services cause disparate health outcomes

Perhaps most importantly, SDOH factors matter because the lived experiences of community members matter and have a direct impact on health outcomes. The public experience with government programs and services constitutes a key determinant of public health outcomes. Reduced administrative burden has been directly linked to increased program participation. A recent study found that the shift to electronic benefit transfer (EBT) in California increased Supplemental Nutrition Assistance Program (SNAP) participation by 19 percent. It’s thus important to understand more than merely traditional SDOH factors like barriers to adequate nutrition or services access. Additional factors to assess include administrative burdens, learning costs and psychological costs involved in engaging with public health and human services systems.

First-person social determinants of health data directly representing the voices of marginalized communities present the next frontier for public health. Listening, understanding and acting on the disparate experiences diverse communities have with public health and human services systems will prove ever more essential to realizing meaningful improvements in health outcomes.

Dr. Sydney Heimbrock is Chief Industry Advisor for Government at Qualtrics, where she uses her global experience transforming governments through investments in workforce development and policy reform to help federal, state and local government organizations design experiences that build public trust.

Chris Schott serves as a Customer Success Manager at Qualtrics, advising State & Local Government agencies on how to leverage technology for better public and internal service provision as well as process improvement. Much of his work focuses on Public Health program optimization, as well as improvements to Human Services delivery. Chris holds a Bachelor’s degree in Government from Cornell University.

Photo by National Cancer Institute on unsplash.com

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