Social Risks, Social Determinants, & Fundamental Causes: At Which Level Should the Health Care System Intervene?

Answer: All 3.  The crucial question is “How?”

Often these terms and others – social risk, social factor, social need, social correlate, social determinant – are conflated and muddled, obscuring which interventions and strategies are likely to have the desired impact.

The draft figure below (please suggest edits and additions!) delineates some actions that hospitals and health systems might take across these three levels to improve health outcomes, address social factors, and mitigate inequities.

Social Risk

The provision of equitable, culturally responsive care to all regardless of ability to pay is the basic building block of how health care can address economic risk and the social disadvantage related to being from a minority community (broadly defined) in the United States.

In addition, hospitals are increasingly screening and making referrals for social risk to ensure patients are connected to relevant community assets and social services. Often overlooked, employee wellness programs – health care is often the largest employer in a given community – can also be focused on prevalent social risks. When scaled and appropriately funded, these referral and employee-based strategies can yield data and momentum that may start to move the needle on…

Social Determinants

Health care organizations are almost universally excellent conveners and routinely find themselves invited to community coalitions, Boards, work groups etc. Helping to build these coalitions (not necessarily to lead them!) is a crucial way that hospitals can contribute to community-based efforts to mobilize for policies and structures that address the unjust distribution of resources (housing, food, education, etc.) across our communities.

Coalitions are also crucial in crafting successful community health needs assessments (CHNAs) and subsequent community health improvement plans (CHIPs) to address community-prioritized health needs, including the SDOH. (AAMC’s own research has shown that taken together the SDOH are the 5th most often CHNA-prioritized health need.)

Finally, “anchor institution” policies – local procurement, local hiring, local investing – adds to the economic vitality of local neighborhoods: Community wealth is community health. These kinds of investments also set the tone and tenor for the health care organization itself, the starting point of efforts that address…

Fundamental Causes

No health care organization can eradicate racism or poverty or homophobia in its community. It can, however, work to address racism and poverty and homophobia within its own walls. Fomenting a culture of inclusion (and allotting the necessary resources and incentives to get there), ensuring local living wages and pay equity for staff, using its own data and expertise to identify and eliminate health care inequities all set a tone that reflects a commitment to equity.

Walking the walk in this way will increase the impact of advocacy efforts to promote social justice both within the health care organization and at local, state, and Federal levels. Health care already has a loud voice. Efforts like the above can pitch it toward social justice.

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By understanding what we’re trying to intervene on – risk, determinant or cause – we can ‘right size’ our interventions (and evaluations!) to build the evidence base of what works to close health and health care inequities and promote social justice in our organizations and in our communities.