Health Equity

What doctors wish patients knew about social drivers of health

Sara Berg, MS , News Editor

AMA News Wire

What doctors wish patients knew about social drivers of health

Dec 15, 2023

Health outcomes are not solely determined by medical interventions. Rather, they are heavily influenced by factors that extend far beyond the walls of a hospital or exam room. From the neighborhoods that patients inhabit to the economic resources at their disposal, social drivers of health—also called social determinants of health—play a pivotal role in a person’s susceptibility to illnesses, access to health care and the effectiveness of medical treatments.

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While often overlooked, understanding and acknowledging social drivers of health can empower patients to take charge of their health. Meanwhile, physicians and health care organizations have a role in screening for these factors and working with community partners to address them.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, three physicians took time to discuss what patients need to know about social drivers of health. They are:

  • Sea Chen, MD, PhD, a radiation oncologist in Chicago and physician director of practice sustainability at the AMA.
  • Dave A. Chokshi, MD, an internist at Bellevue Hospital and professor at City College of New York’s Colin Powell School of Civic and Global Leadership. He served as health commissioner for New York City from 2020–2022.
  • Eboni Price-Haywood, MD, MPH, an internist and system medical director for Ochsner Health’s Healthy State initiative. She is also medical director for Ochsner Xavier Institute for Health Equity and Research. Ochsner is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

Social drivers of health include “all of your surroundings that affect your health that are not necessarily your own personal body and being,” Dr. Chen said. That includes “things like where you get your food or your transportation—getting to and from your appointments. These all affect how you receive health care and your health as a whole.”

The World Health Organization defines social drivers of health “as the circumstances in which you were born, live, work, grow, age, play, all of those things,” Dr. Price-Haywood said. “With that in mind, typically what you think about are things like where do you live? How far did you go in school? What kind of work do you do? Do you have access to food, nutrition? Is your neighborhood safe?”

“Those are the sorts of things that you think about in terms of social factors that might actually impact your health outcomes as a child and also as an adult,” she said. “Your social environment, physical environment, all those things play into social drivers.”

“One key thing to understand is … 80% of what determines your health is upstream of the hospital or the clinic,” Dr. Price-Haywood said. “If we don’t take that into consideration and understanding what you will need as a patient to get better or what may be challenging you in your ability to get better or stay well, it’s going to be a vicious cycle.”

Social drivers of health are “fundamentally important to health inequity because they’re fundamentally important to health,” Dr. Chokshi said. “If you just look at the summary measures of health—whether it’s life expectancy or what I think of as healthy birthdays, which is the number of years that each of us spends in good health—then it’s really the drivers of health that matter the most.”

“When we look at the differences in health status, for example, Native Americans live 10 years less than the average life expectancy in the United States,” Dr. Chokshi added. “Why? It is tied to those drivers of health—and the vast majority of what makes up those differences is also related to the drivers of health.”

There are inequities across different populations “in terms of access to adequate housing, safe workspace, education, how the neighborhood is built and access to grocery stores,” Dr. Price-Haywood said. “All of those things are the political environment in which you exist, and those things can actually determine the access to those various resources.”

“There are often cycles in terms of our health,” Dr. Chokshi said. For example, “let’s say a patient gains weight because they’re not eating healthy enough because they don’t have access to fresh fruits and vegetables.

“So, they gain weight and that worsens their knee arthritis, which means that they’re less physically active, which means that they gain more weight,” he added. Another example is if “someone is hospitalized, they’re no longer earning an income and then they get evicted from their home. That becomes a vicious cycle related to the drivers of health that also results in more illness.”

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“We have to think about interrupting those vicious cycles to be able to improve people’s health too,” Dr. Chokshi said.

More doctors and health care organizations are screening patients for social drivers of health and then using those answers to see how they can connect patients with community resources or referrals to case managers, social workers and others.

With that, patients shouldn’t be embarrassed to answer screening questions honestly. It is also OK to tell the doctor if you have trouble affording your medications, electric bill, food, mechanical repairs to your car, don’t have a safe place to exercise and more. Physicians can use that information to potentially get you help or revise their lifestyle-change recommendations.

“What I recommend patients asking their physician is: What are the most important things to become healthy or stay healthy? That type of open-ended question can really invite the type of conversation to get to the drivers of health,” Dr. Chokshi said. “Another way for patients to think about it and to engage in a conversation with their physicians about it is there are causes of disease.”

“There’s high blood pressure, there’s genetics, there’s unhealthy behaviors like smoking or eating poorly that can lead to lung disease or diabetes,” he added. “But then there’s also the causes of the causes like why is it that someone is smoking? What was it about their background that led them to start smoking in the first place?”

“It might be stress, it might be part of their environment that they were exposed to growing up,” Dr. Chokshi said. “Moving the conversation from just the causes—or what we describe in jargon as ‘risk factors’—to the causes of the causes really opens up the type of conversation that we need to have about the drivers of health.”

“One of the biggest things is support,” Dr. Chen said, noting that “in my clinical role, it was always helpful to have a family member come with the patient to be a second set of ears, not only for medical purposes, but also to ask questions.”

For example, a family member of a patient can bring up social drivers of health “during a medical visit,” he said. They can tell the doctor: “Hey, my mom is having a problem getting rides. Is there something we can do to help that? I can’t, but is there something out in the community that is available?”

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That is important, because then “you can feel free to share what your challenges are,” Dr. Price-Haywood said. “There are some things that are just embarrassing, and people are not going to bring it up. We’re relying on the doctors and everyone else to make us comfortable so that at some point we will reveal what those challenges are.”

Patients “deserve to have a care team that fully cares about and understands their circumstances … and that they’re not in this by themselves,” she said. “We all have pride and part of us being able to ask for help is being in an environment where we feel that we can trust the people who we’re talking to.”

“Have a conversation with your doctor because there may be ways that they can be supportive for whatever it is that you’re going through,” Dr. Chokshi said. “There are burgeoning programs and ways in which doctors are able to assist our patients. For example, we can connect patients to healthier food options.

“We can help them if they’re navigating a challenge when it comes to income or their housing situation. We can connect them with a social worker or a community health worker who may be more skilled and adept at navigating these systems than we are,” he added.

“Instead of trying to figure out all that stuff in the community, work with your primary care docs—whatever doctor you’re seeing—to see if they can connect you with a case manager or social worker or someone who, once they understand what your needs are, they can do the work for you to get you a list of what those resources are,” Dr. Price-Haywood said. “At the end of the day, that’s more effective than an individual person trying to figure out what’s around them and what they can access. That’s the very difficult thing to do.”

“A lot of patients may be worried or scared that their doctor’s going to reprimand them, or they’re embarrassed if they are negatively experiencing any of these social determinants of health,” Dr. Chen said. “But if the doctor doesn’t know about things outside of what’s happening in their office, then they’re not going to be able to help as well as they’d like to.”

“At the end of the day, if we can improve these social determinants of health for our patients and the community at large, it will obviously impact their lives greatly,” he said. “But it will also decrease the amount of dollars spent in the health care system that would be freed up to do even more things for the benefit of everybody.”

Addressing social drivers of health “will improve the health outcomes of everybody in the nation,” Dr. Chen emphasized.