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Social Determinants of Health: The Ripple Effect

A patient with diabetes comes in to the emergency department with severe hypoglycemia. Once the patient is stabilized, you discover the person hasn’t eaten in three days; is unemployed, homeless, and living in a high-risk neighborhood; and doesn’t have anyone to call. You schedule a follow-up appointment to start managing the patient’s diabetes, but how do you tackle the medical issues with so many social issues at hand?

When thinking about the social determinants of health, the reality is that no one determinant is solely responsible for our health. Rather, diverse social factors make up a complex network of causes and effects, playing off our biological factors, which ultimately result in our health outcomes.

Take a look at the diagram below, which displays some key social determinants of health – education, social capital, food security, homelessness and employment, and neighborhoods. Each determinant touches health in its own way, but it also touches each of the other determinants. Much like an actual spider web, pulling on one point or connection causes a ripple effect throughout the entire network.

soc det of health web

For example, dealing with food insecurity may be related to being unemployed and/or homeless. Or feeling unsupported socially may be related to living in an unsafe or hostile neighborhood. Or struggling to find a well-paying job to pay rent may be related to not having completed high school. The list goes on and on.

Each social determinant has its own impact on health, and generally a clear cut solution. However, the inevitable combination of these social factors is what can make or break a care plan.

Treating the Social Determinants of Health

Social factors can be one of the greatest barriers to effective medical care. As seen above, addressing just one issue may not be enough when it comes to treating underlying health factors. Providers must look to see all of the root causes that are negatively impacting health outcomes and care plans. For example, treating a patient for food insecurity may not just be about providing that person with healthy food. It may also include linking the person to general educational development (GED) programs or housing assistance.

One of the best ways to uncover these issues is to get to know patients and listen to their narratives. Sometimes a simple open-ended question may be all it takes to discover what’s really going on behind more apparent issues. Comprehensive needs assessments, as well as utilizing key team members – social workers, community health workers, and patient navigators – can be great ways to reach out to patients and learn what they really need.

As providers for the most vulnerable, essential care teams will most likely encounter the myriad of social barriers to care on a daily basis. But just like the ripple effect in a spider web, addressing one social determinant has the power to reveal opportunities for addressing others.

Many essential hospitals have taken the lead on addressing social determinants in care. They serve as model examples of the care opportunities that come to light with a simple social intervention. Food pantries and demonstration kitchens, respite centers, employment assistance, community beautification projects, school-based health centers – these are all prime examples of ways hospitals can start transforming care for patients. Sometimes the answer is simple and sometimes it needs more time, but all it takes is that first step in treating a patient’s social determinants of health.

Additional Resources

For more information about the social determinants of health and tools for making a change in your hospital or community, please see the resources below.

Social Determinants of Health Web Series

A Critical Focus: The Social Determinants of Health

Social Determinants of Health: Social Capital

Social Determinants of Health: Food Insecurity

Social Determinants of Health: Homelessness and Unemployment

Social Determinants of Health: Exploring Healthography

Social Determinants of Health: Education

Social Determinants of Health Policy Topics

Addressing the Social Determinants of Health through the Alameda County, California, Place Matters Policy Initiative

IOM Recommends Determinants of Health Data for Meaningful Use

Health Policy Brief: The Relative Contribution of Multiple Determinants to Health Outcomes

Project Support and Funding

Robert Wood Johnson Foundation, Building a Culture of Health

Health Leads

Kaiser Permanente Community Benefit

More Information and Education

Unnatural Causes documentary series

Investing in What Works for America’s Communities, website and book

Addressing Patients’ Social Needs: An Emerging Business Case for Provider Investment


About the Author

Janelle Schrag is a senior program analyst with America's Essential Hospitals.

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