case study on social determinants of health

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Social Determinants of Health: A Case Study

The term “social determinants of health” (SDOH) is inescapable in the healthcare industry. But despite the ubiquity of the term, integrating SDOH into front-line medical care remains largely out of reach.

Why? Because there persists a “ wicked problem ” in the U.S. healthcare system; an unfortunate disconnect between the actual problem – meeting the complex health and wellness needs of unique individuals – and our approach to that problem – a complicated and inflexible system doling out prescriptive responses to those needs.

Changing our approach and creating a system that values health seems nearly impossible, given the sheer size of the healthcare industry alone. But innovative programs around the country are showing that it is possible – and the results are mutual “wins” for individuals, point-of-care providers, payers and communities.

An extreme example of how SDOH significantly impact healthcare costs, homeless people who are un- or under-insured often forego preventive care and depend on the emergency room to manage major medical issues. Once their acute conditions are addressed, recovery is hindered by lack of stable housing and limited access to follow-up care, while substance abuse and mental health issues may further interfere. The result is a high rate of complications necessitating costly re-hospitalizations - with little or no improvement in overall health or quality of life in the end.

Seeing the inefficiency and meanness of this cycle, ShelterCare, a nonprofit human services organization in Eugene, Oregon, sought change. In collaboration with Community Health Centers of Lane County (a Federally Qualified Health Centers), Trillium Community Health Plan, the local coordinated care organization, and PeaceHealth Sacred Heart Medical Center, the local hospital, they developed a medical respite care program that meaningfully improves wellness while decreasing costs by integrating SDOH into the care of homeless individuals.

The ShelterCare Medical Recuperation program opened in 2013 and has grown to 22-beds. The 30-day program gives residents a safe, stable housing environment in which to recover, while a community health worker provides medical care coordination and an on-site case manager helps residents connect to community resources to help them regain long-term stability.

As an example, Phil, a homeless man, visits the hospital emergency department with an infected wound. After receiving immediate medical treatment, the hospital refers him to the ShelterCare program, where he is given a small apartment and three meals a day. The medical caregiver on site dispenses medications, checks dressings and arranges for follow-up appointments and transportation. She helps Phil establish care with a primary care provider, who identifies that he has an untreated mental health disorder and a substance abuse problem, and he is referred to both counseling and an addiction treatment program.

Meanwhile, a case manager advocates for Phil with other social service and government agencies, guiding him through the process of applying for Medicaid, Social Security, food stamps, rental assistance, unemployment benefits and other services for which he may qualify. He is given a bus pass and ShelterCare staff take him shopping for clothing and toiletries. He takes part in on-site training workshops that help him create a resume, apply for jobs and learn basic budgeting skills.

While at the end of his month-long stay Phil still has much work to do to regain full stability, he is one of the 80 percent of program participants who leaves the program to move into permanent housing. And, by addressing the social determinants of health rather than continuing the cycle of emergency department visits, Phil’s coordinated care and wraparound services cost 34 percent less while helping him – and by extension, the greater community - make progress toward a significantly better quality of life.

The ShelterCare Medical Recuperation program has saved its community $1.26 million in hospital costs alone since 2014. It is an excellent micro-example of how an adaptive network with shared purpose and responsibility – the health and wellness of individuals – can effectively, efficiently collaborate to manage complex problems. And while the ShelterCare program is focused specifically on those experiencing a predetermined set of conditions, (homelessness and the need for acute recovery assistance), it illustrates both the value and feasibility of an outcome-based, SDOH-integrated network approach to healthcare for all.

Restoring the type of cooperation, adaptiveness and humanity exemplified by the ShelterCare Medical Recuperation program to our greater healthcare delivery system will first require a major shift in how we value healthcare . We must value – and therefore monetize – outcomes, not procedures. And because health outcomes are, in reality, messily influenced by more than biology and physiology, healthcare delivery has to incorporate SDOH if we hope to contribute to meaningful improvements in community health.

This is one reason universal healthcare is not in itself an adequate solution: we will not solve the problem by simply offering more of the same. Today’s reimbursement methods take our focus away from individuals and their unique needs and imposes cumbersome restraints on those who would care for them. Instead, insurance companies, social service agencies, the government, and other stakeholders must come together to enable nimble, patient-focused decisions at the point-of-care.

A self-organized, learning network that engages providers and payers across disciplines will create more options for better outcomes at a lower cost. Curandi ’s networking platform will enable community-focused initiatives to grow and serve a wider swath of the population. But first we must be willing – like those involved in ShelterCare’s respite program – to set aside the entrenched but ineffective standards of healthcare delivery and commit to seeking innovative solutions.

About Curandi

Curandi is a platform that empowers local communities to deliver better, more affordable community health by prioritizing individualized care and using network science to address the social determinants of health. Learn more at https://curandi.org .

Current use

Current utilization of preventive services is about 60-70% of what is clinically suggested in PPACA. Find more at: http://www.healthcaretownhall.com/?p=5596

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Social Determinants of Health Example Case Studies

by Shea Lunt | Dec 1, 2021 | Uncategorized | 0 comments

Social determinants of health (SDOH) are the environmental conditions where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life risks and outcomes. Some examples include income level, transportation, air quality, and access to nutritious food and safe housing. There is emerging awareness that SDOH accounts for 50% of the health factors that ultimately determine health outcomes.

The current Office or Other Outpatient Evaluation and Management (E/M) guidelines allow the E/M of patient SDOH to be captured in the level of the office visit. “Diagnosis or treatment significantly limited by social determinates of health” is noted under the “Moderate Risk” element which correlates to a level 4 visit.

Remember, risk is only one element of medical decision making (MDM) and to support the level of service, two of the three elements must be met (problems, data, risk). The other option to support the level of service for office/clinic visits is to use the total time spent on the date of the encounter.

Let’s look at three examples:

Case Study 1: MDM

A young lady with a hip injury after a fall from a curb presents for initial evaluation. The provider determines that she should have an MRI scan, referral to orthopedics, and remain non-ambulatory. She is a waitress with no healthcare insurance and unable to afford an MRI. In addition, she declines a referral. She is requesting a note for work. The diagnosis is limited to clinical findings, which makes the management decisions more complicated.

MDM: Moderate
Problem: 1 undiagnosed new problem with uncertain diagnosis—Moderate
Risk: Diagnosis significantly limited by SDOH—Moderate
CPT Codes 99204/99214

Case Study 2: MDM

A 12-year-old young lady presents with her grandmother for anxiety and depression and risk for failing in school due to absences related to her mental health instability. She would benefit from medication management, but the parents are divorced and the mother refuses to allow treatment of the condition with medication.

Problem: 1 chronic condition with exacerbation—Moderate
Data: Assessment requires independent historian—Limited
Risk: Treatment significantly limited by SDOH—Moderate

Case Study 3: Time

A 68-year-old gentleman was recently seen in the emergency department for an uncomplicated laceration to his right hand. He presents for a wound check in which possible infection is noted. No additional testing or treatment is required. The provider learns that the patient cannot cleanse the wound at home because his water has been shut off.

Time is 60 minutes
Write letter to utilities for medical waiver of shut off
Discuss case with care manager to enroll patient in meals on wheels
Document applicable SDOH and related plan in EMR
CPT Code 99215

There are also ICD-10-CM diagnosis codes that correlate to SDOH. Z codes are a subset of ICD-10-CM diagnosis codes that represent factors influencing health status and contact with health services that may be recorded as diagnoses. ICD-10-CM codes Z55-Z65 identify SDOH. Utilizing these codes allows providers, hospitals, and health systems to better track patient needs and identify solutions to improve health of their communities.

ICD-10-CM SDOH Categories

Z55 – Problems related to education and literacy
Z56 – Problems related to employment and unemployment
Z57 – Occupational exposure to risk factors
Z58 – Problems related to physical environment (NEW for FY 2022!)
Z59 – Problems related to housing and economic circumstances
Z60 – Problems related to social environment
Z62 – Problems related to upbringing
Z63 – Other problems related to primary support group, including family circumstances
Z64 – Problems related to certain psychosocial circumstances
Z65 – Problems related to other psychosocial circumstances

Shea Lunt, RHIA, CPC, CPMA, PMP

Shea is a consultant for The Haugen Consulting Group with 11 years of health care industry experience. Shea has experience working on the professional fee side of coding, auditing, education and compliance serving coders and physicians.

She earned a bachelor’s degree in health information management and a master’s degree in health services administration from the University of Kansas. Shea is a Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA) and a Project Management Professional (PMP).

Shea, her husband, and their daughters, call the wide-open spaces of central Kansas home.

Social Determinants of Health Case Studies: Targeting the Social Determinants of Health in Geriatric Populations

Date of Review: February, 2019

This is one of 3 ‘case studies’ in a collection of teaching tools called Social Determinants of Health based on Healthy People (HP) 2020 material aimed at teaching Health Professional students to adopt a new perspective that identifies and includes the multitude of factors that affect the SDH of their patient’s communities and populations and incorporate this understanding into their work. This specific module introduces both SDH geriatric health content as well as how their interaction creates the need for addressing these factors in a coordinated and community based care model. The resource contains a 35 minute introductory video/PowerPoint describing the topic areas in detail. There are resources for students and facilitators and they suggest three separate 1.5-2 hour sessions or a single 4.5-5 hour session and can be easily integrated as a flipped classroom format. There are three clinical case videos with various geriatric patient scenarios. Students are each guided to focus on different aspects of care. Following the videos students discuss their findings with a panel of community experts and relevant government agencies. While convening such a panel is certainly a barrier to implementing this resource the available guide does provide detailed suggestions. Four structured reflection assignments are included with a final reflection paper which contains a detailed critical reflection assignment. Faculty experts in this topic area would be needed to facilitate and give feedback on these student deliverables in addition to having contacts with community agencies. While many teaching materials are available in this resource, one must become a member of APTR and have faculty credentials to download the faculty guides and evaluation rubric for the reflection assignment however I think there are enough resources included to easily implement this curriculum. — Ashti Doobay-Persaud, MD, NCEAS

Corresponding Author’s Email:

[email protected]

Institution:

University of Utah Health & THE NET

Where Was the Curriculum Implemented?

Salt Lake City, Utah

Source of the Curriculum/Resource:

Association for Prevention, Teaching and Research

Level of Learner Assessment:

Appreciation of content/attitude assessment (self-reflection, blogging with rubric)

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Corresponding Author:

Cobb, Nadia

Type of Learner:

General Health Care Audience
Medical Students
Nursing Students
Physician Assistant students

SDOH Topic:

Access to Care
Community Medicine
General SDOH

Delivery/Education Method:

Community Partner
Online Module or Video

Curriculum Duration:

Multiple Sessions (less than a year)

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Open Access
© 2020

Social Determinants of Health in Non-communicable Diseases

Case Studies from Japan

Katsunori Kondo 0

Professor of Social Epidemiology and Health Policy, Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, Chiba, Japan

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This book is open access under a CC BY-NC-ND 4.0 license
Presents the first comprehensive review of social determinants of health for non-communicable diseases
Deals with social determinants of health for healthy ageing—a global issue in public health
Introduces social epidemiological evidence from Japan, a super-ageing society with the longest life expectancy in the world

Part of the book series: Springer Series on Epidemiology and Public Health (SSEH)

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16 Citations

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Table of contents

About this book

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Table of contents (20 chapters), front matter, the social determinants of health and trends concerning health disparity.

Katsunori Kondo

Behavioral Problems in Children

Chiyoe Murata

Metabolic Syndrome

Yuiko Nagamine, Kiyoko Yoshii

Cancer and Socioeconomic Status

Takahiro Tabuchi

Coronary Heart Disease

Hirohito Tsuboi, Katsunori Kondo, Hiroshi Kaneko, Hiroko Yamamoto
Naoki Kondo, Katsunori Kondo

Chronic Kidney Disease

Hideyo Tsutsui, Katsunori Kondo

Diabetes Mellitus

Hideyo Tsutsui, Go Tanaka, Katsunori Kondo
Go Tanaka, Katsunori Kondo
Chiyoe Murata, Katsunori Kondo
Kokoro Shirai, Hiroyasu Iso

Falls and Related Bone Fractures

Takahiro Hayashi, Joji Onishi

Malnutrition in Older People

Miyo Nakade, Katsunori Kondo

Oral Health

Jun Aida, Katsunori Kondo

Healthy Aging: IADL and Functional Disability

Masashige Saito

Life Course Epidemiology

Toshiyuki Ojima, Katsunori Kondo

Social Capital and Health

Access to healthcare and health disparities, measures of health disparities and health impact assessment.

Yoshihisa Fujino, Katsunori Kondo
Social determinants of health (SDHs)
Non-communicable diseases (NCDs)
Healthy ageing
Socio-economic status
Social epidemiology
Public health in Japan

Katsunori Kondo is Professor of Social Epidemiology and Health Policy, Center for Preventive Medical Sciences and the Graduate School of Medicine, Chiba University, Japan. He is also the Head of Department of Gerontological Evaluation at the Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology. He is the Principal Investigator of the Japan Gerontological Evaluation Study (JAGES) Project, which is one of the first prospective cohort studies to investigate the influence of social determinants of health and community social capital on health outcomes among older people. He is the author of the bestselling book, Health Gap Society—What is Undermining Mind and Health ? Igaku-Shoin, 2005, which was awarded in 2006 by The Society for the Study of Social Policy. Dr. Kondo also wrote Beyond ‘Healthcare Crisis’—Future of Health and Long-Term Care in the UK and Japan , Igaku-Shoin, 2012; Prescriptions for Health Gap Society , Igaku-Shoin, 2017; and edited and wrote Health Inequalities in Japan: An Empirical Study of the Older People , Trans Pacific Press, Melbourne, 2010; and Social Determinants of Health—Reviews of ‘Health Disparities’ in Non-Communicable Diseases , Japan Public Health Association, 2013.

Book Title : Social Determinants of Health in Non-communicable Diseases

Book Subtitle : Case Studies from Japan

Editors : Katsunori Kondo

Series Title : Springer Series on Epidemiology and Public Health

DOI : https://doi.org/10.1007/978-981-15-1831-7

Publisher : Springer Singapore

eBook Packages : Medicine , Medicine (R0)

Hardcover ISBN : 978-981-15-1830-0 Published: 03 November 2020

Softcover ISBN : 978-981-15-1833-1 Published: 04 November 2021

eBook ISBN : 978-981-15-1831-7 Published: 02 November 2020

Series ISSN : 1869-7933

Series E-ISSN : 1869-7941

Edition Number : 1

Number of Pages : XI, 328

Number of Illustrations : 11 b/w illustrations, 25 illustrations in colour

Topics : Health Economics , Social Structure, Social Inequality , Epidemiology , Health Policy

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Social Determinants of Health

What are social determinants of health.

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

SDOH can be grouped into 5 domains:

Suggested citation

Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved [date graphic was accessed], from https://health.gov/healthypeople/objectives-and-data/social-determinants-health

Social determinants of health (SDOH) have a major impact on people’s health, well-being, and quality of life. Examples of SDOH include:

Safe housing, transportation, and neighborhoods
Racism, discrimination, and violence
Education, job opportunities, and income
Access to nutritious foods and physical activity opportunities
Polluted air and water
Language and literacy skills

SDOH also contribute to wide health disparities and inequities. For example, people who don't have access to grocery stores with healthy foods are less likely to have good nutrition. That raises their risk of health conditions like heart disease, diabetes, and obesity — and even lowers life expectancy relative to people who do have access to healthy foods.

Just promoting healthy choices won't eliminate these and other health disparities. Instead, public health organizations and their partners in sectors like education, transportation, and housing need to take action to improve the conditions in people's environments.

That's why Healthy People 2030 has an increased and overarching focus on SDOH.

How Does Healthy People 2030 Address SDOH?

One of Healthy People 2030’s 5 overarching goals is specifically related to SDOH: “Create social, physical, and economic environments that promote attaining the full potential for health and well-being for all.”

In line with this goal, Healthy People 2030 features many objectives related to SDOH. These objectives highlight the importance of "upstream" factors — usually unrelated to health care delivery — in improving health and reducing health disparities.

More than a dozen workgroups made up of subject matter experts with different backgrounds and areas of expertise developed these objectives. One of these groups, the Social Determinants of Health Workgroup , focuses solely on SDOH.

Explore Research Related to SDOH

Social determinants of health affect nearly everyone in one way or another. Our literature summaries provide a snapshot of the latest research related to specific SDOH.

View SDOH Infographics

Each SDOH infographic represents a single example from each of the 5 domains of the social determinants of health. You can download them, print them, and share them with your networks.

Learn How SDOH Affect Older Adults

SDOH have a big impact on our chances of staying healthy as we age. Healthy People’s actionable scenarios highlight ways professionals can support older adults’ health and well-being.

The Office of Disease Prevention and Health Promotion (ODPHP) cannot attest to the accuracy of a non-federal website.

Linking to a non-federal website does not constitute an endorsement by ODPHP or any of its employees of the sponsors or the information and products presented on the website.

You will be subject to the destination website's privacy policy when you follow the link.

Teaching Social Determinants of Health Through an Unfolding Case Study

Affiliation.

1 Assistant Professor (Drs Hekel and Edwards), Associate Professor (Dr Pullis), and Instructor (Ms Alexander), Jane and Robert Cizik School of Nursing at The University of Texas Health Science Center at Houston.
PMID: 36729930
PMCID: PMC10144315
DOI: 10.1097/NNE.0000000000001333

Background: The impact of social determinants of health (SDOH) was developed to educate nursing students through the use of an unfolding case study.

Problem: SDOH and population health are critical components of prelicensure nursing education. Unfolding case studies are a strategy to develop critical thinking and teach SDOH to nursing students.

Approach: A model was used to develop the case study including a community assessment, which follows a male veteran and family through life events. Implementation of the unfolding case study took place over 3 consecutive semesters in a community health nursing course.

Outcomes: This educational activity achieved standardized examination scores, which are intended to assess student preparedness for the National Council Licensure Examination (NCLEX), above the national averages. Student participation was above 90%.

Conclusion: Unfolding case studies can present realistic scenarios that are useful to teach critical thinking. As the Next Generation NCLEX moves to scenario-based testing, unfolding case studies are a teaching strategy to prepare students.

Education, Nursing*
Education, Nursing, Baccalaureate*
Educational Measurement
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Nursing Education Research
Social Determinants of Health
Students, Nursing*

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case study on social determinants of health

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Global Social Determinants of Health .

Wednesday, may 29, 2024, 1:00-3:00 pm et; 6:00-8:00 pm cet.

This event will launch results from the Global Social Determinants Study (GSDS), the first 8-country nationally representative study that is explicitly designed to document social determinants in low-, middle-, and high-income countries and how they affect population health and well-being.

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Open access
Published: 20 April 2024

Determinants of externally visible birth defects among perinatal deaths at Adama Comprehensive Specialized Hospital: a case-control study

Husen Aman 1 ,
Seifadin Ahmad 2 ,
Getahun Chala 3 &
Mekbeb Afework 4

BMC Pediatrics volume 24 , Article number: 260 ( 2024 ) Cite this article

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Metrics details

Birth defects (BDs) are the major causes of infant morbidity and mortality in both developed and developing countries. Regardless of their clinical importance, few studies on predisposing factors have been conducted in Ethiopia. However, due to a lack of advanced diagnostic materials, we only considered the externally visible BDs.

To assess the determinants of externally visible birth defects among perinatal deaths at Adama Comprehensive Specialized Hospital.

A retrospective unmatched case-control study design was conducted from November 01 to 30, 2021. The sample size was determined by Epi Info version 7 software considering sample size calculation for an unmatched case-control study. A total of 315 participants (63 cases, and 252 controls) were selected by simple random sampling. Data were collected by an open data kit (ODK) and transported to a statical package for social sciences (SPSS) version 26 software for analysis. The bivariate followed by multivariable logistic regression analyses were done to determine the factors associated with the BD.

This study showed that drinking alcohol during pregnancy (AOR = 6.575; 95% CI: 3.102,13.937), lack of antenatal care (ANC) follow-up during pregnancy (AOR = 2.794; 95% CI: 1.333, 5.859), having a history of stillbirth in a previous pregnancy (AOR = 3.967; 95% CI: 1.772, 8.881), exposure to pesticides during pregnancy (AOR = 4.840; 95% CI: 1.375, 17.034), having a history of BDs in a previous pregnancy (AOR = 4.853; 95% CI: 1.492, 15.788), and lack of folic acid supplementation during early pregnancy (AOR = 4.324; 95% CI: 2.062, 9.067) were significant determinants of externally visible BDs among perinatal deaths.

In this study, alcohol use, exposure to pesticides, and lack of folic acid supplementation during pregnancy were identified as the major determinants of externally visible BDs among perinatal deaths. Thus, health education regarding the associated factors of BDs and their preventive strategies should be given to pregnant mothers.

Peer Review reports

Introduction

Congenital anomaly (CA), birth defect (BD), and congenital malformation are synonymous terms defined as a structural or functional anomaly that occurs during intrauterine or after birth in life [ 1 , 2 ]. It is thought to have occurred in both animals and humans as a result of a divine curse or evil in early human history. Some cultures still think that mothers who give birth to infants with BDs have communication with the devil or evil spirits [ 3 ]. However, the International Classification of Diseases (ICD) is stated CAs as congenital defects of body structure or function, likely to result in mental or physical handicap or death. In fact, a child with BDs can be born in any family including young, healthy, with no bad habits, and a normal pregnancy within any society [ 2 ].

A report from the World Health Organization (WHO) [ 4 ] stated that there are more than 6.3 million perinatal deaths occur per year worldwide. Of these, more than 2.64 million are stillbirths and 3 million are cases of early neonatal deaths. 98% of these deaths happen in developing countries. Birth defects are the 5th leading cause of years of potential life lost before age 65 and a major contributor to disabilities of a child [ 5 ]. The risks of BDs are greatest during the critical embryonic period (3rd to 8th week(s) of gestation), which is critical for fetal development. It is stated that approximately 303,000 newborns pass away yearly all over the world within thirty days because of BDs [ 1 , 6 , 7 ].

According to WHO estimation and the maternal and child epidemiology estimation group (MCEE), BDs were responsible for 11% of neonatal mortality in Ethiopia. Only 2.7% of women were prescribed folic acid during the protective period against neural tube defect (NTD), which was very low compared with 21% usage in Croatia, which had similar levels of planned pregnancy [ 8 ]. This contributes to an increase in the prevalence of BDs and their impact in developing countries such as Ethiopia. Birth defects can result in long-term physical, mental, visual, and auditory disabilities if not managed properly, with significant negative consequences for individuals and families, the health care system, and societies [ 1 , 9 ].

Some BDs can be prevented by removing their risk factors and strengthening protective mechanisms. Thus, adequate dietary intake of vitamins (folic acid) and minerals, and avoiding harmful substances including tobacco, alcohol, heavy metals, pesticides, certain medications, and radiation are necessary for mothers to minimize the occurrence of the BDs [ 10 , 11 ].

Although the prevalence of BDs is high in Ethiopia, there are few studies conducted on the determinants of externally visible BDs [ 10 ]. As a result, limited data are available at a local level on BDs for early intervention. This study could help in filling the gap of information on determinants of externally visible BDs among perinatal deaths at Adama Comprehensive Specialized Hospital (ACSH). In addition, it provides baseline data for future studies and public health measures. In this study, we only considered the externally visible BDs due to a lack of advanced diagnostic materials.

Materials and methods

Study setting and period.

The study was conducted at ACSH from November 01 to 30, 2021. This hospital was selected based on patient load.

Study design

A retrospective unmatched case-control study design was used to assess the determinants of externally visible birth defects among perinatal death.

Source and study population

All perinatal deaths that occurred at ACSH were the source population of the study. All perinatal deaths that occurred between January 01 to December 31, 2020 at ACSH were the study population.

Inclusion and exclusion criteria

The Stillbirths or neonatal deaths before the first 7 days of life with and without externally visible BDs were included as cases and controls, respectively. The Stillbirths or neonatal deaths after 7 days with and without externally visible BDs were excluded from the cases and controls, respectively.

Sample size determination and sampling technique

The sample size was calculated using Epi Info version 7 software for unmatched case-control using the Fleiss formula with continuity correction factor and case-control study ratio of 1:4; confidence level of 95%, power of 80%, a significance level of 5%, and a proportion of controls exposed (Drank alcohol) 8.7% [ 12 ], assuming the minimum odds ratio to be detected was 3.125. Adding 10% incomplete medical cards, the calculated sample size was 315 (63 cases and 252 controls). The study samples were selected by a simple random sampling technique based on their hospital registration number.

Study variables

Dependent variable: Externally visible birth defect.

Independent variables: Maternal age, Sex, Residency, Occupation, Deliveries, Number of previous pregnancies, History of abortion, Family history of congenital heart defects, History of maternal chronic illness, History of maternal alcohol intake, Previous history of maternal drug intake, Maternal health, and Diet and substance use during pregnancy.

Data collection tools and technique

The data relating to the information of the study participants were collected from the medical cards and filled into checklist forms. The checklist form was the study instrument that had three sections: sociodemographic, behavioral, and reproductive and obstetric characteristics of perinatal death mothers. Two diploma and one BSc midwife was recruited from ACSH Medical College as data collectors. The data collectors and supervisor took the COVID-19 transmission prevention measures during the data collection period.

Data quality control and management

The collected data were reviewed and checked for omissions, completeness, and consistency by the data collectors and principal investigator on daily bases during data collection time.

Data analysis and interpretation

Data were collected by open data kit (ODK) and transferred to the statical package for social sciences (SPSS) version 26 software for analyses. Binary logistic regression analysis was done to observe the association of each independent variable to the dependent variable and variables with p -values of less than 0.25 were identified. The identified variables were entered into a multivariable logistic regression model to identify the independent factors associated with a BD. The 95% confidence interval (CI) and an associated factor with a p -value of less than 0.05 were considered statistically significant.

Socio-demographic characteristics of the mother

Around 88.9% of mothers of cases and 85.3% of controls were between the ages of 15 and 35 years old. Almost half of the mothers of cases and controls were employed and unemployed, respectively. Over half of the mothers of cases (66.7%) and controls (53.6%) were urban residents. Statistically, there is a significant difference between case and control with regard to the religion of the mothers ( p = 0.008) (Table 1 ).

Reproductive and obstetric characteristics

Mothers who had a previous history of abortion were 28.6% in cases and 23% in controls, and 38.1% of cases and 13.1% of controls had a previous history of stillbirth. The majority of perinatal cases (58.8%) and controls (80.3%) were given birth at term or above, and 41.3% of cases and 29.8% of controls were given birth before 36 weeks. According to the findings of this study, the majority of women (84.1% of cases and 72.2% of controls) were given BD in the 1 to 4 birth order. Contraception was used by 68.3% of mothers who had a child with BDs, and 64.3% of mothers who had no child with BDs. Statistically, there is a significant difference between case and control with regard to the child’s gender ( p = 0.0095) and the history of stillborn ( p = 0.001) (Table 2 ).

Classification of the birth defects

All cases had NTDs. Of these, 24 had anencephaly with three umbilical hernias and one a cleft lip, 18 had hydrocephalus with two imperforate anus, and 5 had microcephaly with a chest deformity. There were also 6 Encephalocele, 5 spinal Bifida with one bilateral clubfoot, and 5 Meningomyelocele with one umbilical hernia.

Determinants of externally visible birth defects

Maternal age, residence, childbirth status, mother’s religion, mother’s occupation, gestational age, contraception and tobacco use during pregnancy, and abortion were not statistically significant in binary logistic regression analysis. The variables that were statistically significant in the binary logistic regression analyses were further examined using multivariable logistic regression. Thus, twelve variables (alcohol drinking, sex of a child, history of stillborn, birth order, vitamin conception, history of pesticide exposure, diabetic mothers, lack of folic acid use, history of injury and BD, caffeine use, and lack of ANC) whose p -value less than 0.25 in the crude odds ratio were entered into the multivariable logistic regression model to identify the predictor variables associated with externally visible BDs.

As a result, alcohol consumption, lack of ANC, history of stillbirth, pesticide exposure, family history of BDs, lack of folic acid conception during pregnancy, and child’s gender were statistically significant at p -values less than 0.05. However, in this study, being a diabetic mother, caffeine and drug use during early pregnancy, vitamin conception, and birth order were not statistically significant (Table 3 ). According to Table 3 , women who drank alcohol during pregnancy were 6.575 times more likely to have a child with BD (AOR = 6.575; 95% CI: 3.102, 13.937) than their counterparts. Women who had an ANC follow-up during pregnancy were 2.794 times more likely to have a child with BD than those who had an ANC follow-up (AOR = 2.794; 95% CI: 1.333, 5.859). Mothers of the stillbirth child were 3.967 times more likely to have a child with a BD than the mothers of live birth (AOR = 3.967; 95% CI: 1.772, 8.881). Women who were exposed to pesticides during early pregnancy were 4.84 times more likely to have a child with BD than those who were not exposed to pesticides (AOR = 4.840; 95% CI: 1.375, 17.034). Women who had a previous history of BD were 4.853 times more likely to have a child with BD than had no previous history of BD (AOR = 4.853; 95% CI: 1.492, 15.788). Furthermore, women who did not take folic acid supplementation during early pregnancy were 4.324 times more likely to have a child with BD than those who did (AOR = 4.324; 95% CI: 2.062, 9.067) (Table 3 ).

In this study, the most common cases of externally visible BDs were the central nervous system. This finding is consistent with studies done in South India, South Africa, Morocco, Tanzania, Northwest Ethiopia, and Southeast Ethiopia [ 3 , 6 , 13 , 14 , 15 , 16 ]. However, this finding is inconsistent with the studies conducted in the United States, England, Ogbomosho, and Nigeria that reported the cardiovascular system was the most commonly affected system, followed by the digestive system [ 17 , 18 , 19 , 20 ]. This finding is also different from studies done in Egypt and India, which reported the most common CAs were GIT and musculoskeletal system [ 7 , 14 ]. The discrepancy might be due to sampling methods. In this study, retrospective study methods were used to identify the determinants of externally visible BDs using secondary data. However, those studies which were different from the current study used a prospective study method to identify associated risk factors and they include both internally and externally visible BDs.

This study indicated that alcohol consumption during pregnancy was found to have a strong association with the occurrence of BDs. This finding is in line with various studies conducted in Southeast Ethiopia (Arsi), Southwestern Ethiopia, and the Amhara region [ 3 , 6 , 12 , 21 ]. Another study also showed that pregnant mothers drinking any amount of alcohol during early pregnancy had direct effects on the growth and morphogenesis of fetuses [ 3 ].

According to the present study, mothers who lack ANC were 2.79 times more likely to have a child with BD than mothers who had ANC. This finding is in line with the report from Tanzania, and Iraq that reported CAs were significantly associated with inadequate ANC [ 9 , 15 ]. This association is also supported by another study in Pakistan where only 32.3% of mothers of babies with CAs had ANC irrespective of the stage of pregnancy [ 22 ].

In this finding, more stillbirths (71.9%) were observed in cases as compared to the controls (11.66%). It is similar to the study conducted in the United States, which reported the overall CA specific stillbirth risk was found to increase among affected fetuses over the occurrence of stillbirth in the general population [ 21 ]. This finding also agrees with a study done in Iran where malformations were seen more significantly in stillbirths as compared to live birth and a study from India where congenital malformation was significantly high in stillborn babies as compared to live-born babies [ 23 , 24 ].

According to this study, drug use during early pregnancy had no significant associations with BDs. This finding is different from a study conducted in Northern Ethiopia where Infants born from mothers who took drugs during pregnancy were 3.55 more likely to have a BD compared to infants born to mothers who did not take any type of the drug during pregnancy [ 3 ]. This difference might be due to the sociodemographic characteristics of the mothers of a child. In this study, the majority of mothers were living in urban areas and employed whereas the report from northern Ethiopia showed that most of the participants were from rural areas and farmers. People who live in urban areas are more informed about the usage of the drug than those who live in rural areas; because in rural areas most people use unprescribed drugs without an order from a physician and traditional medicine.

In this study, mothers who had been exposed to pesticides during pregnancy were 4.84 times more prone to have infants with BDs compared to their corresponding counterparts. This result is supported by studies done in the Amhara region, Southeastern Ethiopia, and Southwestern Ethiopia, which found that maternal pesticide exposure during early pregnancy was strongly linked to the occurrence of CAs [ 6 , 12 , 21 ]. This finding is also consistent with a study from the Bale zone of Ethiopia, which reported pregnant women who had been exposed to pesticides were twice as likely as their counterparts to have congenital malformations [ 11 ].

This study indicated that infants born from mothers who had a previous history of BDs were 4.8 times more likely to have BDs compared to infants born from mothers who did not have a previous history of a child with BDs. This finding is supported by studies done in Pakistan and the United Kingdom where families with a familial condition with pregnancy to CAs are concerned about the risk of recurrence in future pregnancies [ 22 , 25 ].

In this study, there was no strong link between smoking and the occurrence of BDs. This finding is similar to the studies conducted in Tanzania, Nigeria, Iraq, and Ethiopia [ 9 , 12 , 15 , 17 ]. Unlike this finding, studies conducted in Ethiopia revealed a strong association between smoking and the risk of having a child with CAs [ 12 , 21 ]. This difference might be due to socioeconomic, religious, and cultural differences. For instance, in Iraq the number of smokers has increased over the last three decades due to psychological and associated factors with post-war conflicts [ 26 ]. In Egypt, it was estimated that twenty billion people smoke tobacco annually [ 27 ].

There was a strong association between maternal folic acid supplementation during early pregnancy and the occurrence of BDs in this study. Mothers of children who received folic acid supplementation during early pregnancy were significantly less likely to have a child with BDs. Mothers who did not receive folic acid supplementation during early pregnancy had a fourfold increased risk of having a child with BDs. This finding is consistent with studies conducted in Nigeria, Iraq, and Ethiopia, where folic acid supplementation was deficient [ 1 , 17 , 28 ]. This result was also in accordance with some studies done in Sudan and Ethiopia that reported maternal folic acid supplementation significantly decreased the prevalence of NTDs [ 1 , 29 ]. Recent evidence has shown that daily supplements of 400 micrograms of folic acid started 3 months before conception prevent up to 70% of these defects [ 30 ]. Even though the WHO recommends periconceptional folic acid supplementation, studies showed that many women still do not follow the recommendations, particularly women of low socioeconomic status [ 31 ]. Similarly, the Ministry of Health of Ethiopia promotes folic acid supplementation to all pregnant women, but folic acid usage is still low. This is also true in our study; though 17% of the participants had preconception care, only 7.8% were supplemented. This could be due to a lack of healthcare facilities in this area of study and Ethiopia, as well as community resistance due to a lack of knowledge about the importance of folic acid supplementation.

Consanguinity had no strong association with the occurrence of BDs in this study. This finding is in contrast to one study that reported consanguinity was a major risk factor for the development, where 89% of spinal Bifida was a relative parent compared with 67% of controls [ 29 ]. Close consanguinity is a known risk factor for CAs, as well as Mendelian conditions such as inborn errors of metabolism (occurring 1 in 770 births in this study), as confirmed in prior reports from Saudi Arabia and the world literature [ 32 ]. The discrepancy might be due to religious and cultural differences. This is because consanguineous marriage is widely practiced in Saudi Arabia where the majority of people in Saudi Arabia were Muslim and consanguineous marriage were culturally allowed while Ethiopia is a multicultural and religious country where consanguineous marriage is not allowed.

This study revealed that males were 2.131 times more prone to have BDs than females. This finding agrees with studies done in Iran, Brazil, and Ethiopia [ 1 , 4 , 5 , 8 , 11 ]. This could be due to chromosomal abnormalities and gene mutations, which are common in both males and females under similar circumstances [ 11 ]. However, more research is required to justify the condition.

Most of the participants in this study, who had a child with BDs, were less than 35 years old, which was different from studies in Pakistan where higher maternal age was a well-known risk factor [ 22 ]. This study was also different from a study in Iraq which reported CAs showed low incidence with ages less than 20 years and high with ages between 20 and 35 years old [ 28 ]. This could be explained by the fact that the study was conducted in a hospital setting where only those mothers who need special care were referred to this hospital and younger women gave birth at health institutions than elders. Still, deliveries are conducted at home traditionally in this study setting and most of them are elders who are illiterate and ashamed to give birth at health institutions. Youngers are more educated and informed about health services and risk factors related to pregnancy.

Limitations of the study

This study was a retrospective study that covered one medical center. A long-term follow-up and prospective study are required to assess all abnormalities, including functional abnormalities, which were not the case in the present study. We were unable to review all case files of maternal admission and had adequate information on the maternal characteristics and risk factors. This study could not consider the internal congenital anomaly like congenital heart disease due to lack of health facilities so it was difficult to compare with the published researches of birth defects. This was also a hospital-based study, so its findings may not apply to the general population.

In this study, BDs appear to be the most important causes of perinatal deaths and hence it becomes necessary to keep on account its associated risk factors. Of the associated factors with perinatal death with externally visible BDs; alcohol conception, exposure to the pesticide, previous history of stillbirth, and history of BDs were found associated with the externally visible BDs. ANC and folic acid supplementation during pregnancy were identified to have a protective effect against the occurrence of perinatal death with BDs. Public health experts and communities must pay close attention to the risk factors for BDs and their preventive strategies.

Data availability

All data obtained are available in this manuscript. However, any reasonably required data will be available per the corresponding author on request.

Abbreviations

Adjusted Odds Ratio

Birth Defect

Congenital Anomaly

Crude Odds Ratio

International classification of disease

Maternal and child epidemiology estimation group

Neural tube defect

Open data kit

World Health Organization

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Acknowledgements

We would like to forward our special thanks to Addis Ababa University, College of Health Sciences, Department of Human Anatomy for providing Ethical clearance approval for the study. In addition, we want to convey our gratitude to the study participants and staff of the study hospitals for their cooperation during the data collection period.

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Seifadin Ahmad

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Getahun Chala

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Both H.A. and M.A. made a significant contribution to the conception, study design, execution, and acquisition of data. Both S.A. and G.C. equally participated in data analysis and interpretation. All authors took part in drafting and revising the manuscript; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work.

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All experimental protocols were approved following the approval of the ethical guidelines laid down in the Declaration of Helsinki by Departmental of Research Ethics Review Committee (DRERC), Department of Anatomy, School of Medicine, Addis Ababa University with the reference number Anat 159/2021. The data used for the research were obtained from the medical cards (history of mother) in the Hospital archives. Considering the sensitivity of the research topic, medical cards were reviewed after obtaining written informed consent from the adult mother and legal parent/guardian of all under 16s mother of achild, and permission from ACSH. During data collection and processing, the confidentiality of the personal information was kept.

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Aman, H., Ahmad, S., Chala, G. et al. Determinants of externally visible birth defects among perinatal deaths at Adama Comprehensive Specialized Hospital: a case-control study. BMC Pediatr 24 , 260 (2024). https://doi.org/10.1186/s12887-024-04729-8

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Cybersecurity and Data Privacy

Various sessions zeroed in on cybersecurity measures due to the increasing digitization of healthcare, with many conferences offering educational tracks dedicated to the concern. Speakers delved into the escalating threats posed by cyberattacks, ransomware, and data breaches, underscoring the urgent need for robust security measures and proactive risk management strategies. Presenters also highlighted the critical importance of safeguarding patient data and fostering a culture of cybersecurity awareness and resilience within healthcare organizations. Sessions emphasized the imperative of prioritizing cybersecurity and data privacy to safeguard patient trust, preserve organizational integrity, and mitigate the ever-present risks of cyber threats.

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Assessment and Documentation of Social Determinants of Health Among Health Care Providers: Qualitative Study

Brooks yelton.

1 Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States

Jancham Rachel Rumthao

Mayank sakhuja, mark m macauda.

2 Center for Applied Research and Evaluation, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States

Lorie Donelle

3 College of Nursing, University of South Carolina, Columbia, SC, United States

Michelle A Arent

Xueying yang.

4 SC SmartState Center for Healthcare Quality, Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States

Xiaoming Li

Samuel noblet, daniela b friedman, associated data.

Interview guide.

Barriers and facilitators of social determinants of health (SDOH) assessment and documentation.

The data sets generated during and/or analyzed during this study are available from the corresponding author on reasonable request.

Research clearly demonstrates social determinants of health (SDOH) impact health outcomes. Provider consideration of patient SDOH in prevention and treatment planning is critical for improved health care quality and health equity. Despite awareness of the connections between SDOH and improved population health, research demonstrates few providers document patient SDOH.

This qualitative study aimed to better understand the barriers and facilitators of SDOH assessment, documentation, and referral in different health care settings and roles.

Individual semistructured interviews were conducted with practicing health care providers in South Carolina between August 25, 2022, and September 2, 2022. Participants were recruited via community partners’ web-based newsletters or listservs using a purposive sampling design. An interview guide with 19 questions was used to explore the following research question: How do SDOH impact patient health and what are the facilitators and barriers experienced by multidisciplinary health care providers assessing and documenting patient SDOH?

Participants (N=5) included a neonatal intensive care unit registered nurse, a nurse practitioner, a certified nurse midwife, a family and preventive medicine physician, and a counselor (licensed clinical social worker) with careers spanning 12 to 32 years. Participant responses are presented according to the following 5 themes: participants’ understanding of SDOH for the patient population, assessment and documentation practices, referrals to other providers and community-based resources, barriers and facilitators of SDOH assessment and documentation, and SDOH assessment and documentation training preferences. Overall, participants were aware of the importance of including patient SDOH in assessment and intervention but noted a variety of institutional and interpersonal barriers to assessment and documentation, including time constraints, perceptions of stigma around discussion of SDOH, and limited referral protocols.

Conclusions

Incentivizing inclusion of patient SDOH in health care must be facilitated from the top down, so assessment and documentation can be universally implemented in a pragmatic way that works for providers in a variety of roles and settings for the betterment of health care quality, health equity, and improved population health outcomes. Partnering with community organizations can serve to augment health care organizations’ resource and referral availability for addressing patients’ social needs.

Introduction

Social determinants of health (SDOH) are defined by the United States’ Healthy People 2030 (HP 2030) as “the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” HP 2030’s data-driven national objectives categorize SDOH into 5 fundamental domains: economic stability, education access and quality, health care and quality, neighborhood and built environment, and social and community context [ 1 ]. Increased research interest in SDOH among the public health and medical community is driven by evidence SDOH clearly impact health outcomes. Between 30% and 55% of health outcomes are ascribed to SDOH [ 2 ].

Population health has become an increasingly critical focus of health care delivery, especially during the COVID-19 pandemic [ 3 ]. SDOH factors allow clinicians to consider potential contributors to poor health outcomes, reduce health disparities, and transform health care delivery through partnerships with community-based resources [ 4 ]. Using nonbillable diagnostic “Z codes”—specific to SDOH—provided by International Classification of Diseases, 10th Revision, Clinical Modification in electronic medical record (EMR) systems provides clinicians and their medical teams with the opportunity to identify and document SDOH issues, establish appropriate intervention plans, reduce costs, and enhance health care delivery with an eye toward improving health equity [ 5 , 6 ]. To improve health care quality and quality of life, structural health perspectives that recognize and engage with the experiences and backgrounds of diverse individuals are critical in closing equity gaps and reducing health disparities [ 7 , 8 ].

An empirical study of clinical application of Z codes in South Carolina before and during the COVID-19 pandemic found Z codes were only documented for 1.23% of patients in a large statewide sample [ 9 ]. This research demonstrated an overwhelming lack of attention to the social context of (ill) health. This was especially true for individuals requiring outpatient care relative to individuals who were hospitalized. Although EMR systems are an efficient method for clinical data collection, the uncertainty in nonclinical diagnostic Z code use and potential differences in assessment tools and data collection methods limit SDOH information quality [ 10 ]. Furthermore, time constraints associated with the medical care model, varied provider conceptualization of SDOH, institutional practices and priorities, and inconsistent knowledge or availability of referral resources inhibit universal assessment and documentation practice. A recent study found higher awareness regarding the need for documenting SDOH among providers in community health centers, social care–associated payment models, and those with greater knowledge of advanced functions within EMR systems [ 11 ]. Health service organizations have attempted to promote clinician documentation and implementation of SDOH diagnostic codes by providing improved SDOH standardized terminology and data principles for which Z codes are categorized [ 12 ]. However, data regarding the effectiveness and barriers of these efforts are limited.

This qualitative study aimed to examine health care providers’ experiences with assessment and documentation of the SDOH impacting patient health and well-being. Through in-depth interviews, our goal was to better understand the barriers and facilitators of SDOH assessment, documentation, and referral in different health care settings and roles.

Study Design

Qualitative research methods were used to address the following research question: How do SDOH impact patient health and what are the facilitators and barriers experienced by multidisciplinary health care providers assessing and documenting patient SDOH?

In total, 7 team members (BY, JRR, DBF, MAA, MMM, MS, and SN) and 2 clinical partners assisted in the development of a recruitment plan to leverage clinical-academic-community partner web-based newsletters or listservs in a purposive sampling design [ 13 ] deployed between July 12, 2022, and August 30, 2022; the opportunity was also advertised on partners’ social media (ie, Twitter). A snowball sampling strategy was also used [ 13 ]. Direct email invitations were sent to contacts identified by partners. Participants were eligible if they were active, English-speaking primary or behavioral care providers in South Carolina with direct patient involvement. Twelve interested participants reached out via email; 7 did not meet the criteria (5 served in administrative or management roles with no direct patient involvement, and 2 were not providers), while 5 participants met eligibility criteria and agreed to participate. There was no previous relationship between the authors and the participants. Participants were made aware of the authors’ credentials and the purpose of this research in the recruitment language.

An interview guide with 19 questions was iteratively developed by 7 team members (BY, JRR, DBF, MAA, MMM, MS, and SN) and reviewed by 2 partners to explore participants’ current knowledge about SDOH and use of International Classification of Diseases, 10th Revision, Clinical Modification Z SDOH codes. The interview guide was piloted with 2 providers, including a clinical partner ( Multimedia Appendix 1 ).

Individual semistructured interviews lasting between 30 and 45 minutes were conducted between August 25, 2022, and September 2, 2022, by 1 study team member (BY) via Zoom; 1 team member (JRR) sat in on 1 interview to take notes. Interviews were recorded and transcribed verbatim through Zoom transcription services and imported into NVivo (version 12, 2022-2023; QSR International Pty Ltd) for analysis.

For codebook development, 1 team member (BY) initially matched concepts to the interview guide using a deductive approach. Two team members (BY and MMM) then independently reviewed and coded 3 transcripts each for comparison and finalization using an inductive approach. Intercoder agreement resulted from iterative discussions between the 2 coders. One team member (BY) then iteratively coded all 5 transcripts using semantic thematic analysis [ 14 , 15 ], and emergent codes were added to the codebook until no new codes were found [ 16 ]. Participant responses are presented according to the following 5 themes: participants’ understanding of SDOH for the patient population, assessment and documentation practices, referrals to other providers and community-based resources, barriers and facilitators of SDOH assessment and documentation, and SDOH assessment and documentation training preferences.

Ethics Approval

This study was approved by the University of South Carolina Institutional Review Board (Pro00122161). Recruitment language providing a description of this study’s purpose, eligibility, procedure, and incentives for informed consent was disseminated through statewide partner e-listservs. Transcribed interviews were deidentified (participant 1, participant 2, etc), revised for accuracy, and imported into NVivo for data management by 1 team member (BY). Original interview audio files were securely stored in a password-protected, cloud-based storage application with limited team member access. Participants were provided a US $25 incentive for their time.

Sample Characteristics

Participants (N=5) included a neonatal intensive care unit registered nurse, a nurse practitioner, a certified nurse midwife, a family and preventive medicine physician, and a counselor (licensed clinical social worker). Participants’ careers in health care ranged from 12 to 32 years, with 1 to 25 years of experience in their current roles. Three participants currently work within a large health care system, 1 participant works for a university health care system, and 1 participant works at a rural, 2-physician practice. Two participants also serve as faculty members involved in training the health care workforce within a university system ( Table 1 ).

Sample characteristics.

Participants’ Understanding of SDOH for the Patient Population

Participants seemed to have a good understanding of SDOH and were able to reflect on how SDOH might impact their specific patient population. All participants reported SDOH are important to assess for improved treatment planning but described a range of assessment and documentation practices. Participants identified a variety of SDOH impacting their patients including general access barriers (time, transportation, and childcare), health care access and quality (affordability and provider’s time), education and health literacy, poverty and material constraints, food insecurity, and social connectedness. For example, 2 participants gave an overview of the different SDOH affecting patient populations:

The neighborhood around our practice has, you know, folks that have a lower socioeconomic standpoint, so that’d be one, lower education rate as a as another. So, food insecurity is another social determinant. We also look at social connectedness as another one, and finances as a fifth. Participant 4

I would define social determinants of health as those factors that impact patients’ access to care, patients’ understanding of their care, and maybe the resources that are available to them. I think things outside of - yeah, those things that are sometimes kind of hard to quantify and it’s certainly hard to elicit. Participant 3

Another participant focused in on health literacy as a salient problem among patients, further adding limited provider time reduces opportunities for health education:

You know, so a lot of our patients, you know, you can break it down to the sixth-grade level, and it’s still over their head. You know, it’s like, you know, the population when it comes to understanding, having what I call “health intelligence”, are not even at the second-grade level. So, social determinants of health, you know, education is a joke, our healthcare system doesn’t allow the health care providers the time they need to teach the patients and then of course, on the patient side, they just gave up. Now, that’s not all of them, that’s just most of them. Participant 2

Participant 5 explained how using SDOH can help understand patient challenges and improve outcomes:

If I look at, just in general, my work in mental health, the patients are very often hindered from whatever they want, because of other things like finances, or they don’t have food. So, for example, I’ve served as a home health social worker, and I was only pulled into the cases where they weren’t getting better because of the social determinants of health. Obviously, if you’re not eating, your wound won’t get better, right? Obviously, if you’re about to be evicted and you’re taking care of your loved one who’s dying, you can’t take care of them, you’re working on the eviction. Participant 5

The issue of access (whether it be constraints on time, transportation, and childcare) highlighted by participant 1 illustrates the importance of supportive health care services that attend to the entire family (parent caregivers) as well as patients.

I think the biggest social determinant and social justice problem that I see is with our patients – I mean, the parents of these patients – is their access, and their availability to be able to be with their babies at this very, very vulnerable time. So, making sure they have what they need and the equal opportunity to be able to access their child is a big problem that we see. Participant 1

Assessment and Documentation Practices

While 2 participants were familiar with International Classification of Diseases Z codes (Z55-65) specific to SDOH, 3 were not. Only 1 participant reported the use of these Z codes to actively document patient SDOH, indicating the codes were recommended by their EMR system to be added to the problem list and visit encounter. Three participants documented SDOH via provider notes or the patient education or care plan, and 2 participants indicated an automatic screener.

All participants agreed that assessing and documenting patient SDOH was very important and beneficial for improved health outcomes; however, most (n=4) noted SDOH are not systematically or consistently assessed. One participant stated asking whether SDOH is standard social work practice. Another participant mentioned that while sometimes more basic questions are asked, there is often no in-depth assessment, especially for outpatient care:

The focus is on the disease process and how to -- which medication to prescribe. I’ve seen it before, you know, I mean, they don’t really dig deeply these days. Now, if we’re talking about a medical student, or medical resident, or patients being admitted, man do they dig. But when you get out into a practice, like outpatient, stuff like that -- the social determinants really are boiled down to a few very minor things that are “yes” or “no” questions or basic answers when they fill out an application. Participant 2

I think everybody, if we’re intervening with the patient, I think it is [our] ethical and moral responsibility to ensure that we’re addressing the needs of the entire patient, because it’s not just a medical need, or the daughter doesn’t just take care of the medical needs, or the nurse just doesn’t take care of nursing needs; I mean we take care of the whole patient in their family.... It doesn’t need to be this conversation of, “Oh, well we don’t talk about these things,” or “This is just the way that it is.” I mean, we’re all human beings and we all deserve the right to access equal access and equal opportunity. Participant 1

When asked, “How often do you or does someone in your practice ask patients about social determinants of health?” no participants reported having a universal protocol to assess patient SDOH at each visit. All participants indicated they will either start to notice patterns or patients will specifically bring SDOH up over time, despite not actively screening for them. One participant stated they ask the patients questions about their lives in a conversational manner at each visit to glean information about SDOH, and 1 participant indicated an annual electronic screener all patients attending their practice receive. One participant said they ask at each initial appointment if the patients are affiliated with one of their grants requiring assessment of certain SDOH.

Referrals to Other Providers and Community-Based Resources

When asked what is done when a need is identified, all 5 participants reported they refer patients to a variety of external providers and local community partners who provide health and social services such as new parent education, counseling and substance use services, and vocational rehabilitation. Specific national organizations participants mentioned included Ronald McDonald House, United Way, and First Steps, and 1 participant mentioned partnering with 2 community organizations through the NowPow platform [ 17 ]. One participant specified “attributed life” patients with certain insurance plans are eligible for referrals (official work orders) to the care coordination wing of the health care facility, bypassing the in-office social worker. One participant, a social worker, reported they actually provide the client with a list of suggestions for outside services, including legal or welfare benefits assistance, and this is documented in the patient’s case notes along with whether or not the patient followed up.

Three participants indicated they would make contact with an internal provider, such as a social worker, or to a provider who does semiregular drop-ins, such as a nutritionist, physical therapist, or podiatrist. Two participants reported directly addressing the need on-site at the time of the encounter:

We do have that very close-knit relationship [within our care team] where we can just go and talk to [our providers] face-to-face and be like, “Well, we need to get somebody to come address this, or we just need to, you know, have an intermediate interdisciplinary meeting, where we have everybody there at the same time.” Things like that. As far as transportation, we can get with social work to try to get like taxi vouchers or bus vouchers or whatnot. Participant 1

So, there are some organizations that will help. It’s just a matter taking the time and making the phone call. I find if you give the patients the information and ask them to cold call, they don’t seem to. So, we kind of take the groundwork, and [if] they have a contact person, I think it seems to work a little bit easier. We’ll bring them in the office. I’ll bring them in my office, and we’ll make the call and see if we can’t get them. Participant 3

Barriers and Facilitators of SDOH Assessment and Documentation

Participants offered their perspectives on barriers to assessment and documentation of SDOH (see Multimedia Appendix 2 for participant quotes specifically focused on the theme of barriers and facilitators). When asked, “What makes it difficult to assess and/or document patient social needs?” the majority of participants referred to the system-level barrier of profitability, with the most frequent responses relating to insurance or billing demands and limits to time with patients. Two participants reflected on how revenue generation, for better or worse, is a driving force in modern clinical practices.

Although participants identified several limitations in relation to billing, there was acknowledgment insurance companies are attempting to be more holistic when it comes to patient assessments and to reimburse clinics more appropriately when they have patients with complicated health issues. In addition, currently, Z codes are not reimbursable, so there is little incentive for clinic personnel to take the time to enter them.

From the microlevel perspective, patient reluctance and a sense of stigma were mentioned most frequently. For example, patients may find SDOH questions intrusive and not the purview of a medical provider. However, all participants perceived patient-provider trust and rapport as a facilitator of SDOH assessment, noting it is important to be conversational with patients, to “normalize” the questions, and to build long-term relationships. The next most frequently perceived barrier was an inability to address the patient’s SDOH, whether due to a lack of provider knowledge as to how to help the patient when an issue was identified or a lack of available resources or services to which the patient could be referred.

SDOH Assessment and Documentation Training Preferences

Participants identified continuing education credit-eligible brown bag sessions (informal meetings or trainings typically occurring over a lunch break), web-based courses, catered dinners, and destination conferences as their general preferences for training formats . Two participants stated they had training in assessment of SDOH during their nursing or social work education, while the other 3 expressed they have learned through experience. The 2 participants involved in training the health care workforce acknowledged this is still being done at the educational level and felt additional training targets, such as patient-provider simulations, could be incorporated into the curriculum.

We do something like this [with our students], like they get X amount of stipend, like with their paycheck, and then they have to go to all the community sources and make sure they can get groceries. But then I gotta pay the light bill, and this is like, they realize how quickly sometimes their money can go. Even incorporating that, now you’ve been hospitalized, and you could incorporate that into a lot of nursing education. Participant 1

From a standpoint on how to ask the question, we do well. I guess part of my job is actually to help train the residents and medical students on how to ask the questions. And, so we do more of video feedback for the residents, and such.... But, for the attending faculty like myself, that is not necessarily something that they do for us per se. So, I’ve kind of more learned on my own, when it comes to that. Participant 4

While only 1 participant reported having training on the use of Z codes from the “billing aspect,” the majority of participants did not feel training on SDOH assessment and documentation would be very beneficial without a system-wide push for a standardized protocol.

Four participants stated they would not benefit from training on how to ask patients about SDOH; 1 participant felt they would benefit from training to improve their knowledge of Z codes and more efficient documentation to save time.

Yeah, I guess I think about, you think about behavioral change, or you think about practice improvement or quality improvement, is that the more that you can do it a higher functioning level where it doesn’t rely on the individual person to change that actually makes it a more sustainable model. And so, giving a doctor education on the importance of health literacy, I think in the end is the least helpful long term. It needs to be something where it is with, like in the EMR, how the social determinants of health from the screener say, you know, “here’s some ICD-10 codes you should add to your bill,” and all you gotta do is click a few buttons. Because, I can scan it and agree, like “yep, yep, yep”, and then I can move on. Participant 4

Principal Findings

Overall, participants in our study conceptualized the SDOH of their patient populations in accordance with HP 2030 and could indicate how individuals in their care were affected by the 5 HP 2030 SDOH domains. Microlevel social needs identified by participants included material constraints such as time (to be with their child in the hospital), transportation, financial and food access barriers, and social disconnectedness. Identified SDOH at the macrolevel included poor education quality, with specific attention to a lack of health education that can contribute to limited knowledge of positive health behaviors and limited health literacy on the individual level. All participants mentioned the broader aspects of the SDOH domain of health care access and quality when describing the barriers to assessing and documenting SDOH during the clinical encounter (ie, time constraints and inconsistent documentation protocol).

Organizational Challenges to Assessment and Documentation of SDOH

Participants realized the context of one’s life has a crucial role in the development and management of health conditions. All participants agreed assessing and documenting patient SDOH were very important and beneficial for improved health outcomes but most (n=4) noted it is not done consistently. Consistent with findings by Heidari et al [ 18 ], participants in our study mentioned several barriers regarding the assessment of SDOH and appropriate referrals, including a lack of universal screening protocol and little incentive to screen for SDOH or to use Z codes. Medical providers have very limited time with patients, so any additional information gathering can be difficult to accommodate consistently if not designed to seamlessly (efficiently) integrate within the health care encounter.

Despite the lack of formal methods of screening, all participants noted patient social needs are often revealed over time, whether through direct patient disclosure or indirect indicators of barriers to treatment adherence (eg, inability to read a prescription label, lack of transportation, and food insecurity). While 2 participants delivered annual or semiannual formal SDOH assessments to some or all of their patients, all participants suggested a more conversational approach often served to elicit depth of information on patient SDOH. However, even in instances where SDOH information is gathered informally, it can be difficult to act upon the information, since resources can be difficult to find or unavailable. This can lead to providers becoming frustrated since they feel they cannot help their patients and are thus wasting valuable visit time.

Z codes, while they present a way to quickly and consistently record SDOH information, are not billable to insurance so they may be supplanted by billable codes when numbers of codes are limited. Entering codes was also seen by participants as an inefficient use of time, especially in for-profit settings, since entering nonbillable codes takes time away from the entering of billable codes. Billing code disincentives have created unintended consequences for individual clinics to inquire about SDOH or to use Z codes that must be addressed at the system level. For example, validated screeners may provide a way to gather SDOH information but must be implemented as a system-level policy. Thus, especially in for-profit settings, the use of Z codes must be aligned with economic goals. Insurance companies can already support SDOH screening by using value-based models that incentivize longer-term patient outcomes. Making codes for SDOH billable would help further move medical services in the direction of more holistic care [ 19 ]. Efforts to consistently and adequately address unmet patient social needs may require state-level actions, such as those being implemented in North Carolina through the Healthy Opportunities Pilot initiative [ 20 , 21 ]. While this serves as a potential model, it is unclear how this type of collective intervention may be impacted by state Medicaid expansion decisions, legal, and budgetary constraints [ 22 ]. Additional strategies are needed to ensure all patients’ social needs are addressed, regardless of income or type and level of health care coverage.

Community and Societal Challenges to Clinical Documentation of SDOH

Participants perceived patient reluctance and apprehension of stigma as interpersonal barriers to the assessment of SDOH. There is some emerging evidence related to the stigmatization of the SDOH. Rather than an acknowledgment of the important ways in which the life context impacts our health and well-being, participants in this study alluded to the SDOH negatively, demonstrating SDOH are perceived as deficits rather than basic health and human rights, such as access to adequate food, income, education, transportation, supportive social networks, housing, freedom from racism, and freedom from other discrimination. This is in opposition to the intended assessment and documentation of patient SDOH as important social “vital signs” impacting health outcomes [ 23 ]. Addressing the SDOH speaks to an understanding of the context of health and demonstrates clinician and organizational knowledge and insight into the factors influencing equitable conditions for optimal health and well-being. The stigmatization of the SDOH undercuts opportunities to positively impact individual and population health outcomes [ 24 ]. In addition, providers should be intentional in communication practices, using language that carries less stigma to underserved or historically marginalized community members and incorporating questions surrounding cultural, linguistic, and spiritual patient needs [ 25 ].

The next most common perceived barrier was an inability to address the patient’s SDOH. Our findings are consistent with those of Kostelanetz et al [ 26 ], who reported clinician-perceived barriers to SDOH screening among acute care patients including limited resources to address social needs, limited or no time or staff allotted for SDOH screening, and lack of training to address existing social care needs. There is growing consensus for health system and organizational accountability in support of SDOH assessment and documentation by ensuring adequate resources for screening education, patient support services, and referral to institution resources, community organizations, and public health agencies and to create stronger partnerships with community organizations for care that extends beyond the scope of medicine.

Participants suggested trust and rapport facilitate the assessment of patient social needs and felt long-term patient-provider relationships and standardization of SDOH assessment can reduce patient perceptions of provider judgment and reduce a sense of a power dynamic. This creates significant tension for clinicians who predominantly practice within a biomedical model of care and have limited educational exposure or incentive to adopt a social-ecological model of health care that includes attention to the SDOH. Given the importance of patient-provider trust and rapport, clinician practice of cultural humility is necessary for equitable patient care. Cultural humility entails provider openness, self-awareness, and humbleness [ 27 ], and “incorporates a lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic” [ 28 ]. Further, increased patient-provider contact, transparency, physician competency regarding patient social contexts, and genuine demonstrations of care and authenticity in communication can improve patient trust [ 29 , 30 ].

Challenges With Referrals Following Assessment of SDOH

While systematically assessing and documenting patients’ SDOH are extremely important, ensuring there is a clear next step that involves assisting patients with social factors that impact health through referrals to community resources and organizations is vital for improved health outcomes [ 31 ]. Participants referred patients to both external providers and local community partners, documenting these in the EMR regardless of the need for a direct referral. Some participants, particularly those practicing in more rural areas, expressed frustration over the lack of local services to meet some of their patient needs. In addition, the concept of “social prescribing,” or recommending patients who engage in civic, art, recreational, or other activities to improve overall health and well-being [ 32 ], encourages sustainable, socially engaged outlets for patients. To alleviate provider burden for identifying and connecting with adequate, vetted, and accessible referral sources, there needs to be a concerted effort to connect to or build a referral infrastructure (ie, NowPow) to reduce future time burdens. This would require partnerships across health-serving sectors, including hospital systems, government agencies, and community agencies. For example, referrals to community adult literacy centers can provide patients with assistance in reading and understanding general and health-related information to improve their health literacy [ 33 ]. Another example is the development of medicolegal partnerships to aid patients in gaining access to or redressing issues impacting a variety of social needs including housing, material assistance, disability, or supplemental income supports [ 34 ]. Additionally, more hands-on referral approaches, where the patient is assisted in making the connection with the referral source and the referral source adequately assists the patient in navigating complex processes (ie, public benefit or housing applications), may eliminate barriers to “referral uptake” for better health outcomes [ 35 ].

Limitations

This study has some limitations. First, we used purposive and convenience sampling to recruit participants. Second, the number of participants interviewed was quite small (N=5), limiting our ability to obtain findings generalizable to a specific health system, to the state of South Carolina, or to other US states. Third, participants had a range of years of experience within the health care field; however, some were newer to their current roles and thus had less experience within their current health care system. This poses a potential limitation for data source triangulation. Future research is warranted with additional providers to further explore assessment and documentation practices, barriers, and facilitators in additional settings in South Carolina. Examining provider and clinic practices by medical specialty and geographic location as well as proximity to referral resources will be important for supporting patients’ social needs following any assessment, documentation, or patient-provider discussions about SDOH. Despite these limitations, findings from our work will help providers and health care systems consider how to effectively integrate SDOH screening during patient-provider encounters, as findings offer important insights into providers’ perspectives and recommendations for SDOH assessment and the barriers and facilitators associated with it.

SDOH have a clear and direct impact on individual and community health status. Clinical providers understand these ties; however, they struggle with the best approach to assess and document SDOH issues in clinical settings. Time constraints in clinic visits, perceived stigma of SDOH, and preference for a more conversational approach to the patient-provider discussion add complexities to data collection, which result in incomplete and inconsistent interactions across populations. Perhaps an institutional culture shift is required to ensure consistent screening and assessment of patients for unmet social needs and provision of appropriate resources, including connections to organizations in the community to assist with these needs. Unfortunately, the stigma surrounding SDOH issues, social isolation, and financial hardships continues to pervade society. Bringing these challenges into the open and talking to patients about them are necessary if the goal is to improve the overall health of patients.

Acknowledgments

We would like to thank the participants for sharing their time and expertise with our team. We would also like to thank our partners Diana Zona (South Carolina Hospital Association) and Dr David Isenhower (Self Regional Healthcare) for their assistance in interview guide development and recruitment planning.

Abbreviations

Multimedia appendix 1, multimedia appendix 2, data availability.

Conflicts of Interest: None declared.

IMAGES

Social Determinants of Health
What Are the Social Determinants of Health?
The 5 Social Determinants of Health and why they matter
Case study on social determinants of health
What Are Social Determinates Of Health
WHO guidelines on Social Determinants of Health

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Methods. An exploratory comparative case study design using qualitative research methods was adopted for the study. A case was defined as action by a CHW (Mitanin) or team of CHWs (Mitanins) on nutrition or violence against women, which has resulted in a positive change in the particular social determinant of health in the context of the village/cluster of villages for which the CHW/s are ...
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Interoperability, Workflow Improvements, Data Quality, AI and NLP. Lauren Stockl, IMO's Trade Shows and Events Manager, explores the top 5 trade show topics of early 2024, from AI to telehealth to interoperability in healthcare. Conferences serve as powerful platforms where the healthcare and health tech industries converge to discuss ...
Assessment and Documentation of Social Determinants of Health Among
Social determinants of health (SDOH) are defined by the United States' Healthy People 2030 (HP 2030) as "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." ... This qualitative study aimed to examine ...

Social Determinants of Health: A Case Study

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Social Determinants of Health Case Studies: Targeting the Social Determinants of Health in Geriatric Populations

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Social Determinants of Health in Non-communicable Diseases

Professor of Social Epidemiology and Health Policy, Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, Chiba, Japan

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Behavioral Problems in Children

Metabolic Syndrome

Cancer and Socioeconomic Status

Coronary Heart Disease

Chronic Kidney Disease

Diabetes Mellitus

Falls and Related Bone Fractures

Malnutrition in Older People

Oral Health

Healthy Aging: IADL and Functional Disability

Life Course Epidemiology

Social Capital and Health

Social Determinants of Health

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Determinants of externally visible birth defects among perinatal deaths at Adama Comprehensive Specialized Hospital: a case-control study

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Sample size determination and sampling technique

Study variables

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Data analysis and interpretation

Socio-demographic characteristics of the mother

Reproductive and obstetric characteristics

Classification of the birth defects

Determinants of externally visible birth defects

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