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Building a Better Evidence Base to Address the Social Determinants of Health

A recent literature review revealed most studies of social need interventions were poorly designed, inadequately documented, and inconsistently presented. In this post, Robert Dubois of the National Pharmaceutical Council, an AcademyHealth Organizational Member, outlines the state of the research and provides recommendations to improve study design quality.

Students gathered around a computer.

The COVID-19 pandemic brought out some of the most innovative parts of health care, especially the remarkably fast development of vaccines. But it also shone a brighter spotlight on some of the most significant disparities in the American health system, including greater declines in life expectancy among Blacks and Hispanics.

During the pandemic, Blacks and Hispanics also have seen poorer outcomes resulting from social determinants of health (SDOH) -- factors that include education, neighborhood and physical environment, employment, racism and social support networks, as well as access to health care. These factors often have as much or more to do with health outcomes than what many people might call “traditional” health care.

In recent years, there has been significant enthusiasm among policymakers and other stakeholders to develop ways to address these health-related social needs. It is critical to take the steps, however, to evaluate  programs targeting the SDOH to ensure that resources are directed toward interventions that make the impact that is so desperately needed. Unfortunately, these programs have yielded mixed results.

When we look at ways to evaluate how to address health care disparities through social determinants, we must start with a series of key questions:

  • Are these interventions reaching the right groups?
  • What characteristics determine their effectiveness and cost-effectiveness?
  • Who is funding these initiatives and how sustainable are these projects across long periods of time?

To address these questions, Altarum, in partnership with the National Pharmaceutical Council, examined more than 200 publications assessing SDOH interventions across 11 domains, including housing, transportation, income and education.

We found that overall, a large portion of the literature reviewed consisted of studies that were poorly designed, inadequately documented, and inconsistently presented. Only a handful of studies provided enough evidence to determine whether there was a connection between the intervention and the return on investment.

Successful programs had common themes, such as:

  • Housing: interventions that tended to be targeted to populations most in need, used care coordinators and had an education component.
  • Nutrition: interventions where meals were medically tailored to patient needs, included opportunities to socialize, and involved partnerships between community organizations and hospitals.
  • Transportation: interventions that targeted services to low-income patients with specific medical conditions, such as diabetes or hypertension, and involved community-hospital partnerships.
  • Case management: interventions that addressed multiple types of social support, focused on a clear outcome, such as 30-day readmissions or utilization of skilled nursing facilities, and involved community-hospital partnerships.

Going forward, we recommend improving the study design quality through formal guidelines for conducting and evaluating SDOH studies. These guidelines for SDOH evaluations could include focusing on what sample size to use, what outcomes should be reported and the areas for a proper study design.

The truth is that right now, current research lacks the answers we need to determine the best practices to address social risk. We do, however, have some direction for next steps.

The association between social determinants and health care outcomes is clear. Unfortunately, what is less straightforward is how we can address these risk factors in a strategic and data-driven way to know that programmatic efforts are truly making the much-needed difference.

Because improved health outcomes are such an important goal in SDOH interventions, it is all the more vital that we take a smart, step-wise approach to obtaining the evidence needed to show how an intervention improves health.  

As the research pointed out, most studies done to date do not even assess an intervention’s financial impact. Failing to get even basic economic data hurts the ability to evaluate whether an intervention’s benefits, whatever they are, are worth the cost. With health spending on the rise and resources sometimes scarce, knowing whether funds are well-spent is critical.

We need much more robust, granular data, accurately reflecting patient populations, to ensure our health system works best for vulnerable populations. It is truly unacceptable that many communities in the United States have poorer health outcomes and lower life expectancy. Progress is incumbent upon knowing that our interventions are reaching the right people and directing resources to the right places.

Organizational Members are a critical link in AcademyHealth’s ability to effectively advocate for the field, and support the future field of health services researchers. Organizational Members gain visibility among AcademyHealth membership, enjoy unique networking opportunities, and benefit from event discounts. Click here to learn more.

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Author, Presenter

Robert W. Dubois, M.D., Ph.D.

Chief Science Officer and Executive Vice President - National Pharmaceutical Council (NPC)

Robert W. Dubois is the chief science officer and executive vice president of the National Pharmaceutical Coun... Read Bio

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