Carolanne Wartman, PharmD, BCPS, BCPP
Clinical Assistant Professor of Pharmacy Practice
The University of Mississippi School of Pharmacy
Social Determinants of Health (SDOH) encompass the social conditions shaping individuals’ lives including where they are born, grow, work, live and age. This complex framework significantly influences not only one’s health, but also their overall well-being and quality of life.1 These SDOH are commonly grouped into five distinct domains, seen in Figure 1.
Figure 1: The five domains of social determinants of health, by the Centers for Disease Control and Prevention.2
SDOH play a pivotal role in shaping mental health outcomes by contributing to chronic stress, anxiety, depression, among others.3 This impact extends beyond individual experiences to create a ripple effect in the broader spectrum of health disparities evident across communities. These disparities are intricately rooted in factors like race, class, geography, education, and health care access. The interconnectedness of these determinants underscores the need for a holistic understanding of health, by acknowledging the complex interplay between societal conditions and mental well-being.
When I began asking patients about SDOH, I felt as if I was being intrusive or potentially causing reemergence of trauma. It’s crucial to recognize this possible discomfort, which may necessitate the building of rapport before the patient feels comfortable sharing this information with you. On the other hand, others may readily share their experiences. Just as we provide individualized care and approach each patient uniquely, you may need to adjust the timing and approach to inquiring about SDOH with each patient.
Understanding that SDOH encompasses various elements allows for a seamless integration into patient assessments. In recent years, electronic health records (EHR), like Epic, have incorporated SDOH screening tools into patient charts, serving as a reminder for clinicians to assess these various domains.4 Unfortunately, accessibility varies across health systems and even locations within the same health system. Thus, it is imperative for clinicians to implement their own routine for assessing these factors. If discussions regarding SDOH do not naturally occur, a simple way to integrate them into practice is when asking about other social aspects of care, such as with family and social history. For example, when addressing diet and physical activity, it’s imperative to first inquire about means of access. Asking “Do you have access to nutritious food?” or “Do you have opportunities to engage in safe, physical activity?” before providing education on healthy practices. This patient-centered approach respects individual circumstances and contributes to a more comprehensive model of care.
Many of my patients face greater challenges than I could ever imagine. As an individual with considerable privilege, addressing some of these issues often feels daunting. It’s not uncommon to experience discouragement, grappling with the realization that I can’t do more for my patients – remember that this feeling is normal! Navigating various SDOH requires collaboration by establishing partnerships with community organizations, being knowledgeable of local resources, and adopting a multidisciplinary approach. The table below outlines a few examples of questions and practical approaches to address each SDOH domain. Additional screening tools can be found online, such as the North Carolina Department of Health and Human Services SDOH Screening Questions.
Table 1: Example of Screening Questions and Practical Approaches to Address the Five SDOH Domains
| SDOH Domain | Examples of Questions to Ask | Ways to Address |
| Education Access and Quality |
|
|
| Health Care and Quality |
|
|
| Neighborhood and Built Environment |
|
|
| Social and Community Context |
|
|
| Economic Stability |
|
|
Identifying SDOH is an ongoing process that requires a dynamic and patient-centered approach. Implementing standardized questions, such as those listed above, has been a practical strategy for enabling a systematic evaluation of SDOH. Additionally, fostering open and non-judgmental communication with patients creates an environment where they feel comfortable sharing personal information related to their social context. Given the evolving nature of SDOH, it is imperative to continuously ask about the various domains and monitor progress on SDOH interventions. Regular follow-up assessments, coupled with open communication, allow providers to gauge the impact of interventions and adjust as needed. Utilizing technology, such as the EHR, can also facilitate the tracking of SDOH-related data. By incorporating specific indicators related to social determinants into patient records, health care teams can systematically monitor changes over time. This data-driven approach enhances accountability and allows for evidence-based adjustments to interventions.
The integration of SDOH into mental health care is a professional and ethical responsibility. It is essential to approach discussions regarding SDOH with respect for a patient’s boundaries and with compassion. As health care providers, we must remain committed to evolving with the understanding that promoting mental health goes beyond traditional clinical boundaries and requires a holistic, patient-centered perspective.
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