We have a terminology problem

By Austin Frakt

The community of scholars (including some of us on this project) and the health care industry have been using “social determinants of health” to mean so many things that it has lost its original meaning. Sometimes precise definitions don’t matter too much if everyone knows what is meant from context. But I don’t think that’s the case here. We need to be more careful with our words.

In the broad space that encompasses social determinants, social needs, social risk factors, and population health (and related concepts), there are many important concepts worthy of precise terminology. I want to focus just a few issues here.

The first issue is that many conflate the terms “social needs” and “social determinants of health” (SDOH). Are they the same thing? I will argue they should not be, but I have been guilty of confusing them. Some of the early writing on this project, and even on this site, reflects this confusion. Here are two other examples:

• A recent JAMA paper focused on “social needs” screening is careful to use that term, but an Axios piece about it called it screening for “social determinants of health,” a term that does not appear in the paper (apart from references).
• A JAMA Open paper largely used the SDOH term but also used “social needs” when referring to the same concepts.

Of 64 people who responded to an informal Twitter poll for this project, 84% believed that SDOH and social needs were different things. What is the difference?

On the Health Affairs blog, Brian Castrucci and John Auerbach put it this way:

[W]hen you take a closer look, these articles [on “SDOH”] aren’t about improving the underlying social and economic conditions in communities to foster improved health for all – they’re about mediating patients’ individual social needs. If this is what addressing the social determinants of health has come to mean, not only has the definition changed, but it has changed in ways that may impede efforts to address those conditions that impact the overall health of our country.

SDOH pertain to broad social conditions found in communities and society. Or, as defined by the WHO, they are “the conditions in which people are born, grow, live, work and age,” which are “shaped by the distribution of money, power and resources.” In other words, they are underpinned by major structural factors and institutions. Though they affect the health of individuals, they are not individual-level factors.

“Social needs,” on the other hand, are individual-level. An individual’s housing instability or food insecurity are social needs. Naturally, they can stem in complex ways from SDOH (e.g., racial discrimination), but they are not themselves SDOH.

It is disappointing that this term also uses the word “social” since that conveys that it pertains to the organization of society or to the relationships among people (plural). That’s closer to what SDOH is about. It is also disappointing that the term uses the word “needs,” as it implies that only disadvantages in certain areas affect health. That’s not true. Advantages can help support good health just as disadvantages can promote poor health. (It is worth noting that others have suggested the terms “social risk factors” and “behavioral risk factors” [for behaviors, like smoking or substance use] instead of “social needs.”)

It’s of some significance that RWJF reports that, according to its metrics, progress has stalled on addressing SDOH. A prerequisite to making progress is to understand what it is. Focusing on social needs and believing that addressing them at an individual level will also address society-wide SDOH reflects a large misunderstanding.