Healthify Blog

Collecting SDoH Data to Address Health Inequities

social worker with client

How gathering SDoH data can inform population health strategies

As the healthcare industry continues to recognize the impact of the social determinants of health (SDoH) on overall health, it's becoming critical for health plans and providers to look beyond the four walls of clinical care to address these nonclinical factors. And even though research has shown that SDoH can have an impact on up to 40% of an individual's overall health, for some communities that impact can be even more significant. In minority populations, particularly, SDoH can be challenging to overcome.

To close the health equity gap, a better understanding of the social needs impacting minority communities is vital. By having better insight into the different domains of SDoH affecting minority populations, healthcare organizations (HCOs), government, community-based organizations (CBOs) and advocacy groups are in a better position to create programs that drive targeted interventions for specific needs within those communities.

SDoH Disproportionately Impacts Minority Communities

SDoH challenges affect people everywhere, but numerous studies have revealed that they can disproportionately impact minority populations. For chronic conditions like diabetes, there are associations between differences in health literacy and self-care that is attributed to differences in education and income, including job stress, difficulty paying for health care expenses and lack of affordable transportation. Because of this, socioeconomic factors may largely account for racial disparities in health behaviors and health literacy.

For example, a recent study found that diabetes affects 12.7% of African Americans, 12.1% of Hispanics and 8.0% of Asians compared to 7.4% of whites. By 2050, diabetes cases are expected to increase in the Asian population by 212.9%, Hispanics by 187.9%, and African Americans by 71.3%, compared to 32.4% growth in the white populations.

A number SDoH factors are attributed to the disparity, including social factors such as the influence of family, friends and coworkers, but also housing instability, food insecurity, physical activity, socioeconomic position and care access. Environmental factors, such as a lack of restaurants serving healthy foods, less safe neighborhoods and a lack of accessible walking trails can also contribute to a higher risk of diabetes, researchers found.

Despite the association between SDoH and chronic conditions, there are likely resources that already exist within communities that can help overcome these challenges. And by collecting, compiling and sharing population-level and patient-level data, healthcare organizations (HCOs) can have a better idea of the needs in the community and what levers need to be pulled to meet those needs.

Collecting SDoH Data to Identify Health Inequities

In the last few years, Grand Rapids, Michigan was identified as one of the fastest-growing US cities with economic opportunities for businesses and one of the best places to call home. But those polls did not reveal the bigger picture: Grand Rapids also ranked among the worst large US cities for African Americans economically. Almost 40 percent of African Americans in the area live in poverty and are three times as likely to be unemployed as whites and more than 40 percent of Hispanics live in poverty.

After recognizing the stark health disparities, the city of Grand Rapids launched a citywide effort to improve racial equity. Part of that initiative included developing comprehensive reporting structures to inform new systems, initiatives and programs that address the growing health inequities in the area. For example, the city worked with the NYU School of Medicine's City Health Dashboard (CHDB) Advisory Committee to help adapt a resource for local groups to have access to more city- and neighborhood-level data. The CHDB allows users to compare data points⁠—social and economic factors, physical environment, health outcomes, health behavior, and clinical care⁠—of Grand Rapids to the national average on a citywide level.

Using this data, local organizations can develop targeted approaches to the issues facing their community. To complement the CHDB, the city's economic development department developed an interactive Economic Opportunity Dashboard that shows economic inequities and compiles historical data on city investments. It also compares education attainment, unemployment, and racial demographics between different neighborhoods in Grand Rapids, Michigan.

Key SDoH Takeaways

SDoH data plays a significant role in the development of targeted interventions and population health programs. As healthcare costs continue to rise and health equity gaps continue to widen, organizations must recognize the efficiency associated with understanding the needs of their populations, beyond clinical data, and the importance of gathering and reporting the data across the care continuum.

On Monday, June 24th, Healthify's CEO and Cofounder, Manik Bhat, will talk about how to better understand social needs in your community and how to leverage partnerships and local resources to address SDoH. Join us at the RISE National Summit on Social Determinants of Health for the panel at 4:25 pm and learn more about:

  • Steps to understand needs in your community
  • Barriers to coordinating with community partners
  • Metrics to align on to track the success of a network
  • Intervention design with community partners
  • Emerging trends in reimbursement for community partners

Click the button below to learn more about the RISE National Summit on Social Determinants of Health and the panel.

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Topics: healthcare delivery population health minority health SDoH data