Teaching Family Medicine Residents How to Identify and Address Social Determinants of Health

Social determinants of health (SDH) are the conditions in which people are born, live, learn, work, play, and age. Resources that enhance quality of life, such as safe housing, access to education, and availability of healthy foods can have a significant influence on population health outcomes.¹ Studies suggest that medical care accounts for 10%-20% of the modifiable contributors to health. The other 80%-90% are determined by a person’s social determinants of health.²

Training programs have begun to address social determinants of health in their curricula, however, the best way to approach this topic is undetermined.³ Most current strategies aim to increase awareness of the social needs of patients but do not address them in an effective or practical way.^3-6 Curricula are inconsistent and have insufficient connections to community-based resources.³ Currently, inclusion of this material into standard residency training is sporadic and often optional.³

We designed a curriculum using cognitive constructivism and behavioral change theory. Cognitive constructivism was implemented by developing critical thinking through reflection. Behavioral change theory was utilized as the learners were given the skills and environment to elicit a changed behavior.⁷ This curriculum was unique because it taught the concepts and improved awareness of SDH and also allowed the trainees to apply their new knowledge by changing their behavior in clinical practice. The goal of this program was to train residents in how to screen for and address the social determinants of health of their patients.

The program was instituted at a community hospital family medicine residency program. Thirty residents participated in the program. This program was exempted from formal institutional review board approval by the Feinstein Institutes for Medical Research Northwell Health due to the limited data collected from participants, and because the study design prevented the identity of the subjects from being readily ascertained.

We used a mixed-methods approach to evaluate the program. The researchers designed a survey instrument using a 5-point Likert scale to evaluate program success. The survey was based on other surveys used by similar programs aiming to teach SDH to residents.⁶ Several faculty members and residents reviewed and edited the questions to maximize face validity. The Cronbach α was 0.8, indicating excellent internal consistency in the responses. We analyzed this survey by a quantitative method using a paired t test. The researchers designed a reflective exercise for the study. We analyzed the reflections using grounded theory with a descriptive coding strategy (a qualitative research method). The survey and reflection are available on the STFM Resource Library.⁸ We identified and agreed upon several recurring themes in the reflections.

Both the surveys and reflections were administered on paper. We used an identifying number, known only to the participant, to link pre- and postsurveys and maintain anonymity. We manually transferred the deidentified data to Microsoft Excel.

The first survey was administered before the curriculum was implemented. After 6 months, the follow up survey and reflection were completed. Implementation of this program required four 1-hour didactic sessions.

Residents were able to design a screening tool to meet the needs of their patient population using the Health Leads Screening Toolkit.⁹ Health Leads provides recommended screening and alternative questions. All questions were validated and their precision and reading level were available for reference. During the didactic session, the residents, as a group, discussed and voted on which question to use for each domain. The screening tool they designed is available on the STFM Resource Library.¹³ After participating in the didactic sessions, residents were expected to apply their new knowledge at their ambulatory clinic. SDH screenings were completed for all annual physicals. Residents were expected to address any positive screens, refer the patients to appropriate resources and follow up with each patient, as needed, until the social needs had been sufficiently addressed. 

Thirty family medicine residents participated in the program and all participants completed the surveys and reflections. We analyzed pre- and postsurvey scores using a paired t test. The P value was <.05 for all individual questions and the total scores, which showed a statistically significant change in the residents’ level of comfort as well as their understanding and consistency of addressing social determinants of health.

Several themes emerged upon analysis of the residents’ reflections. These are shown in Table 4. Twenty-seven out of 30 residents identified a specific plan to address SDH after graduation.

Prior studies highlighted that most curricula increased awareness but did not address SDH in an effective way.^2-4 Educational programs lacked practical application⁴ or an association showing physicians increasingly addressed these needs after training⁵. This program was unique in that it taught the content in didactic sessions and also provided the residents with the practical skills required to address these needs with their patients.

The surveys showed a significant improvement in the residents’ level of comfort, understanding, and consistency of addressing SDH. The reflections showed an increase in awareness of social needs such as financial strains, ability to access resources and the importance of thorough conversations with patients. Most residents identified a specific plan detailing how they will address the social needs of their patients upon graduation. This extension of knowledge to practice is important, as 80% of a patient’s health depends on their SDH.¹

Study limitations included that the program was implemented at one institution with a limited number of residents and all of the data were learner self-reported. Compliance with the screening tool was overseen by faculty. There was no external verification of how often or consistently the screening tool was used and if the needs identified were resolved. Further research could include a retrospective chart review to determine if this curriculum led to increased identification of social needs and how many patients were able to access resources after being identified. We could also follow residents beyond graduation and determine how many graduates address SDH as a standard of care in their practices. We anticipate that further studies that address SDH in residency education can positively impact the health outcomes of patients.