SDOH and Health Systems Research

Current AHRQ Research Initiatives

SDOH Data Integration and Analytics Grants

In 2019, AHRQ awarded $6 million in grants for an initiative that uses data and analytics to support primary care and community interventions to improve chronic disease prevention and management and population health. Over three years, three grantee organizations will integrate data on chronic disease, SDOH, and community services to create actionable dashboards to support better management of high-risk individuals and populations. Grantees will create and disseminate electronic tools that primary care providers can use with health records to identify social needs and engage with community providers in meeting them. To learn more, read the AHRQ Views Blog Empowering Primary Care Using Data and Analytics to Build a Healthier America.

Selected AHRQ Research Findings Related to SDOH

AHRQ funds and conducts research to improve understanding of the impacts of SDOH and how to mitigate them, through the lens of the healthcare system. AHRQ looks at the relationship of SDOH to healthcare access and use, as well as the effectiveness of healthcare interventions to address patients’ social needs. The following are some examples of AHRQ-supported articles related to SDOH. 

• Adults with diabetes residing in "food swamps" have higher hospitalization rates. The study concludes that the effect is stronger in rural than urban communities, and that improvements to local food environments may help to reduce this disparity.
• Comparing health care system and physician practice influences on social risk screening. This study examined the association of multilevel organizational capabilities and adoption of social risk screening among system-owned physician practices.
• Experiences of community violence among adults with chronic conditions: qualitative findings from Chicago. Investigators found that patients often struggled to balance the challenges imposed by community violence with the demands of living with and managing their chronic conditions.
• Health literacy universal precautions are still a distant dream: analysis of U.S. data on health literate practices. Using MEPS data, AHRQ researchers found that the proportion of adults in the U.S. who reported receiving health literate care increased from 2011 to 2014, but fell far short of health literacy universal precautions recommendations of delivering health literate care to everyone.
• High perceived social support and hospital readmissions in an older multi-ethnic, limited English proficiency, safety-net population. Researchers found that among minorities, those with high social support had half the odds of admission or death than those with low social support. High perceived social support seemed to have the opposite effect among whites.
• Improving social needs intervention research: key questions for advancing the field. In collaborating with SDOH experts in the field, AHRQ researchers summarized the emerging evidence for social needs interventions in healthcare, and identified key areas where more research is needed to advance implementation and policy development.
• A patient navigation intervention for drug-involved former prison inmates. Researchers conducted a randomized controlled trial of patient navigation to reduce barriers to healthcare and hospitalizations for former prison inmates. Their results suggest a significantly lower rate of hospitalizations among navigation participants, although the rate of emergency department/urgent care visits was not improved.
• Patient-provider communication disparities by limited English proficiency (LEP): trends from the U.S. Medical Expenditure Panel Survey, 2006-2015. AHRQ researchers found that before 2010 patient-provider communication was getting worse among LEP individuals and disparities in patient-provider communication were widening. After 2010, patient-provider communication improved for LEP individuals and language disparities by English proficiency either narrowed or remained the same.
• Psychometric evaluation of the Screener for Intensifying Community Referrals for Health. This study validated Screener for Intensifying Community Referrals for Health (SINCERE), a 10-item, low-literacy screening tool developed to elicit social needs, in an emergency room setting.
• What evidence do we need before recommending routine screening for social determinants of health? This editorial discusses the need to determine if SDOH should be discussed during a primary care visit.

For additional AHRQ-supported articles related to SDOH, search AHRQ Research Studies.

For other SDOH analyses using AHRQ datasets, go to SDOH Data and Analytics.

Resources for Researchers

SDOH Data and Analytics: Learn about AHRQ datasets and data analytic tools that can be used to conduct research on the intersection of healthcare and SDOH. Examples include:

• The AHRQ Healthcare Cost and Utilization Project (HCUP)
• The AHRQ Medical Expenditure Panel Survey (MEPS)
• The AHRQ National Healthcare Quality and Disparities Report (QDR)
• The AHRQ PCOR SDOH Data Platform

Tools and Instruments to Assess Individuals’ Social Needs: Find tools including validated instruments to assess research subjects’ social needs.

Community Context: The following data sources from other Federal agencies can help investigators consider the SDOH community context in their research of healthcare.

• Bureau of Labor Statistics  Consumer Price Index
• Department of Housing and Urban Development (HUD) Data Resources
• Federal Bureau of Investigation Uniform Crime Reporting (UCR) System
• HRSA Area Health Resources Files
• HRSA Bureau of Health Workforce, Health Professional Shortages Areas
• HRSA Uniform Data System Resources (including Community Health Centers)
• US Census Bureau American Fact Finder Table
• US Census Bureau, Census County Business Patterns 
• US Census Bureau, Small Area Health Insurance Estimates  
• US Census Bureau Small Area Income and Poverty Estimates (SAIPE)