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MODULE 18: POPULATION HEALTH AND VALUE-BASED CARE
Section 18.3: Addressing Health Equity and SDOH Factors
A critical exploration of the non-clinical factors that drive health outcomes. We’ll discuss the pharmacist’s role in identifying and mitigating the impact of Social Determinants of Health (SDOH).
SECTION 18.3
Addressing Health Equity and SDOH Factors
From Clinical Care to Life Context: The Pharmacist as a Bridge to Health Equity.
18.3.1 The “Why”: The Limits of the Prescription Pad
As a pharmacist, you have been meticulously trained to be an expert in the science of therapeutics. You can adjust a warfarin dose based on a patient’s INR, recommend an antibiotic based on renal function, and select a third-line agent for resistant hypertension. You are a master of the clinical variables that influence medication outcomes. Yet, time and again, you have likely encountered a frustrating reality: you can design a clinically perfect, evidence-based medication regimen, and the patient still fails to get better. Their blood pressure remains high, their A1c is uncontrolled, their asthma exacerbations continue. Why?
The answer, more often than not, lies far outside the realm of pharmacology. It lies in the patient’s life context. The most effective antihypertensive is useless to a patient who has to choose between paying for their prescription and paying their rent. The most advanced insulin is ineffective for a patient who doesn’t have reliable access to healthy food. The most effective inhaler provides no benefit to a patient who lacks the transportation to get to the pharmacy to pick it up. These non-clinical, life-context factors are known as Social Determinants of Health (SDOH). They are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.
Mounting evidence shows that clinical care accounts for only about 20% of a person’s health outcomes. The other 80% is driven by a combination of health behaviors, socioeconomic factors, and the physical environment—all components of SDOH. This is a profound and humbling realization for healthcare providers. It means that to truly improve health, we must look beyond the pill bottle and the clinic walls. We must begin to understand and address the real-world barriers that prevent our patients from achieving the outcomes we all desire.
This work is the foundation of health equity, which the CDC defines as the state in which everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care. As one of the most accessible healthcare providers, pharmacists are uniquely positioned to identify patients struggling with SDOH and to serve as a critical bridge, connecting them to the resources they need to thrive. This section will provide you with the framework, tools, and language to transform your practice from one that treats disease to one that advances health equity.
Pharmacist Analogy: The Master Gardener and the Soil
Imagine you are a master gardener, renowned for your expertise in cultivating prize-winning roses. A person comes to you with a struggling rose bush and asks for your help. In your traditional role, you focus entirely on the plant itself. You identify the species, diagnose a fungal infection, and provide a powerful, perfectly dosed fungicide (the medication). You give expert instructions on how and when to apply it. The person takes your fungicide, thanks you, and leaves.
A month later, they return, and the rose bush looks even worse. The fungicide didn’t work. Why? Because you never asked about the soil. You never asked if the plant was getting enough sunlight, if it was being watered properly, or if the soil was rocky and nutrient-poor. The fungicide, though clinically perfect, was destined to fail because the fundamental conditions for the plant’s survival were not being met.
The population health pharmacist, working to advance health equity, is a new kind of master gardener. You still have all your expertise about the fungicide—the medication remains your core competency. But you now understand that your job doesn’t end there. Your first step is to assess the soil (the SDOH). You ask the questions: “Tell me about where this plant lives. Is it getting sunlight (health literacy, social support)? Does it have access to water (transportation, financial stability)? Is the soil itself healthy (food security, housing stability)?”
You realize the problem isn’t the fungicide; it’s the environment. So, in addition to providing the fungicide, you also provide a bag of nutrient-rich soil (a referral to a food bank), a guide on proper watering (patient education in plain language), and a plan to move the pot to a sunnier spot (arranging for medication delivery). You understand that the health of the rose bush is inextricably linked to the health of its environment. This holistic approach—treating the patient’s life context with the same rigor as you treat their clinical condition—is the essence of addressing social determinants of health.
18.3.2 Masterclass: The Five Domains of SDOH – A Pharmacist’s Field Guide
To systematically address these issues, public health organizations like Healthy People 2030 have categorized the Social Determinants of Health into five key domains. As a pharmacist, you must understand how medication use and health outcomes are profoundly impacted by each of these areas. This framework will become your mental model for assessing the non-clinical barriers your patients face.
1. Economic Stability
Poverty, employment status, food security, housing stability.
2. Education Access & Quality
Early childhood education, enrollment in higher education, high school graduation, language and literacy.
3. Health Care Access & Quality
Access to health care, access to primary care, health literacy.
4. Neighborhood & Built Environment
Access to healthy foods, crime and violence, environmental conditions, quality of housing.
5. Social & Community Context
Civic participation, discrimination, incarceration, social cohesion.
Deep Dive: The Pharmacist’s Role in Each Domain
Let’s examine each domain through the practical lens of a pharmacist and identify the specific problems and potential interventions that fall within your scope.
Domain 1: Economic Stability
This is often the most immediate and impactful barrier to medication access. If a patient cannot afford their medication, all other interventions are irrelevant. This is known as cost-related non-adherence, and you are on the front lines of this battle.
| SDOH Barrier | How It Manifests in Your Practice | Pharmacist-Led Interventions |
|---|---|---|
| Medication Cost / Underinsurance | A patient doesn’t pick up a new prescription. A patient asks, “Which one of these is most important? I can only afford one.” A patient is splitting their pills or taking them every other day to make them last longer. |
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| Housing Instability / Homelessness | A patient has no stable address for mail-order delivery. A patient loses their insulin because they have no access to refrigeration. A patient misses appointments because they are transient. |
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Domain 2: Education Access and Quality
This domain is centered on health literacy, which the CDC defines as the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. It is not about intelligence; it is a specific skill set. An estimated 36% of US adults have basic or below basic health literacy, making it difficult to understand prescription labels, package inserts, and verbal instructions.
The Teach-Back Method: Your Health Literacy Superpower
The single most effective technique to ensure understanding is the “teach-back” method. It is a simple, evidence-based communication strategy that is not a test of the patient’s knowledge, but a test of how well you explained the concept.
Do not ask: “Do you have any questions?” or “Do you understand?” (These almost always elicit a “yes” response, regardless of actual understanding).
Instead, ask: “I want to be sure I did a good job explaining this new medication. Can you tell me in your own words, how are you going to take this when you get home?” or “We’ve gone over a lot of information. Just to make sure we’re on the same page, can you show me how you’re going to use this inhaler?”
If the patient’s explanation is incorrect or incomplete, you now know exactly where the communication breakdown occurred, and you can re-explain that specific point using a different approach.
Domain 3: Health Care Access and Quality
Even with good insurance and education, physical barriers can prevent patients from accessing the care and medications they need. Pharmacists can play a pivotal role in bridging these gaps.
| SDOH Barrier | How It Manifests in Your Practice | Pharmacist-Led Interventions |
|---|---|---|
| Lack of Transportation | A patient repeatedly misses refills or appointments. A patient lives in a rural area far from the pharmacy. An elderly patient no longer drives. |
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Domain 4: Neighborhood and Built Environment
A patient’s zip code can be a better predictor of their health than their genetic code. This domain encompasses the safety and healthfulness of a patient’s physical environment.
| SDOH Barrier | How It Manifests in Your Practice | Pharmacist-Led Interventions |
|---|---|---|
| Food Insecurity / Food Deserts | A patient with diabetes tells you they often run out of food at the end of the month. Their diet consists mainly of cheap, processed foods because they live in a “food desert” with no nearby grocery stores. This leads to poor glycemic control and hypoglycemia when they take their insulin without eating. |
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Domain 5: Social and Community Context
This domain relates to the social support systems, relationships, and societal norms that influence health. It is often the most personal and challenging domain to address, requiring trust and cultural humility.
| SDOH Barrier | How It Manifests in Your Practice | Pharmacist-Led Interventions |
|---|---|---|
| Social Isolation / Lack of Support | An elderly patient lives alone and has no one to help them manage their complex medication regimen. They become overwhelmed and non-adherent. A patient feels stigmatized by their mental health condition and doesn’t engage with care. |
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18.3.3 The Pharmacist as SDOH Investigator: Screening and Intervention
You cannot solve a problem you don’t know exists. While some patients will volunteer their struggles, many will not due to feelings of shame, embarrassment, or a belief that these problems are “not medical.” Therefore, proactive, systematic screening for Social Determinants of Health is a necessary evolution of the patient interview process. The goal is to make asking about life-context barriers as routine as asking about allergies.
The Art of the Sensitive Question: Normalizing the Conversation
How you ask is as important as what you ask. The key is to be respectful, empathetic, and to normalize the questions by framing them as a routine part of providing comprehensive, safe care. This requires a shift in your communication style.
Scripts for Navigating Difficult Conversations
Here are some examples of how to introduce and ask sensitive SDOH screening questions within a typical pharmacy workflow:
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Introducing the Topic:
“To make sure I’m giving you the best possible advice about your medications, I’d like to ask you a few questions about some things that can affect your ability to stay healthy. These are questions we ask all our patients to make sure we’re not missing anything important. Is that okay with you?”
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Screening for Cost Barriers:
Instead of: “Can you afford this?” (Can sound judgmental).
Try: “Many people find it difficult to afford their medications these days. Has cost ever made it hard for you to pick up a prescription?” or “When you look at your budget, how difficult is it for you to find money for your medications each month?”
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Screening for Food Insecurity:
Instead of: “Do you have enough food?” (Can be too direct).
Try: “We know that having healthy food is a big part of managing conditions like diabetes. In the past month, have you ever worried that you might run out of food before you had money to buy more?”
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Screening for Transportation Barriers:
Instead of: “How do you get here?”
Try: “Getting to and from appointments and the pharmacy can be a real challenge for some folks. In the last few months, have you had to miss an appointment or delay picking up a medication because of trouble with transportation?”
From Identification to Action: The “Warm Handoff”
It is critically important to remember: you are not expected to solve these deep-seated social problems by yourself. You are not a social worker, a housing expert, or a financial counselor. Your primary role is to identify the problem, empathize with the patient, and connect them to the expert who can help. The most effective way to do this is through a “warm handoff.”
- A Cold Referral is giving a patient a phone number or a pamphlet and hoping they make the call. The success rate is very low.
- A Warm Handoff is a facilitated, personal introduction to the resource. It demonstrates to the patient that you are part of an integrated team working on their behalf.
Example of a Warm Handoff:
“Mrs. Smith, thank you for sharing with me that it’s been hard to afford groceries lately. That sounds really stressful, and it’s definitely going to make it harder to manage your diabetes. Our clinic has a social worker, Sarah, who is an absolute expert at connecting people with programs like SNAP and local food banks. She’s helped many of my other patients. Would it be okay if I walked you over to her office right now to introduce you? Or, if you prefer, I can send her a message with your permission, and she can give you a call this afternoon.”
