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If social determinants of health are so important, shouldn’t we ask patients about them?

BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4150 (Published 24 November 2020) Cite this as: BMJ 2020;371:m4150

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Re: If social determinants of health are so important, shouldn’t we ask patients about them?

Dear Editor

I was delighted to see this headline in an influential medical journal as there is a desperate need for healthcare providers to collect some of the social risk factors even if they can't do anything about, for example, a person's marital status. By some estimates the non-clinical risk factors are of the same magnitude as all the medical risk factors combined. But I, feel that there needs to be a bit of clarification.

The Index of Multiple Deprivation (IMD) is a measure of AREA socioeconomic status (SES) and, as such, is a measure of accumulated social advantage and disadvantage of the people included in that census area. Considerable research has shown that both iindividual and area-level SES measures are independent health risk factors. The mistake that many researchers make is in assuming that IMD is just an aggregation of individual SES but it is much more sophisticated than that and derived from 7 domains of advantage and disadvantage.

Unfortunately, individual level SES is not straight forward to measure as it is a social construct. One of the best explanations of this is a 40 year old paper (Liberatos, P., Link, B. G., & Kelsey, J. L. (1988). The measurement of social class in epidemiology. Epidemiologic Reviews, 10, 87–121). As examples - The education expectations of jobs have changed over time, 40% of the population is not in work at any one time (too young, in education, carer, retired). And, occupational prestige rankings evolve over time.

Perhaps we should just be asking some key questions? I can think of two which tap into areas shown to increase the risk for heart disease. Are you not in employment when you would like to be? Do you live alone? I'm sure we could come up with a core list.

The key message is that both where you live, and your personal characteristics, matter.

Professor Shona Kelly

Competing interests: No competing interests

30 November 2020
Shona Kelly
Professor
Sheffleid Hallam University
Montgomery House, Sheffield Hallam University, S10 2BP