In previous articles, we covered Loneliness, Social Cohesion, Civic Participation, Discrimination, and a two-part article on Incarceration. Each of the previous articles addressed a piece of Social and Community Context, one of five pillars that make up the Social Determinants of Health (SDOH).  This article will look at how we can measure these elements to confirm that we address the specific elements of SDOH.

Nelson Mandela said, “It can be said that there are four basic and primary things that the mass of people in a society wish for: to live in a safe environment, to be able to work and provide for themselves, to have access to good public health and to have sound educational opportunities for their children.” I started with this quote as this is the importance of each of the elements we are working with.  It speaks to the challenges facing the incarcerated and those left behind, the lonely and those seeking connection.

Introduction

The definition of outcome is something that follows as a result or consequence. The importance of the definition lies in the fact that it is the basis for determining the efficacy of medicines, vaccines, medical processes, and projects.  A more specific definition looks to quantifying effectiveness and the measurable variables needed to determine if we have met the objective. This article intends to review the existing measures, and where absent, to propose additional measures to track the various elements.

Healthy People 2030

Health People 2030 identified quality measures based on the vision of “A society in which all people can achieve their full potential for health and well-being across the lifespan. Our specific review will focus on the outcomes related to Social and Community Context.

The first of the objectives, DH-01, Reduce anxiety and depression in family caregivers of people with disabilities. The objective is only in the development stage, so no method of collection or standards exists. The interesting element of this objective is that none of the elements of this SDOH included specific mention of persons with disabilities. Nor is it clear as to which element this objective addresses explicitly.

The next objective, SDOH-05, is to reduce the proportion of children with a parent or guardian who has served time in jail.  As of 2018-2019 (the last year data was available), 7.5% of children met this objective. The goal is 5.2%. The measure uses the National Survey of Children’s Health.  Goal SDOH-05 specifically addresses the issues identified in the articles on Incarceration, part 1 and part 2. Implicit in this goal is to decrease the number of people incarcerated, which is a valuable outcome to meet the vision of the SDOH.

The following two objectives specifically address adolescents. First, DH-DO1, Reduce anxiety and depression in family caregivers of people with disabilities. At this time, the measure is under development. Similar to DH-101, this measure addresses the needs of the disabled community. Consequently, it is not clear which element this objective addresses.

The second outcome is AH-03, Increase the proportion of adolescents who have an adult they can talk to about serious problems.  In 2019 79.0% of adolescents met this objective with a goal of 82.9%.  The measure uses the National Survey on Drug Use and Health. The goal addresses the challenges faced by adolescents from parent incarceration to drug use addressed in the elements of SDOH.

The following three outcome measures address outcomes specifically focused on children. EMC-01, increase the proportion of children and adolescents who communicate positively with their parents. In 2018-2019, 65.3% of children met this objective; the target is 73.0%. The measure uses the National Survey of Children’s Health for calculation. The outcome measure addresses communication and healthy relationships as discussed in Social Cohesion, focusing on developing communication skills to assist in relationship building.

The following measure is EMC-02, Increase the proportion of children whose parents read to them at least four days per week. In 2018-2019 55% met this goal against a target of 63.2%. The measure uses the National Survey of Children’s Health. The outcome objective meets multiple elements.  In the Incarceration articles (part 1 and part 2), we discussed the number of persons in jail that had dropped out of school; the impact of this objective will increase preparedness for school and perhaps increase the graduation rate.

The third measure for children is EM-DO7, Increase the proportion of children and adolescents who show resilience to challenges and stress. Currently, this objective is under development. This objective’s value is the relationship between the challenges faced by an incarcerated parent and the everyday challenges children may find in school or the community. There is no published timetable indicating when it will be available.

The following two outcome measures address health communication. The first measure is HC/HIT-04, increase the proportion of adults who talk to friends or family about their health. In 2017 86.9% of adults met this objective against a target of 92.3%. The measure uses the Health Information National Trends Survey.  The objective addresses the value of Social Cohesion, which includes the value of talking about health issues.

The second measure is HC/HIT-R01.  Increase the health literacy of the population.  Currently, this objective is under development. The importance of this objective relates to the high number of people that do not have access to regular medical care, nor do they have the information needed to make good health-related decisions.

There is one measure that references Health IT, HC/HIT-07. The objective seeks to increase the proportion of adults who use IT to track health care data or communicate with providers.  In 2017 80.0% of adults met this objective against a target of 87.3%. The measure uses the Health Information National Trends Survey. The objective tracks access to health information and healthcare, as without a doctor, you will not have healthcare data to track.

The following objective deals with LGBT students. Measure LGBT-001 seeks to reduce bullying of transgender students. This measure is currently under development with no delivery date.  The specific elements of Social and Community Context did not include the LGBT community, so there is a question why include this objective.

The following outcome measure addresses nutrition and healthy eating.  Measure NW S-02 has a goal to eliminate very low food security in children. As of 2018, 59% of children met this goal, and the target is 0.00%, indicating no low food insecurity. The measure uses the Current Population Survey Food Security Supplement for calculating this measure. The link to Social and Community Context includes both health and Civic Participation, where we discussed the value of community gardens.

The final element of Healthy People 2030 for Social and Community Context addresses people with disabilities. Measure DH-03 seeks to reduce the proportion of people with intellectual and developmental disabilities who live in institutional settings with seven or more people. As of 2015, 21.5% of persons met this goal with a goal of 11.5%. The measure used the Residential Information Systems Project Annual Survey of State Developmental Disabilities Agencies. It is unclear which element this measure refers to as no element addressed persons with disabilities.

How Do We Measure The Rest

While the outcome measures laid out above address various elements of the SDOH, they fail to address three remaining elements, Loneliness, Civic Participation, and Discrimination. In addition, they only partially address Social Cohesion. In the following sections, we will discuss suggested measures for addressing the remaining elements.

Loneliness

The UCLA Loneliness Scale provides a 20 question assessment to determine loneliness and social connectedness.  While the full assessment provides valuable information, I am recommending the three-question assessment. The three questions include how often you feel left out; how often you feel that you lack companionship; and how often you feel isolated from others.  The questions address both loneliness with words like left out, lack companionship, and isolated.  Responses include 1-hardly ever 2-some of the time or 3-often. The responses will provide insight into loneliness and related social cohesion.  Based on the importance of addressing loneliness and social cohesion, we should set a goal that only 30% score above five on these measures.

Civic Participation

Usually, civic participation is part of an over-arching study or process related to the community, or individual interviews determine civic participation. We are recommending an outcome assessment that addresses the individual.  Specifically, we recommend the question set in Civic Engagement in Low Income and Minority Neighborhoods.  The assessment looks at nine different areas, including:

• Voting
  • 1= Yes, but I don’t vote in most elections; 2= Yes, I vote in some elections; 3= Yes, I always vote; 4= No, I am not a registered voter
• Community group participation
  • 1= Never; 2= Less than 1/ month; 3= 1/ month; 4= More than 1/ month but < 1/ week; 5 = 1/ week; 6= More than 1/ week.
• Religious services attendance
  • 1= more than once a week; 2= Once a week;3= At least once a month;4= Less than once a month;5= major religious holidays; 6= Never
• Hours donated to non-church non-profit activities
  • 1= None; 2= Some but < 1 hour; 3= 1-5 hours; 4= 5-10 hours; 5= more than 10 hours
• People in the neighborhood can be trusted
  • 1= Strongly Disagree; 2= Disagree; 3= Neutral; 4= Agree; 5= Strongly Agree
• People in the neighborhood will help each other
  • 1= Strongly Disagree; 2= Disagree; 3= Neutral; 4= Agree; 5= Strongly Agree
• People in the neighborhood do not share the same values
  • 1= Strongly Disagree; 2= Disagree; 3= Neutral; 4= Agree; 5= Strongly Agree
• People would organize to save firehouse if scheduled to be shut-down
  • 1= Very Likely; 2= Likely; 3= Neutral; 3= Unlikely; 5= Very Unlikely
• People in the neighborhood would loan cash to someone who was starting a business
  • 1= Very Likely; 2= Likely; 3= Neutral; 3= Unlikely; 5= Very Unlikely

We need to create an adequate scoring mechanism for these questions that includes reverse scoring in some instances and scoring review.  Once completed, we will have the necessary outcome measures to understand Civic Participation.

Discrimination

The final element to consider is discrimination.  A widely used scale to determine the level of discrimination is the Everyday Discrimination Scale.  he scale includes ten questions with a single set of responses: 1) Almost everyday, 2) At least once a week, 3) A few times a month, 4) A few times a year, 5) Less than once a year, and  6) Never. The questions include:

In your day-to-day life, how often do any of the following things happen to you?
1.    You are treated with less courtesy than other people are.
2.    You are treated with less respect than other people are.
3.    You receive poorer service than other people at restaurants or stores.
4.    People act as if they think you are not smart.
5.    People act as if they are afraid of you.
6.    People act as if they think you are dishonest.
7.    People act as if they’re better than you are.
8.    You are called names or insulted.
9.    You are threatened or harassed.

We should base our goal on a high number for each assessment for this outcome measure; 54 would indicate no discrimination. We recommend a goal that 75% of respondents score a 50 or higher on the assessment. The entire population can take this assessment. We will include demographic information to analyze the data by different groups, such as gender, race, sexual orientation, and physical disability.  The previously identified outcome measures did not address discrimination, yet discrimination affects housing, Incarceration, and employment, all critical elements of the SDOH.

Final Thoughts

We have spent several weeks defining and explaining the elements that make up Social and Community Context; it is not enough to explain without assessing if we are doing what we can to address the issues.  We can only judge our level of success with outcome measures not addressing the few but addressing each element identified. Social and Community Context plays an essential part in the SDOH; let’s do what we can to address the community’s needs correctly and ensure we have data to prove our success or need for more work. We determine value by outcomes and what could be more valuable.