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Using HRA Data to Identify Social Determinants of Health and Support At-Risk Populations

By Wellsource, Inc.

When it comes to providing wellness initiatives to your population, it’s no surprise that health risk assessments (HRAs) are an essential component. A trustworthy and reliable HRA will do a great job of assessing individual risk factors, providing the information to the end-user, and providing population data to the administrator. For many individuals, these results may not be that surprising. An individual who struggles with their weight and leads a sedentary lifestyle likely won’t be caught too off guard if their assessment indicates that they’re at-risk for developing obesity or diabetes.

But the data provided to assessment administrators can also give information on subsets of your population that are at-risk through Social Determinants of Health (SDoH). All populations may be facing disruptions to their routines and resources due to the COVID-19 pandemic. But vulnerable populations are most at risk—and not only in the midst of global health concerns. It’s essential  to pay attention to SDoHs at all times. HRA data can help you routinely monitor and consider SDoH factors as jumping-off points for wellness initiatives in all circumstances.

What Are Social Determinants of Health?

Defined by the World Health Organization as the conditions in which people are born, grow, live, work, and age, SDoHs can have a significant impact on both individual and population health, especially for those enrolled in Medicaid. Some examples of SDoH are:

  • Residential location
  • Financial security
  • Access to food
  • Access and/or utilization of preventive care and medical coverage
  • Social connections and support

These factors can impact health in several ways. For some factors, such as access to food and medical services, the impact on health is evident. But others, such as social connections and support, can be more nuanced. For example, in our recently released Wellsource Annual Data Review, the data we analyzed indicates that 7% of individuals report feeling lonely. Within that 7%, there are measurably higher rates of obesity, diabetes, alcohol and tobacco use, and lung problems when compared to the remainder of the population.

Loneliness is a factor that should be addressed,  but it’s not always readily apparent. An individual must self-report their feelings, social connectedness, or lifestyle habits. And yet, in a recent survey by Welltok, almost half of respondents were not sure what SDoH they should report to health and wellness professionals. This underscores the importance of directly asking your population the questions that will help you identify SDoH deficiencies.

Being able to identify your at-risk populations with SDoH measures means you can create resources and wellness initiatives to specifically target these individuals for a greater impact on  improving their health. Examples of possible interventions include:

  • Creating social groups—virtually during this pandemic time and in real life when it becomes safe to do so—for individuals with like-interests to join.
  • Working with a local organization or farm to deliver fresh vegetables and fruits to individuals at risk of food scarcity. Make plans to host a regular farmers’ market for your population to patronize once distancing restrictions are lifted.
  • Hosting community wellness events where vaccines are offered at a convenient location to increase vaccination rates in the community. Individuals hesitant to receive annual flu shots might be more receptive once a COVID-19 vaccine is available.

How Does COVID-19 Further Impact At-Risk Populations?

Situations like the COVID-19 pandemic, or others that create long-term disruptions in routines and resources, can be a significant cause for concern for at-risk populations. In general, individuals who are at-risk for developing chronic diseases and facing challenging SDoHs may find it difficult to access proper nutrition or medical care. Adding a situation where life has turned completely upside down for just about everyone into the mix can make things exponentially more difficult.

The social distancing and shut-down guidelines that are in place during the pandemic may make people (not just those in at-risk populations) hesitant to venture to the grocery store for healthy foods. Instead, they’re relying on restaurant delivery or takeout. For individuals that experience food scarcity and generally depend on the on-site cafeteria for their meals, the situation could be even more dire. If they’ve been moved to remote work or are suddenly out of a job, they may find they no longer have access to healthy or plentiful options. Administering an HRA at this time can help you identify changes in food access or nutrition habits so you can intervene. 

Similarly, individuals may be wary of scheduling an in-person appointment or going to urgent care or the emergency room when necessary out of fear of contracting the virus. This avoidance of in-person care could lead to delayed diagnoses or treatment or a gap in routine monitoring that could exacerbate a condition. Telehealth services are available for many people, and should be promoted to your population.

Additionally, individuals who identify as lonely may feel even more isolated while working from home or being out of work entirely. And, of course, that’s before you get into the additional stressors that the pandemic can place on one’s mental and physical well-being. Administering a mid-year HRA can help you identify individuals who are emotionally suffering during this time of social isolation so you can connect them with remote counseling services.

By using HRA data—including Social Determinants of Health—to identify at-risk populations, you can ensure that the appropriate resources and interventions are created and offered. If you’re interested in learning more about how SDoHs can affect an individual’s overall health, check out our Second Annual Data Report Getting the Full Picture of Wellness: Enhance Your Understanding of Social Determinants of Health with Health Risk Assessment Data today.

2nd Annual Data Review: Social Determinants of Health

"Good health is your greatest asset. You will never regret a decision to take better care of your health."

Don Hall, DrPH, CHES, Founder Wellsource