To improve individual lives, a top-down approach won’t work (Part 1)

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Nov 16, 2021

In the health care industry, we have settled on the term ‘social determinants of health’ to refer to the societal, population-level structures that influence health outcomes. But when we talk to patients about the difficulties they face, we usually ask them about social determinant risk factors, not about the unique progress they are seeking to make in their lives. In short, we are not asking about their jobs to be done. This disconnect is a result of seeking to address individual situations with population-level thinking, and it diminishes the impact of well-meaning interventions. We can’t solve bottom-up needs with a top-down approach.

Our language is rarely clear in health care, and unfortunately, the topic of social determinants of health (SDOH) is no exception. There are multiple competing definitions for SDOH. The World Health Organization defines SDOH one way, the CDC’s definition differs, and a quick Google search turns up a variety of other options. 

These definitions all suffer from a high level of complexity. And more importantly, they do not encapsulate the individual’s perspective. In fact, research from the Health Initiative indicates that individuals find the language of SDOH  “confusing, alienating, and even demeaning.” If we confuse, alienate, and demean those we serve, we cannot help them improve their lives. In short, our framing is wrong. 

‘Determinants’ and ‘health’ don’t embody the individual’s perspective 

When providers or payers screen individuals for social determinants of health issues, they aren’t truly asking about determinants (population-level systems). They are asking about patients’ risk factors that relate to those determinants. While risks are more individualized than determinants, knowledge of risks doesn’t uncover what the individual truly needs or desires. 

For example, when seeing her doctor for an annual exam, a young mom’s social screening may indicate she has an elevated risk of food insecurity. But her most salient job to be done may be to have consistent, affordable childcare so she can go to work and have income to buy food, which will address her risk of food insecurity. She may be seeking a solution for childcare instead of a referral to a food pantry. 

In this case, the woman’s risk of food insecurity is not what matters most to her. What she wants is to have consistent and affordable childcare. But uncovering her desired progress isn’t part of typical social screening questions, despite its impact on her health and life outcomes. Unfortunately, most business models in our existing health care system lack a consistent path for a provider or payer to learn this information. 

Additionally, by using the term ‘social determinants of health,’ we insinuate that ‘health’ is the end goal. But what if that’s not the case? In six years of interviewing patients, I cannot recall hearing any of them say they wanted ‘more health.’ Instead, they talked about the life experiences, interactions, and activities in which they wanted to participate. They talked about living better lives. For them, health was a means to an end, and everyone does not have the same end goal, or job to be done.

Changing the lens to incorporate the individual’s perspective 

The way we currently screen individuals for the impact of social determinants and social risks does not enable providers or payers to uncover the progress people seek. While risk factors are correlated with health outcomes, they don’t provide the full picture. To discover that, we also have to look at the progress the individual is looking to make in their lives. We have to understand their perspective in addition to their experience with an influential social risk. We have to see the world through their eyes.

By talking about determinants and screening for risks without knowledge of individuals’ jobs, we are committing the classic error of looking at correlation, not causation. We are missing the causal mechanisms that drive improved lives. As a result, our national health care system has made little progress on improving individual life outcomes at scale. Until we consistently seek to understand what outcomes the individual cares about, we can’t enable people to have more life in their years. 

We need an individual-level, not a population-level, approach. Part 2 of this blog post will look at innovators who are changing the lens by building new business models that uncover the progress individuals seek. In the interim, you can check out Rebecca Fogg’s 2017 report, Health for Hire, where she highlights a few examples.  

In your work, how are you addressing patients’ and consumers’ jobs to be done to improve their health outcomes and quality of life? We’d love to hear from you. You can reach us here

Ann Somers Hogg is a senior research fellow at the Christensen Institute. She focuses on business model innovation and disruption in healthcare, including how to transform a sick care system to one that values and incentivizes total health.