Incorporation of Social Risk in US Preventive Services Task Force Recommendations and Identification of Key Challenges for Primary Care

Importance  In its mission to improve health, the US Preventive Services Task Force (USPSTF) recognizes the strong relationship between a person’s health and social and economic circumstances as well as persistent inequities in health care delivery.

Objective  To assess how social risks have been considered in USPSTF recommendation statements and identify current gaps in evidence needed to expand the systematic inclusion of social risks in future recommendations.

Evidence  The USPSTF commissioned a technical brief that reviewed existing literature on screening and interventions for social risk factors and also audited the 85 USPSTF recommendation statements active as of December 2019 to determine how social risks were addressed in clinical preventive services recommendations.

Findings  Among the 85 USPSTF recommendation statements reviewed, 14 were focused on preventive services that considered health-related social risks. Social risks were commonly referenced in parts of USPSTF recommendations, with 57 of 85 recommendations including some comment on social risks within the recommendation statement, although many comments were not separate prevention services. Social risks were commented on in USPSTF recommendations as part of risk assessment, as a marker of worse health outcomes from the condition of focus, as a consideration for clinicians when implementing the preventive service, and as a research need or gap on the topic.

Conclusions and Relevance  This report identified how social risks have been considered in the USPSTF recommendation statements. It serves as a benchmark and foundation for ongoing work to advance the goal of ensuring that health equity and social risks are incorporated in USPSTF methods and recommendations.

The US Preventive Services Task Force (USPSTF) is an independent, volunteer panel of national experts in prevention and evidence-based medicine that works to improve the health of all US people by developing recommendations about clinical preventive services. The USPSTF recommendations are based on a rigorous review of peer-reviewed evidence and are intended to help clinicians and patients make informed decisions about clinical preventive services that are delivered or referrable from primary care settings.

The USPSTF recognizes the strong relationship between a person’s health and social and economic circumstances and also the inequities in health care delivery that have caused persistent health disparities in underresourced communities.¹ Intervenable individual-level social and economic conditions or factors (social risks) are often influenced by the broader underlying social determinants of health. It is important to understand whether screening for, identifying, and addressing social risk factors such as insecurities in food, housing, or transportation improves health outcomes, as well as whether systematically addressing social risks while delivering preventive services can improve health outcomes.

While the question of how social risks can be effectively addressed in primary care is critical, some answers remain unclear.^2,3 In addition, it is unclear how social risks can be the focus of clinical preventive service recommendations or incorporated into other recommendations to acknowledge their role in increasing disease risk, limiting the benefits of evidence-based interventions, or both. Although the USPSTF does not consider interventions that are delivered solely in community settings, an increasing focus of community engagement and cross-sector approaches may mean screening for social risk factors by primary care clinicians and referring individuals to services in the community.

The objective of this report was to assess how social risks have been considered in USPSTF recommendations and identify gaps in evidence needed to expand the systematic inclusion of social risks in future recommendations.

Quiz Ref IDTo answer these questions, the USPSTF commissioned a technical brief that reviewed existing evidence and subsequently audited the 85 USPSTF recommendation statements active as of December 2019 to understand how social risks are addressed in clinical preventive services.^4,5 The technical brief identified and described research related to screening and interventions for social risk factors and the challenges and evidence gaps with incorporating screening and interventions for social risks in primary care. In addition, the brief assessed USPSTF recommendations to determine which social risks were addressed and how they were included in the recommendations.

The USPSTF defines social determinants of health as the underlying “social and economic conditions in which people live, rather than the immediate needs of any one individual”⁶ and social risks as the measurable and intervenable individual-level social and economic conditions or factors that are shaped by broader social and structural determinants of health (see Table 1).^6-8Quiz Ref ID For example, a community's economic stability is a social determinant of health, whereas a person’s employment status, food insecurity, and housing instability are social risks. Use of the term “risks” is not intended to imply a deficit; risk is the probability of an event that can have a positive or negative effect. These social risks are distinct from unmet social needs that are based on patient preferences and perceptions about what they need to address their social risk factors.

USPSTF recommendation statements on depression, unhealthy drug use, intimate partner violence, and child maltreatment have been described.^2,9 The USPSTF has also outlined the methods and processes by which it might consider recommending screening for social risks in primary care settings.^2,3,9 This article draws on the technical brief to highlight how social risks have been incorporated into the USPSTF recommendations and identify the gaps related to advancing systematic inclusion of social risks in future clinical preventive services recommendations. This expansion could be accomplished with specific recommendations about screening for social risks as a preventive service or by incorporating social risks into recommendations more systematically.

The scope and approach of the USPSTF determine the evidence needed for its recommendations about social risks. The recommendations are made for people without signs and symptoms of the target condition, rather than considering interventions to address patients with known needs. For instance, the USPSTF would address whether clinicians should screen all patients or entire at-risk populations for food insecurity rather than whether patients with known food insecurity benefit from interventions. In addition, the USPSTF considers services that are provided in or referable from primary care, including referrals to community or public resources.

Given this, and the potential breadth of social risk domains, the USPSTF focused the technical brief on select domains. The USPSTF aligned the technical brief review of the evidence to the social risk domains in the Centers for Medicare & Medicaid Services Accountable Health Communities Model, since all domains were required to be intervenable, among other factors.^3,5 These target domains included housing and food insecurity, transportation difficulties, utility assistance needs, interpersonal safety (except for the aspects of interpersonal safety already addressed by USPSTF recommendations [intimate partner violence, elder abuse, and child maltreatment]), education, and financial strain. The USPSTF limited its review of the evidence on screening and interventions for social risk to these target domains. However, evaluation of the recommendations considered other domains as well (nontarget domains) to look more broadly at various types of social risks (eg, race and ethnicity, which in many cases is a surrogate for exposure to structural racism). Table 1 details the definitions the USPSTF used and the focus of the technical brief.

As of December 2019, the USPSTF had published 85 active recommendation statements.

A focus of the technical brief was to investigate inclusion of social risks in existing USPSTF recommendations. Among the 85 active USPSTF recommendations, 14 focused on a specific topic that is included in definitions of social risks, but many of these are more commonly considered healthy lifestyle topics (eg, behavioral counseling for diet or physical activity) or mental health topics (eg, screening for depression) and not a social risk or within the targeted domains of the Centers for Medicare & Medicaid Services Accountable Health Communities Model. The assessment of recommendations also evaluated whether social risks were incorporated in other ways, beyond the topic of the recommendation. Among the 85 active recommendation statements, 57 (67%) incorporated social risks to some degree. However, many of these were not separate prevention services and were nontargeted social risks.

Targeted social risks (eg, financial strain) were rarely prespecified elements of the systematic evidence review on which the USPSTF recommendation is based. Of the 7 target social risks for the literature review (Table 2), financial strain was discussed most often (n = 28), followed by education (n = 9), interpersonal violence (n = 3), and housing instability (n = 2). Transportation, utility assistance needs, and food insecurity were not mentioned in any recommendations.⁵

Social risks were incorporated into USPSTF recommendations as risks for having a condition, a marker of worse health outcomes from having a condition, a consideration for clinicians when implementing a preventive service, and a research need or gap that needs to be addressed (eg, a gap in understanding how the social risk affects health outcomes of the condition or preventive service).⁵ The section of the recommendation in which social risks were addressed largely depended on how the risk related to the preventive service. Table 2 shows examples of how both target and nontarget social risks were included in recommendations.

Quiz Ref IDThe social risk most often included in some section of the recommendation was race and ethnicity (n = 46). Race and ethnicity are typically thought of as nonmodifiable variables and were not among the target domains. However, in many cases, race is a surrogate for exposure to systemic racism, and “The USPSTF considers systemic racism to be a pervasive set of societal and interpersonal practices within and outside health care institutions that foster discriminatory practices to create systematic disadvantage and health inequities in a racial group.”¹ Systemic racism occurs when racial bias has been codified into the policies and practices of an institution or society¹⁵ and contributes to racial health disparities and can be considered a social risk that affects health.¹⁶ Systemic racism directly and indirectly affects other social risks, such as housing instability, food insecurity, educational opportunities, and exposure to violence and trauma, and also affects health care access and the quality of health care received. While 46 of the 85 USPSTF recommendations discuss race or ethnicity in the context of risk factors, research gaps, or health disparities, no recommendation statements address racism or historical social injustice directly.

The other focus of the technical brief was to examine evidence gaps and challenges to expanding the systematic inclusion of social risks in future clinical preventive services recommendations.

To consider screening for social risks as a preventive service or to systematically address risk factors in recommendations, accurate screening tools to identify social risks are needed. The technical brief^4,5 identified a systematic review of multidomain social risk screening tools, which found that the reliability and validity of these tools were uncertain.¹⁷ Few multidomain screening tools were assessed in multiple studies, further limiting the ability to assess the reliability and validity of the instruments. In addition, while the technical brief focused on screening for social risks, it is also important to understand the distinction between social risks and unmet social needs to guide delivery interventions to persons most likely to accept them and ultimately benefit.

Quiz Ref IDThe technical brief found studies that reported positive associations with some interventions that addressed social risks, including improved processes (eg, intervention or program activities such as delivery of social services or patient use of referrals), reduced social risks (eg, better access to transportation), reduced health care costs, and improvements for clinicians (eg, a better understanding of a person’s social risk and greater confidence in addressing social risks). However, there was limited evidence to link these improvements with improved health outcomes for patients, such as improved quality or length of life.^4,5 It is likely that effective interventions for adverse social risks could improve some health outcomes. For example, co-located debt advice or welfare benefits in the health care system may reduce financial strain, which in turn could improve quality of life. Research testing the linkage from intermediate outcomes for social risks (such as reduced financial strain) to improved quality of life is needed.

Many studies on interventions to address social risks lacked comparison groups. This is critical for understanding whether outcomes were improved by the intervention or by other factors. Designs that could support causal relationships include a stepped wedge or delayed intervention design. While randomized clinical trials are ideal for understanding the effect of interventions, other types of comparative observational designs could be used to infer associations between implementation of interventions and outcomes, particularly if there were ethical concerns with a comparator not addressing a social risk (eg, not intervening in the case of exposure to violence).

Few studies about screening or treating social risks assessed or reported on potential harms. To understand the net benefit of clinical preventive services, the USPSTF methods require evidence on both benefits and harms. Potential harms (or unintended consequences) could range from privacy concerns, to frustrations related to an inability to change social risks, to direct harms such as social stigma/labeling and loss of parental rights. The systematic assessment of harms and strategies to mitigate harms should be routinely incorporated and evaluated in primary studies for screening and addressing social risk.

The USPSTF makes recommendations for clinical preventive services that are addressed or referred by primary care clinicians. Although primary care clinicians screen for social factors, interventions can occur in health care facilities or in social service and community-based organizations outside of health care. Evaluating the benefits and harms of social and community services that operate completely independently of the health care system would be outside the scope of the USPSTF, but given the potential role of primary care clinicians in screening and identifying people experiencing social risks and offering or referring them to interventions, it is important to understand the role the health care system may have in addressing social risks.

Evidence is needed to understand the added value for primary care clinicians in linking or referring to social service delivery organizations, as well as how to best build connections between primary care and these programs. A report from the National Academies of Sciences, Engineering, and Medicine included recommendations for integrating health care and social risk delivery.¹⁸ Examples of potential integration include primary care that routinely identifies and reflexively refers food-insecure patients to resources, such as the Supplemental Nutrition Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and food pantries¹⁹; practices offering door-to-door transportation at no cost to patients seeking care²⁰; and identifying cases of poor-quality housing during a primary care visit and offering onsite legal services to address housing needs.²¹

Even if the USPSTF were to find sufficient evidence to recommend screening for a social risk, or to incorporate social risks into a clinical preventive service, implementation may be a challenge for most primary care practices.^22,23 Understanding the key elements to improve adoption, implementation, and sustainability of effective interventions will be essential.²³ By clearly describing patient, intervention, comparator, and outcomes of referral to a studied social risk intervention, researchers can better support effective implementation in primary care.

Quiz Ref IDConsistent with its mission, the USPSTF seeks to improve the care and well-being of all US people, and advancing and achieving health equity is necessary to achieve its mission. Incorporating social risks into clinical preventive services and focusing on them as a topic are opportunities to improve health outcomes and achieve health equity. Accordingly, the USPSTF is assessing the potential to incorporate social risks more systematically into its recommendations and determining when the targeted social risks should be the focus of future recommendation statements to expand current approaches to address health equity. For instance, systematic evidence reviews currently commissioned by the USPSTF as part of the recommendation development process consider whether the prevalence of a condition is higher or outcomes are worse in certain populations.²⁴

There are multiple ways the USPSTF can and has incorporated social risks in its recommendations. Recommendations have highlighted the needs of diverse populations by considering which groups have higher risk or experience worse outcomes from a condition.²⁵ This assessment of how social risks have been incorporated into the USPSTF recommendations is part of ongoing work to advance the goal of expanding the systematic inclusion of social risks in future recommendations but also identifies strategies that could be considered to improve USPSTF processes. Despite currently incorporating some social risks in its recommendations and focusing directly on certain social risks in other recommendations, there is the potential to systematically include more social risk evidence in all recommendations and aid the USPSTF to target social risks for preventive services when appropriate.

Other organizations have described equity-focused systematic evidence reviews that could inform USPSTF approaches.²⁶ The PRISMA-Equity Extension reporting guideline describes how to identify, extract, and synthesize evidence on equity in systematic reviews.²⁷ The GRADE Evidence-to-Decision Framework includes a review of the effect of recommendations on health equity (eg, asking “What would be the effect on health inequity?”).^28,29 These tools can help provide a roadmap for primary studies, systematic reviews, and ultimately USPSTF recommendations to include an explicit focus on health equity.

This report has several limitations. First, the recommendations that were reviewed represent a single point in time (all recommendations active as of December 2019), and the USPSTF processes for addressing social risks in its recommendation statements have continued to evolve; additional evaluation is needed to assess whether and how social risks have been considered in more recently issued recommendation statements. Second, there is limited evidence on social risks in clinical preventive service recommendations or as the target of a preventive service, and the proposed advances in the USPSTF methods will be impeded without a rapid increase in the primary study database. Third, many social risks and social determinants of health continue to be measured simplistically and without nuance, which will also limit the USPSTF methodologic advancements. For example, stating the number of African American individuals included in a study does not allow inferences to be made about the levels of structural racism, financial stability, or transportation needs represented in that study. Without careful assessment of social determinants of health, social risks, and social needs in persons included in primary prevention studies, insights into these factors for driving population health will be limited, as will the recommendation statements that are based on these studies.

This report identified how social risks have been considered in the USPSTF recommendation statements. It serves as a benchmark and foundation for ongoing work to advance the goal of ensuring that health equity and social risks are incorporated in USPSTF methods and recommendations.

Corresponding Author: Karina W. Davidson, PhD, MASc, Feinstein Institutes for Medical Research at Northwell Health, 130 E 59th St, Ste 14C, New York, NY 10022 (chair@uspstf.net).

Accepted for Publication: July 16, 2021.

Published Online: September 1, 2021. doi:10.1001/jama.2021.12833

Author Contributions: Dr Davidson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Conflict of Interest Disclosures: None reported.

Disclaimer: The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of the Agency for Healthcare Research and Quality (AHRQ). No statement in this report should be construed as an official position of AHRQ or the US Department of Health and Human Services.