The report is a product of the VA/HSR Evidence Synthesis Program.

Evidence Review: Social Determinants of Health for Veterans

Social determinants of health usually refer to factors that are socially constructed and/or impact health through socio-cultural mechanisms (e.g., socioeconomic status, education, and social support networks). Social determinants can substantially influence health outcomes and contribute to health disparities. Understanding the role of social determinants in the health of Veterans -- and identifying clinical and research opportunities to impact the pathways between social determinants and health -- are critical for VA's mission to serve and improve health outcomes for all Veterans. Thus, VA's Office of Patient Care Services, Population Health Services, and the Office of Rural Health (hereafter referred to as VA partners) requested an evidence review to examine social determinants of Veterans' health, particularly those social determinants that may be more important for Veterans' health outcomes (or for certain Veteran groups), as compared with non-Veterans.

Investigators with VA's Evidence-based Synthesis Program site located in Minneapolis, MN conducted this evidence review with the goal of guiding VA planning for healthcare services that may be influenced by, or should be targeted to social determinants contributing to poorer health and greater care needs among Veterans. They engaged VA partners in developing frameworks for the evidence review, and selecting high-priority social determinants that would undergo more detailed review of results (i.e., rurality, trauma history, sexual orientation, and gender identity). Investigators searched MEDLINE, CINAHL, PsycINFO, and Sociological Abstracts for relevant articles published from database inception through January 2017. After reviewing more than 7,000 abstracts, 450 published articles underwent full-text review, along with 6 articles from a search of clinical trials, recommendations from experts, and a review of national cohorts and VA research programs. Investigators identified 131 articles that were included in the evidence map, and 37 of these underwent detailed review for high-priority social determinants.

Summary of Findings
While extensive literature addresses education, marital status, income, and/or employment, little published work exists that compares the role of other social determinants of health (i.e., trauma and sexual orientation) for Veterans (or for certain Veteran groups) and non-Veterans. That being said, the evidence review shows:

Rurality
There is moderate strength evidence that there are no substantial differences in rurality between Veterans and non-Veterans or engaged (i.e., enrolled in or using VA services or benefits) and non-engaged Veterans (i.e., not enrolled in or using VA services or benefits). Included articles were consistent in reporting lack of differences, but there was wide variation in the definition of rurality, limiting interpretations. There is insufficient evidence on the effects of rurality on differences in healthcare use, health behaviors, or health outcomes between Veterans and non-Veterans or engaged and non-engaged Veterans.

Trauma
There is low strength of evidence that there is increased trauma exposure, including non-military exposures, among Veterans as compared with non-Veterans, and among engaged Veterans compared with non-engaged Veterans. There is low-strength evidence that trauma exposure contributes to differences in prevalence of smoking between Veterans and non-Veterans. There were no articles that addressed the role of trauma exposure on health services access, health behaviors, or health outcomes between engaged and non-engaged Veterans. Included articles on trauma examined a wide variety of exposures, including type, timing, and measures used.

Sexual Orientation or Gender Identity
There is insufficient evidence regarding differences in prevalence of sexual minority between Veterans and non-Veterans. Only two articles examined sexual orientation for Veterans and non-Veterans and included only women. No articles addressed gender identity for Veterans and non-Veterans.

FUTURE RESEARCH
Following is a summary of major research gaps and recommendations for how to fill these gaps.

• Promote inclusion of consistent and accurate assessments of high-priority social determinants (i.e., trauma exposures, sexual orientation) for existing or ongoing national datasets that also capture Veteran status.
• Develop new data sources and/or improve the ability to link with existing non-VA data sources, in order to understand social determinants and outcomes for Veterans engaged and not engaged in VA healthcare services or benefits.
• Apply measures of social determinants more consistently and, whenever possible, provide sufficient detail to address how social determinants may be affecting outcomes.
• Develop and utilize clear conceptual frameworks that guide analytic decisions and interpretation of results.

Implications for VHA Policy/Practice
According to Population Health Services, the ability to assess the impact of gender identity or sexual orientation will be improved with VA's implementation -- in line with the Institute of Medicine's recommendations -- of systematic capture of these demographic variables in the system of records. The self-identified gender identity field has already been activated, and planning is underway to capture sexual orientation in a computable format.

Reference
Duan-Porter W, Martinson BC, Taylor B, Falde S, Gnan K, Greer N, MacDonald R, McKenzie L, Rosebush C, Wilt TJ. Evidence Review: Social Determinants of Health for Veterans. VA ESP Project #09-009; 2017.

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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