Capturing Social and Behavioral Domains and Measures in Electronic Health Records Phase 2 (2014) / Chapter Skim
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3 Identified Candidate Domains
3 Identified Candidate Domains
Pages 55-126
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The following section describes the justification for the use of the life course approach that guided the committee's deliberations. While the committee did not identify any specific populations or settings for selected candidate domains, measures for these domains will be identified in Chaper 4 and these measures may be tailored to specific populations, as guided by use of the life course perspective.
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The concept of life course perspective is often equated with life span development (Alwin, 2012) , which views human development, socialization, and adaptation as lifelong processes of continuity and change.
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. A gender-based life course perspective suggests that health inequities result from differences in protective and risk factors among groups of women over the course of their lives (Manton et al., 2008)
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That is, the health of adults is related to their health as children. Stimulated by a series of studies demonstrating how growth during fetal and early life relates to the risk of chronic conditions in adulthood, life course health science as a field has begun mapping the developmental mechanisms of health (Ben-Shlomo and Kuh, 2002; Lynch and Smith, 2005)
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. The life course perspective provides a framework for understanding how an individual's health and environmental exposures are connected to the development of disorders, disabilities, and death (Halfon and Hochstein, 2002; Hertzman, 1999; Hertzman and Power, 2003)
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born Education Employment Financial resource strain: Food and housing insecurity Psychological Domains Health literacy Stress Negative mood and affect: Depression and anxiety Psychological assets: Conscientiousness, patient engagement/activation,1 optimism, and self-efficacy Behavioral Domains Dietary patterns Physical activity Tobacco use and exposure2 Alcohol use Individual-Level Social Relationships and Living Conditions Domains Social connections and social isolation Exposure to violence 1 ThePhase 1 report had several editorial errors in the labeling of domains/subdomains. The report has been updated to correct the errors.
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. Lesbians might experience higher levels of breast cancer risk than heterosexual women, but more research is needed to identify if the risk is due to not bearing children or other risks factors, such as alcohol consumption or being overweight (IOM, 1999)
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Usefulness If individual health care providers have information about their patients' sexual orientation, they can be better equipped to diagnose and counsel them on conditions that may be transmitted through sexual contact and to perform appropriate tests (Makadon, 2011)
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. Throughout the life course, health disparities by race and ethnicity are apparent from an early age.
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The most consistent findings are for African Americans and Native Americans. For example, among cardiovascular and related chronic diseases, the incidence of heart failure has increased at a higher rate among younger black males, suggesting that management of associated hypertension and diabetes is needed to reduce these racial disparities (Husaini et al., 2011)
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. Usefulness If individual health care providers have information on their patients' racial and ethnic identity and ancestry, they can be better equipped to look for specific risks.
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Communication is essential for health and effective health care (see the Health Literacy section later in this chapter)
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Knowledge about a patient's country of origin can improve the quality of care through better (1) communication that recognizes potential limitations in health literacy and the need for interpreters and culturally competent care (i.e., understanding the role of acculturation as a facilitator or barrier to health promotion)
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. Although education may operate in part by affecting health literacy, the latter is a distinct domain that is discussed here.
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linking SES indicators during childhood with mortality in adulthood, regardless of the SES level in adulthood. Among male adults studied, lower childhood SES was linked with an increased risk of mortality from chronic disease, such as coronary heart disease; stroke; respiratory disease; diabetes; cancers of the lung, liver, and stomach; and digestive system diseases.
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. Perceived job insecurity is also an important predictor of poor health, and job loss has been found to have adverse health consequences, including increased morbidity and mortality not only from mental illness but also from cardiovascular disease (Bartley, 1988, 1996; Bartley and Ferrie, 2001; Burgard et al., 2007; Dupre et al., 2012; Gallo et al., 2004; Martikainen, 1998; Martikainen and Valkonen, 1996; Strully, 2009; Sullivan and von Wachter, 2009; Valkonen and Martikainen, 1996; Voss et al., 2004)
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. Chronic exposure to occupational noise is strongly associated with increased rates of coronary heart disease and hypertension compared to those never exposed (Gan et al., 2011)
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. Financial Resource Strain: Food and Housing Insecurity Financial resource strain encompasses both the subjective sense of strain as the result of economic difficulties and the specific sources of strain, including employment insecurity, income insecurity, housing insecurity, and food insecurity.
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For example, although job insecurity was shown to have little impact on persistent inequalities in morbidity and cardiovascular risk factors (with the exception of depression) , and despite steep gradients in perceived job insecurity among employed persons (ScottMarshall and Tompa, 2011)
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Health Literacy Health literacy is defined in the IOM report Health Literacy: A Prescription to End Confusion as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (IOM, 2004, p.
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(2011) found insufficient evidence for causal associations among health literacy, ambulatory care, health care services, risk perception accuracy, and accurate interpretation of health information; but it did find that numeracy appeared to mediate some health disparities for specific health outcomes in patients with diabetes and HIV infection.
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Literacy and numeracy may mediate between health literacy and poor health outcomes for some populations (e.g., members of racial minority groups, people with limited education) and define additional health and health care vulnerabilities that have yet to be identified.
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In addition to the physiological effects of toxic stress that increase an individual's risk for disease, individuals may also try to cope with these stressors through behaviors with negative health consequences (Adler and Stewart, 2010)
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For some sources of toxic stress, like interpersonal violence, health care providers can be helpful to patients in developing the skills, resources, and support networks that they need to address the problem and can provide critical social support (Coker et al., 2002; McCaw et al., 2002)
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, but milder, subclinical levels of depression and anxiety are also important, in that they diminish quality of life and can increase the risk of other diseases, such as diabetes and cardiovascular disease. Thus, they are simultaneously health outcomes and determinants of health.
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. A meta-analysis of 20 prospective studies showed that anxiety predicts incident coronary heart disease, with more robust effects found for cardiac mortality (Roest et al., 2010)
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as part of the mental health parity required by the Patient Protection and Affordable Care Act.6 They also need to plan for ways to link patients to treatment given evidence that a diagnosis of depression or anxiety is often not enough to lead patients to seek treatment (Kravitz et al., 2013)
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examined the association of conscientiousness with health behaviors. In general, conscientiousness-related traits were positively related to beneficial health behaviors -- for example, physical activity -- and negatively related to risky health behaviors -- for example, cigarette smoking.
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. Even though a strong relationship has been shown to exist among health care decision making, patient engagement/activation, and health literacy, these concepts exert distinct effects on patient participation in care and subsequent health outcomes (Smith et al., 2013)
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. Usefulness If individual health care providers have information on whether their patients are conscientious, optimistic, or pessimistic and score high or low on self-efficacy or patient engagement/activation, they can better anticipate difficulties their patients may have in being able to cope with specific chronic diseases, to follow a demanding medical treatment, or to introduce behavioral changes.
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. Dietary patterns have been linked to health throughout the life course.
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. Usefulness If individual health care providers have information on their patients' dietary patterns, they can recommend that their patients utilize ancillary services such as lifestyle counseling, including dietary counseling, to
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. If researchers have information on dietary patterns as part of the EHR, studies could identify interventions that should be used in clinical practice to enhance adherence to dietary advice in the context of a variety of chronic diseases (Desroches et al., 2013)
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Among adults, physical activity has been associated with a variety of positive health outcomes such as improved mood, positive affect, and better sleep quality. It also reduces the risk of coronary artery disease, stroke, hypertension, type 2 diabetes, obesity, osteoporosis, breast and colon cancer, and depression (Penedo and Dahn, 2005; Physical Activity Guidelines Advisory Committee, 2008; Powell et al., 2011)
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Tobacco use increases the rates of many diseases and health consequences such as coronary heart disease, stroke, lung cancer, and obstructive lung diseases, as well as pregnancy complications (Fagerström, 2002)
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The 2012 Surgeon General's report Preventing Tobacco Use Among Youth and Young Adults presents a comprehensive synthesis of the findings of the many scientific reviews conducted on the relationship between tobacco use and chronic diseases (CDC, 2012c)
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Nonsmokers who are exposed to secondhand smoke at home, at work, or in other enclosed spaces increase their heart disease risk by approximately 28 percent and their lung cancer risk by approximately 28 percent (CDC, 2013e)
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Alcohol use involves drinking beer, wine, or hard liquor. Alcohol use is more complicated than some other behavioral risk factors because it has both negative and beneficial effects on health, as alcohol use involves a continuum of risk (Mayo Clinic, 1998–2014)
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Evidence of Association with Health High blood alcohol levels can suppress the central nervous system, which can lead to health consequences, including loss of consciousness, low blood pressure, respiratory depression, and death (CDC, 2013c; Sanap and Chapman, 2003)
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Not surprisingly, therefore, aspects of their social relationships are fundamentally important determinants of their health and of the way in which they relate to and are affected by health care providers and systems. The impacts of social relationships on health rival or exceed those of major biomedical factors (e.g., high blood pressure, cholesterol, and blood sugar)
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Other forms of social relationships/engagement are sometimes considered, including participation in political, civic, or governmental groups and activities. The second way in which social relationships can be understood is the level of social support, which refers to the actual aspect or perceived support or a benefit that a person derives from such relationships.
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and the National Health and Nutrition Study (Thurston and Kubzansky, 2009) , women who experienced frequent bouts of loneliness had an increased risk of developing coronary heart disease.
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. Usefulness If health care providers know the social integration/isolation, social support, and loneliness of individual patients, they may better understand not only the patient's health but also his or her use of and need for health care services.
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The negative health consequences become more extreme as the strength and persistence of the exposure or experience increases. Interpersonal violence affects many groups of individuals.
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, mental health problems (e.g., depression, suicide) , and chronic diseases (e.g., chronic obstructive pulmonary disease, ischemic heart disease, lung cancer)
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. Usefulness If individual health care providers know whether their patients are being exposed to or experiencing violence, they can create a comfortable space for their patients to disclose more about their experience, opening the door for appropriate care (see the vignette in Box 1-2 in Chapter 1)
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In light of the co-occurrence and potential exacerbating effects of other social and behavioral determinants (education level, psychological attributes such as impulsivity and substance abuse) , information on experiences of, exposure to, and access to violence and the weapons of violence will help provide the data needed to advance a full understanding of health determinants and the ability to achieve precision medical care.
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Indicators of immigrant composition from foreign-born individuals can be used for gathering information. Evidence of Associations with Health Indicators of area socioeconomic composition have been shown to be related to many different health-related outcomes, including behaviors and other risk factors for disease, morbidity, outcomes among persons with disease, and mortality (Diez-Roux and Mair, 2010; Gerber et al., 2008, 2011a,b)
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. In contrast, findings on neighborhoods with predominantly Latino and foreign-born individuals suggest that segregation can be health protective, possibly as a result of greater social support or lower levels of acculturation of residents to health-damaging aspects of U.S.
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While the majority of the candidate domains identified favor individual capacities and characteristics rather than social level issues, this reflects that data reported by individual patients are most accurate regarding their personal attributes and experiences. Characteristics of their social environment will require additional input; some of this can occur via potentially geocodable items such as area socioeconomic composition, while other information will require linkage to other data sources, a topic that will be addressed in the committee's next report.
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2013. Culture in the context of health literacy: Update.
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2002. A life course approach to chronic disease epidemiology: Conceptual models, empirical challenges and interdisciplinary perspectives.
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2011. Health literacy interventions and outcomes: An updated systematic review.
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American Journal of Cardiology 94(2)
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http://www.cdc.gov/motorvehiclesafety/ impaired_driving/impaired-drv_factsheet.html (accessed January 8, 2014)
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2005. Effects of endurance training on blood pressure, blood pressure–regulating mechanisms, and cardiovascular risk factors.
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2000. The life course.
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2003. Health literacy and knowl edge of chronic disease.
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American Journal of Epidemiology 153(9)
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1999. Effects of walking on coronary heart disease in elderly men: The Honolulu Heart Program.
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2011b. Innovations in health literacy: Workshop summary.
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2003. Life course epidemiology.
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2006. The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006 483)
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2005. A life course approach to chronic disease epidemiology.
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2011. Interpersonal violence in childhood as a risk fac tor for obesity: A systematic review of the literature and proposed pathways.
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Health literacy. http://www.
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2005. Evaluating the evidence for models of life course socioeconomic factors and cardiovascular outcomes: A systematic review.
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2010. Anxiety and risk of incident coronary heart diseases meta-analysis.
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Associations between health literacy, patient activation, and health.
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2010. Social relationships and health behavior across the life course.
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2013. Perceived job insecurity as a risk factor for incident coronary heart disease: Sys tematic review and meta-analysis.
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American Journal of Public Health 100(Suppl.
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