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Overview

One of the tasks that health care professionals perform is that of translating health care information so laypersons can understand that information.  All too frequently we forget that what is everyday language to us is as foreign as Klingon (Star Trek) or Sindarin (Lord of the Rings) to others.  It is our responsibility to convey health information so it can be understood.  The task in this assignment is to review an article (one you have used in a previous assignment) and create an explanation of that article that would be understood by a layperson.

Some useful material can be found in the Module 4 Instructional Materials folder.

are required for the initial post; one can be the ACOG article. The initial post is to be 250-300 words in length.

Instructions

1.    Read the 
ACOG article
 (Committee on Health Care for Underserved Women) also found in the Instructional Materials folder in Module 3.
2.    Provide an explanation of the relationship between the social determinants of health and cultural awareness in the delivery of health care.  This explanation must be tailored to the understanding of a layperson.
3. The initial post explanation needs to be between 250-300 words in length.
4. A minimum of two (2) reference is required for the initial post.  This reference will be in addition to any reference you wish to use from the ACOG article.  It is okay to use textbook material to support points in the discussion, but it does not count towards the required minimum reference.
5. As with the other discussion boards you need to respond to two (2) peers.  The responses must be between 150-200 words each.  Remember that the responses cannot be posted on the same day that you post the initial post.

VOL. 131, NO. 1, JANUARY 2018 OBSTETRICS & GYNECOLOGY e43

Importance of Social Determinants of Health and
Cultural Awareness in the Delivery of Reproductive
Health Care

ABSTRACT: Awareness of the broader contexts that influence health supports respectful, patient-centered
care that incorporates lived experiences, optimizes health outcomes, improves communication, and can help
reduce health and health care inequities. Although there is little doubt that genetics and lifestyle play an important
role in shaping the overall health of individuals, interdisciplinary researchers have demonstrated how the conditions
in the environment in which people are born, live, work, and age, play equally as important a role in shaping health
outcomes. These factors, referred to as social determinants of health, are shaped by historical, social, political,
and economic forces and help explain the relationship between environmental conditions and individual health.
Recognizing the importance of social determinants of health can help obstetrician–gynecologists and other
health care providers better understand patients, effectively communicate about health-related conditions
and behavior, and improve health outcomes.

Recommendations
The American College of Obstetricians and Gynecologists
makes the following recommendations for obstetrician–
gynecologists and other health care providers to improve
patient-centered care and decrease inequities in repro-
ductive health care:

• Inquire about and document social and structural
determinants of health that may influence a patient’s
health and use of health care such as access to stable
housing, access to food and safe drinking water, util-
ity needs, safety in the home and community, immi-
gration status, and employment conditions.

• Maximize referrals to social services to help improve
patients’ abilities to fulfill these needs.

• Provide access to interpreter services for all patient
interactions when patient language is not the clini-
cian’s language.

• Acknowledge that race, institutionalized racism, and
other forms of discrimination serve as social deter-
minants of health.

• Recognize that stereotyping patients based on pre-
sumed cultural beliefs can negatively affect patient
interactions, especially when patients’ behaviors are
attributed solely to individual choices without recog-
nizing the role of social and structural factors.

• Advocate for policy changes that promote safe and
healthy living environments.

Background
Traditional biomedical explanations of disease tend to
focus on biologic and genetic factors as well as indi-
vidual health behavior as determinants of who gets sick
and from what conditions. Although there is little doubt
that genetics and lifestyle play an important role in shap-
ing the overall health of individuals, interdisciplinary
researchers have demonstrated how the conditions in the
environment in which people are born, live, work, and
age, play equally as important a role in shaping health
outcomes (1–5). These factors, referred to as social deter-
minants of health, are shaped by historical, social, politi-
cal, and economic forces and help explain the relationship

ACOG COMMITTEE OPINION
Number 729 • January 2018 (Replaces Committee Opinion Number 493, May 2011)

Committee on Health Care for Underserved Women
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Committee on Health Care for Underserved
Women in collaboration with committee members Carolyn Sufrin, MD, PhD, Autumn Davidson, MD, MS, and Glenn Markenson, MD.

Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.

Unauthorized reproduction of this article is prohibited.

e44 Committee Opinion Importance of Social Determinants of Health OBSTETRICS & GYNECOLOGY

between environmental conditions and individual health
(6). It is well established that social determinants of
health are responsible for a large proportion of health
inequities that exist in the United States. Awareness of the
broader contexts that influence health supports respectful,
patient-centered care that incorporates lived experiences,
optimizes health outcomes, improves communication, and
can help reduce health and health care inequities. Social and
structural factors account for more than one third of total
deaths in the United States in a year, and evidence sug-
gests that addressing social needs of individuals results in
improved overall health (7–9).

Social and Structural Determinants of
Health
Social and structural determinants of health describe
environmental conditions, both physical and social, that
influence health outcomes. Physical conditions such as
lack of access to safe housing, clean drinking water, nutri-
tious food, and safe neighborhoods contribute to poor
health. Socio-political conditions such as institutional
racism; police violence targeting people of color; gender
inequity; discrimination against lesbian, gay, bisexual,
transgender, queer, or questioning (LGBTQ) individu-
als; poverty; lack of access to quality education and jobs
that pay a livable wage; and mass incarceration all shape
behavior and biological processes that ultimately influ-
ence individuals’ health and the health of communities
(5, 10–12). Such social conditions not only influence
individual health but also work to create cycles that per-
petuate intergenerational disadvantage.

Social determinants of health have been shown
to affect many conditions treated by obstetrician–
gynecologists, including but not limited to preterm
birth, unintended pregnancy, infertility, cervical cancer,
breast cancer, and maternal mortality (13). Obstetrician–
gynecologists and other health care providers should
seek to understand patients’ health care decision making
not simply as patients’ individual-level behavior, which
at times may appear foreign or irrational to health care
providers, but rather as the result of larger systems that
create and maintain inequalities in health and health
care. Recognizing the importance of social determinants
of health can help obstetrician–gynecologists and other
health care providers better understand patients, effec-
tively communicate about health-related conditions and
behavior, and improve health outcomes.

The social determinants of health approach also
acknowledges intersectionality—the overlapping catego-
ries of social identities such as gender, race, class, disabil-
ity status, and sexual orientation and related structures of
oppression and discrimination as they manifest in health
care and outcomes. The reproductive justice framework
acknowledges this interconnected nature of social and
structural forces as they come to bear, in part, on people’s
sexual and reproductive health (14). Relatedly, a shared

history and daily experiences of discrimination among
patients of color might negatively influence their health
outcomes and feelings about health care systems (15).
For some, this may be expressed as avoiding care, mis-
trusting health care providers, or not following recom-
mended treatments; this also may be true for LGBTQ
patients seeking sexual and reproductive health care
(16). Immigration status also is a social and structural
determinant of health. For example, an undocumented
immigrant may not access health care because of lack
of coverage, or may fear deportation if she presents to a
health care facility (17, 18).

A patient-centered approach to care recognizes the
role of such historical and contemporary forces in clini-
cal encounters. For example, a pregnant patient with
gestational diabetes who has not checked her blood
sugars may be labeled as irresponsible or noncompliant.
An approach that recognized the effect of social determi-
nants of health may probe deeper and discover that the
patient lacks stable housing and forgets to bring her glu-
cometer each time she moves to another family member’s
or friend’s house. Communicating with this patient about
the importance of blood sugar control as the only strategy
to address glycemic control would be ineffective. Rather,
working with social services to address her housing issues
would more likely enable her to manage her diabetes.

Another example is a pregnant patient with poor
weight gain who is evaluated for medical comorbidities
when deeper probing into the etiology reveals she was
fired from her job and cannot afford enough food for
herself and her two children. Ordering tests or discussing
the importance of good nutrition in pregnancy would
be meaningless if not accompanied by referrals for food
assistance. Another commonly encountered scenario
influenced by social determinants of health is the ability
of patients to arrive at scheduled appointments on time.
Many low-income women rely on often unreliable public
transportation and may arrive late to appointments and
be forced to reschedule, which creates the impression of
nonadherence. Such examples highlight the importance
of inquiry into the underlying reasons for these care
challenges. In fact, asking about certain social factors can
be time-saving in some circumstances and can help to
address systematic barriers to health care. This strategy
has been shown to reduce clinician burnout, decrease
health disparities, and also may reduce health care spend-
ing (19).

Most physicians recognize the importance social
determinants play in health outcomes. In one survey,
85% of physicians felt that patients’ social needs were as
important to address as their medical ones, yet 80% felt
they were not confident in addressing them (20). Indeed,
addressing the root cause of many of these problems
requires wide-reaching, policy-level changes, and most
health care settings are generally under-resourced to
address the social needs of individual patients. However,
tools have been developed to assist clinicians in screening

Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.

Unauthorized reproduction of this article is prohibited.

VOL. 131, NO. 1, JANUARY 2018 Committee Opinion Importance of Social Determinants of Health e45

from a particular country to learn about cultural specifici-
ties of that group, recognize variations within that group,
and understand the overlaying general experience of
being an immigrant.

Instead of “competence,” which mistakenly implies
that culture is a skill that one can master, other ways
to recognize that culture matters in certain clinical
encounters include cultural humility, cultural awareness,
cross-cultural care, and cultural respect (24–26). These
approaches include the clinician being humble about rec-
ognizing the limits of her or his knowledge of a patient’s
situation, avoiding generalizing assumptions, being aware
of clinicians’ and patients’ biases, ensuring mutual under-
standing through patient-centered communication, and
respectfully asking open-ended questions about patients’
circumstances and values when appropriate (27).

Practical Tools
Although attention frequently is focused on reducing
health inequities through public health initiatives and
state and national policies, obstetrician–gynecologists
and other health care providers can have a significant
effect by designing their own clinical practice with
an awareness of the importance of the key social and
structural determinants of health. Even small changes
in practice can make a significant difference with mini-
mal financial sacrifices if deliberate planning is done to
address these determinants. Some changes to consider
include the following:
• Screening for Social Determinants of Health—

Provide patient-completed intake questionnaires,
expanded medical history questions, and integrated
electronic medical records prompts. When purchas-
ing or customizing electronic medical records for the
office, obstetrician–gynecologists and other health
care providers should request structured fields that
capture information on social and behavioral deter-
minants (12, 21, 28, 29) (see Table 1).

• Medical–Legal Partnerships—Obstetrician–gynecologist
practices that are part of a community health care
clinic or network should encourage the facility to
establish medical–legal partnerships. This involves
colocating legal services in the same site as the clinic,
which enables patients to receive assistance with
problems such as toxic environmental exposures
in their homes, access to stable housing, legal aid
for immigration challenges, and other legal matters
that directly affect individuals’ health. Medical–legal
partnerships are available in many federally funded
health care clinics and have been shown to positively
affect health outcomes, including adverse pregnancy
outcomes such as low birth weight (5, 30). Individual
obstetrician–gynecologist practices may not be able
to have such services on location, but relationships
can be developed with existing medical–legal part-
nerships to provide needed services.

for some conditions, such as food insecurity and housing
instability, and to incorporate these questions into elec-
tronic medical records (19, 21). Including social indicator
prompts in physician encounter tools has been shown
to increase referrals to social services (19). Providing
referrals to housing or food services while patients are
in the clinic can improve their health care usage (19).
These and other strategies have been described in an
approach called “structural competency” (5). This frame-
work recognizes that the way society is structured (for
example, through racial, economic, and gender inequali-
ties) influences clinical interactions and health outcomes.
Structural competency aims to help clinicians intervene
on these upstream contributions to disparate health out-
comes, and also to recognize that these structural expla-
nations have limitations and are not comprehensive (5).

Cultural Awareness, Humility, and
Sensitivity
In the 1990s, a concerted recognition emerged among
health care professionals and educators that patients
come from diverse cultural backgrounds that may influ-
ence their understanding of health and illness, interac-
tions with health care providers and institutions, and
engagement with treatment recommendations (22). This
was formalized into the framework of “cultural compe-
tence,” which provided health care professionals with
tools to address cultural differences in their patient care
interactions. It aims, in part, to understand patients’
health-related behaviors as resulting from their cultural
beliefs—beliefs that may influence patients’ health care-
decision making.

Although this approach has elevated discussions of
diversity in health care settings, an over-emphasis on
culture frequently conveys stereotyped representations
of individuals from various ethnic groups while also
overlooking diversity within groups by equating indi-
vidual beliefs with group beliefs (23). Categorizations
like race and class often are reduced to cultural posi-
tions, rather than complex political, social, historical, and
economic phenomena. Moreover, cultural competency
overlooks the cultural dimensions of health care systems
and clinicians themselves. It also suggests that we can
be “competent” in another person’s culture, when cul-
ture itself is not a skill to be mastered. The emphasis on
cultural beliefs thus tends to simplify patients’ behavior
into simple, individual choices, which impedes a deeper
understanding of complex interactions of the social,
economic, political, and environmental circumstances of
patients’ lives.

Despite the limitations of a cultural competence
approach, it is nonetheless critical for health care provid-
ers to recognize that both patients and clinicians hold
their own set of values stemming from individual life
experience and, in some cases, cultural backgrounds. It
may be especially helpful, for instance, for a clinician
working in a locale with a large population of immigrants

Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.

Unauthorized reproduction of this article is prohibited.

e46 Committee Opinion Importance of Social Determinants of Health OBSTETRICS & GYNECOLOGY

small steps can have a significant effect on health out-
comes at the individual level and can help reduce health
inequities at a population level.

For More Information
The American College of Obstetricians and Gynecologists
has identified additional resources on topics related to this
document that may be helpful for ob-gyns, other health
care providers, and patients. You may view these resources
at www.acog.org/More-Info/SocialDeterminants.

These resources are for information only and are not
meant to be comprehensive. Referral to these resources
does not imply the American College of Obstetricians
and Gynecologists’ endorsement of the organization, the
organization website, or the content of the resource. The
resources may change without notice.

• Liaisons with Community-Based Social Needs
Programs—Obstetrician–gynecologists and other
health care providers should develop partnerships
with social workers and local community advocates
who provide assistance with basic resources such as
food pantries and home utility bills. Patients in need
may feel less inhibited from using assistance pro-
grams when the obstetrician–gynecologist frames
the referral letter to the community assistance pro-
gram as a prescription, for example, to promote a
healthy pregnancy. For more details on methods
linking physicians to community social services see
the Health Leads website at www.healthleadsusa.org.

• Interpreter Services—Language barriers can be
partially addressed by having professional inter-
preters available when the patient’s language is not
the clinician’s language (see Committee Opinion
No. 587, Effective Patient–Physician Communica-
tion). In-person interpretation can enhance inter-
personal interactions, but when this is not possible,
using a phone service or video interpretation ser-
vice is a good option with high patient-satisfaction
ratings (31).

• Transportation and Logistics—Underserved popu-
lations often have difficulties obtaining transporta-
tion to health care facilities. Therefore, access to
public transportation should be considered when
planning office locations. In addition, underserved
women often must bring family members to an
office visit. In order to facilitate attendance at health
care appointments, obstetrician–gynecologists and
other health care providers should avoid making
arbitrary rules that prevent children and other family
members from attending office visits.

Conclusion
Social and structural determinants of health affect health
outcomes as much as biological and individual level
factors. Although cultural competency is advocated to
improve patient–health care provider communication
with the ultimate goal of reducing racial and ethnic
inequities in health outcomes, the model has significant
limitations. Obstetrician–gynecologists and other health
care providers should be aware of these limitations and,
rather than solely explain health inequities by cultural
differences, recognize that inequities are largely the result
of forces that influence health at a point upstream from
individual behavior. By understanding these inequities
as manifestations of larger social pathologies, health care
providers may begin to address patient needs in a deeper
and more effective way. Obstetrician–gynecologists and
other health care providers may address social determi-
nants of health by implementing key practices such as
employing multilingual staff, ensuring adequate inter-
preter services, partnering with medical–legal organiza-
tions, and engaging with community resources. These

Table 1. Sample Screening Tool for Social Determinants of
Health 

Domain Question

Food In the last 12 months, did you ever eat
less than you felt you should because
there was not enough money for food?

Utility In the last 12 months, has your utility
company shut off your service for not
paying your bills?

Housing Are you worried that in the next 2 months,
you may not have stable housing?

Child care Do problems getting childcare make it
difficult for you to work, study, or get to
health care appointments?

Financial resources In the last 12 months, have you needed to
see a doctor but could not because of cost?

Transportation In the last 12 months, have you ever had
to go without health care because you did
not have a way to get there?

Exposure to violence Are you afraid you might be hurt in your
apartment building, home, or neighborhood?

Education/health Do you ever need help reading materials
literacy you get from your doctor, clinic, or the
hospital?

Legal status Are you scared of getting in trouble
because of your legal status? Have you
ever been arrested or incarcerated?

Next steps If you answered yes to any of these
questions, would you like to receive
assistance with any of those needs?

Modified from Health Leads. Social needs screening toolkit. Boston (MA): Health
Leads; 2016; and Bourgois P, Holmes SM, Sue K, Quesada J. Structural vulnerabil-
ity: operationalizing the concept to address health disparities in clinical care. Acad
Med 2017;92:299–307.

Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.

Unauthorized reproduction of this article is prohibited.

VOL. 131, NO. 1, JANUARY 2018 Committee Opinion Importance of Social Determinants of Health e47

19. Gottlieb L, Sandel M, Adler NE. Collecting and applying
data on social determinants of health in health care settings.
JAMA Intern Med 2013;173:1017–20. 

20. Robert Wood Johnson Foundation. 2011 physicians daily
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21. Estabrooks PA, Boyle M, Emmons KM, Glasgow RE,
Hesse BW, Kaplan RM, et al. Harmonized patient-reported
data elements in the electronic health record: supporting
meaningful use by primary care action on health behaviors
and key psychosocial factors. J Am Med Inform Assoc
2012;19:575–82. 

22. Saha S, Beach MC, Cooper LA. Patient centeredness, cul-
tural competence and healthcare quality. J Natl Med Assoc
2008;100:1275–85. 

23. Kleinman A, Benson P. Anthropology in the clinic: the
problem of cultural competency and how to fix it. PLoS
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24. Tervalon M, Murray-Garcia J. Cultural humility versus
cultural competence: a critical distinction in defining physi-
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25. Carrillo JE, Green AR, Betancourt JR. Cross-cultural pri-
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public-liaison/clear-communication/cultural-respect.
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27. DasGupta S. Narrative humility. Lancet 2008;371:980–1. 
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29. Health Leads. Social needs screening toolkit. Boston (MA):
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The American College of Obstetricians and Gynecologists
409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920

Importance of social determinants of health and cultural awareness
in the delivery of reproductive health care. ACOG Committee Opinion
No. 729. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2018;131:e43–8.

Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.

Unauthorized reproduction of this article is prohibited.

e48 Committee Opinion Importance of Social Determinants of Health OBSTETRICS & GYNECOLOGY

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is
voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care.
It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in
the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or
advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publica-
tions may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.

While ACOG makes every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy,
reliability, or otherwise, either express or implied. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or
person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabili-
ties, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Copyright ª by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.

Unauthorized reproduction of this article is prohibited.

Rubric #1, Discussion Board and Response (for M1-A3, M2-A3, M3-A3, M4-A3)

Use the information in each of the boxes below each category, e.g., accomplished or proficient, to guide you in
meeting the goals of a specific assignment. The final number of points seen below the grid indicate your level
of accomplishment.

Discussion Board and Response

Area Evaluated
20 points each

Accomplished Proficient Needs Work Unacceptable

Organization

3 points maximum

Well organized
Clear introduction
and thesis specified
Intro, thesis, body,
and conclusion flow
easily & with clarity

Organized
Introduction & thesis
present. Lacks some
clarity
Missing one element,
i.e. intro, thesis,
body, conclusion

Lacks a cohesive
argument.
Missing more than
one element

Unorganized
No clear argument
Missing more than
two elements

Completeness

4 points maximum

Addresses all
questions and topics
with sufficient depth

Missed one question
or inadequately
addressed

Missed two
questions or used
unsubstantiated
claims

Three (3) or more
questions missed or
inadequately
addressed

Accuracy/support/
Integration of course
material

4 points maximum

No factual errors
No unsubstantiated
claims
Course material is
integrated to support
comments

No more than one (1)
factual error or
unsubstantiated
claim
Includes some course
material

Adds some additional
information but does
not add much to the
discussion

Three or more
factual errors
Unsubstantiated
claims
Limited or no
inclusion of course
material

Response to peer

3 points maximum
for each response

Constructive
comments
Adds additional
information & depth
to the discussion OR
takes discussion in
new, clear direction

Adds some additional
information but only
expands the depth of
understanding
slightly

May add some
information and does
not add

No new information
provided
Basically a repeat of
original post
Lacks substance

APA & MUGS

3 points maximum

No more than one (1)
error in mechanics of
writing or APA
format
Flow makes sense.

No more than three
(3) errors

No more than five (5)
errors

More than five (5)
errors

Interpretation of Final Points Accomplished: 20.00 – 18.00 points
Proficient: 17.99 – 16.00 points
Needs Work: 15.99 – 14.00 points
Unacceptable: 13.99 – 0 points

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