The association between social needs and chronic conditions in a large, urban primary care population

Caroline G. Heller, Colin D. Rehm, Amanda H. Parsons, Earle C. Chambers, Nicole H. Hollingsworth, Kevin P. Fiori

Research output: Contribution to journalArticlepeer-review

17 Scopus citations


There is consensus that social needs influence health outcomes, but less is known about the relationships between certain needs and chronic health conditions in large, diverse populations. This study sought to understand the association between social needs and specific chronic conditions using social needs screening and clinical data from Electronic Health Records. Between April 2018–December 2019, 33,550 adult (≥18y) patients completed a 10-item social needs screener during primary care visits in Bronx and Westchester counties, NY. Generalized linear models were used to estimate prevalence ratios for eight outcomes by number and type of needs with analyses completed in Summer 2020. There was a positive, cumulative association between social needs and each of the outcomes. The relationship was strongest for elevated PHQ-2, depression, alcohol/drug use disorder, and smoking. Those with ≥3 social needs were 3.90 times more likely to have an elevated PHQ-2 than those without needs (95% CI: 3.66, 4.16). Challenges with healthcare transportation was associated with each condition and was the most strongly associated need with half of conditions in the fully-adjusted models. For example, those with transportation needs were 84% more likely to have an alcohol/drug use disorder diagnosis (95% CI: 1.59, 2.13) and 41% more likely to smoke (95% CI: 1.25, 1.58). Specific social needs may influence clinical issues in distinct ways. These findings suggest that health systems need to develop strategies that address unmet social need in order to optimize health outcomes, particularly in communities with a dual burden of poverty and chronic disease.

Original languageEnglish (US)
Article number106752
JournalPreventive Medicine
StatePublished - Dec 2021


  • Chronic disease
  • Electronic health records
  • Mental health
  • Population health
  • Primary healthcare
  • Social determinants of health

ASJC Scopus subject areas

  • Epidemiology
  • Public Health, Environmental and Occupational Health


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