Social History and Socioeconomic Status Assessment in Patient Interviews
A comprehensive social history interview should systematically assess five core domains: educational attainment, employment and occupation, income and financial security, housing and living situation, and psychosocial stressors including substance use and social support networks. 1
Educational Attainment
- Ask patients directly about their highest level of education completed, as education is the strongest and most consistent predictor of health outcomes among all socioeconomic measures 2
- Educational level independently predicts cardiovascular risk factors, chronic disease burden, and health literacy more reliably than income or occupation alone 2
Employment and Occupation Assessment
Current work status should be documented using standardized categories: 1
- Working now (full-time or part-time)
- Temporarily laid off, on sick leave, or maternity leave
- Looking for work/unemployed
- Retired
- Disabled (permanently or temporarily)
- Keeping house/unpaid primary caregiver
- Student
Additionally ask: "Do you want help finding or keeping work or a job?" with response options including help finding work, help keeping work, or no help needed 1
- For patients with chronic illness, recognize that one-third of heart failure patients become unemployed within 12 months of hospitalization, demonstrating the bidirectional relationship between health and employment 3
- Specifically inquire: "At any point in the past 2 years, has seasonal or migrant farm work been your or your family's main source of income?" 1
Income and Financial Security
Ask directly: "What is your best estimate of the total income of all family members from all sources, before taxes, in the last calendar year?" 1
- Income is the single most indicative measure of population socioeconomic status and should be prioritized when time is limited 4
- Always provide options for "refuse to answer," "don't know," or "not ascertained" to respect patient autonomy 1
- Two-thirds of patients with chronic illness who don't take medications due to cost never disclose this to their physician, making direct inquiry essential 3
Screen for food insecurity, which affects one-fifth of adults with diabetes and increases risk for uncontrolled hyperglycemia and severe hypoglycemia 3
Housing and Living Situation
Document housing stability by asking about: 1, 3
- Current living situation (own home, rent, temporary housing, homeless)
- Housing instability or risk of eviction
- Utility needs and ability to maintain essential services
- Whom the patient lives with and their support role 1
Substance Use Assessment
Use open-ended, nonjudgmental questions to assess: 1, 5
- Tobacco use (current, past, pack-years)
- Alcohol consumption (frequency, quantity)
- Recreational drug use including marijuana, cocaine, methamphetamine, ecstasy, and ketamine 1
For active injection drug users, specifically ask about: 1
- Drug-use practices
- Source of needles
- Whether needles are shared
Social Support and Safety
Identify existing social supports by asking: 1, 3
- Whom the patient has informed of their health status
- How they have been coping with their diagnosis
- What kinds of support they have been receiving
- Who serves as their surrogate decision maker 1
Screen for interpersonal safety using the Accountable Health Communities tool, which assesses safety concerns in the home environment 1, 3
Transportation and Healthcare Access
- Document transportation access, as this directly affects ability to attend appointments and obtain medications 1, 3
- Assess healthcare access barriers including insurance coverage, which often depends on employment status 1
Psychosocial Stress Assessment
Use the validated single-item stress question: "Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his/her mind is troubled all the time. Do you feel this kind of stress these days?" 1
- Response options: Not at all, A little bit, Somewhat, Quite a bit, Very much 1
- This question correlates with health indicators and psychosocial work characteristics 1
Screen for depression using PHQ-2: "Over the past 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?" 1
- A cutoff score ≥3 has 83% sensitivity and 92% specificity for major depression 1
Sexual and Reproductive History
Obtain sexual history in an open, nonjudgmental manner, asking about: 1
- Past and current sexual practices
- Condom and contraceptive use
- Whether partner(s) have been informed of any relevant health status
- Plans for having children 1
Family Medical History in Socioeconomic Context
- Ask about family history of conditions that predispose to malignancies, neurologic diseases, and atherosclerotic disease 1
- Document history of myocardial infarction in first-degree relatives (before age 55 in males, before age 65 in females) 1
Critical Implementation Considerations
Avoid these common pitfalls: 3
- Do not assume racial, ethnic, or ancestral groups are monolithic; recognize intersecting identities including class, gender identity, and residential neighborhood 3
- Do not apply population-level data rigidly to individual patients without considering individual variation within socioeconomic categories 3
- Recognize that 70% of physicians have implicit preference for whites over blacks, which affects medical decision-making and communication 3
Use standardized screening tools like the Accountable Health Communities 10-item tool, which efficiently assesses housing instability, food insecurity, transportation needs, utility needs, and interpersonal safety in busy clinical settings 1, 3
Document findings systematically in electronic health records, as consistent data collection enables population health research, service monitoring, and equity improvements 6, 7
Connect assessment to action by providing patient education about available social service resources and making appropriate referrals based on identified needs 3