Examining How Social Risk Factors Are Integrated Into Clinical Settings Using Existing Data: A Scoping Review

Wivine M. Ngongo, Jonna Peterson, Dawid Lipiszko, Lauren A. Gard, Katherine M. Wright, Aaron S. Parzuchowski, Paul A. Ravenna, Andrew J. Cooper, Stephen D. Persell, Matthew J. O'Brien, Mita Sanghavi Goel

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


PURPOSE Integrating social care into clinical care requires substantial resources. Use of existing data through a geographic information system (GIS) has the potential to support efficient and effective integration of social care into clinical settings. We conducted a scoping literature review characterizing its use in primary care settings to identify and address social risk factors. METHODS In December 2018, we searched 2 databases and extracted structured data for eligible articles that (1) described the use of GIS in clinical settings to identify and/or intervene on social risks, (2) were published between December 2013 and December 2018, and (3) were based in the United States. Additional studies were identified by examining references. RESULTS Of the 5,574 articles included for review, 18 met study eligibility criteria: 14 (78%) were descriptive studies, 3 (17%) tested an intervention, and 1 (6%) was a theoreti-cal report. All studies used GIS to identify social risks (increase awareness); 3 studies (17%) described interventions to address social risks, primarily by identifying relevant community resources and aligning clinical services to patients’ needs. CONCLUSIONS Most studies describe associations between GIS and population health out-comes; however, there is a paucity of literature regarding GIS use to identify and address social risk factors in clinical settings. GIS technology may assist health systems seeking to address population health outcomes through alignment and advocacy; its current application in clinical care delivery is infrequent and largely limited to referring patients to local community resources.

Original languageEnglish (US)
Pages (from-to)68-74
Number of pages7
JournalAnnals of family medicine
StatePublished - 2023


  • disparities
  • geographic information systems
  • geography, medi-cal
  • geospatial data
  • health information technology
  • needs assess-ment
  • population health
  • social determinants of health
  • social risk factors
  • vulnerable populations

ASJC Scopus subject areas

  • Family Practice


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