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ARTICLE IN PRESS
Enfermería Clínica xxx (xxxx) xxx---xxx
www.elsevier.es/enfermeriaclinica
LETTER TO THE EDITOR
Health social determinants in
primary healthcare, coding and
treatment夽
Determinantes sociales de la salud en las
consultas de atención primaria, codificación y
tratamiento
Dear Editor,
Health depends on the circumstances in which people are
born, grow up, live, work and age, and includes their health
system. These circumstances are known as the social deter-
minants of health and there are various models and theories
that explain them. Notable among them is Dalgheren and
Whitehead’s model,1 in which the determinants are repre-
sented as layers around the individual and the relationship
between them all conditions the health of individuals and
communities, establishing the levels of health that they can
achieve.2
It is thought that the social determinants of health can
only be influenced by health administration, public health,
or policy. However, we are unaware of the role that primary
care nursing plays in this area.
Primary care is crucial in a health system as it is the
first contact with the health service for a large part of the
population. A person may consult the primary care nurse
for a variety of reasons ranging from prevention, promo-
tion and monitoring of health and illness to end-of-life care.
All these situations in an individual’s life course involve
a nurse/patient relationship. Therefore, the primary care
nurse plays a privileged and relevant role in providing out-
reach to the population and detecting social determinants.
However, surveillance and data collection systems must
be able to capture changes specific to the social context,
and not only focus on global averages or established groups
and use the results to show the importance of social deter-
minants. Primary care teams should be involved as they are
DOI of original article: https://doi.org/10.1016/j.enfcli.2021
.12.001
夽 Please cite this article as: Rodoreda Pallàs B, Vidal-Alaball
J. Determinantes sociales de la salud en las consultas de aten-
ción primaria, codificación y tratamiento. Enferm Clin. 2022.
https://doi.org/10.1016/j.enfcli.2021.12.001
2445-1479/© 2021 Elsevier España, S.L.U. All rights reserved.
closest to citizens and because they have a real vision of the
social context in the area.
When coding diagnoses, in most cases nurses tend to
record only clinical diagnoses, even though the impact that
social determinants can have on the onset of disease has
been amply demonstrated.2 In primary care, social determi-
nants of health are recorded using ‘‘Z-codes’’, non-clinical
diagnoses that are found in Chapter 21 of the International
Classification of Diseases, ICD-10. These codes represent the
reasons for contact due to a circumstance or problem that
affects the health status of the person but does not consti-
tute an illness or injury. This coding can be used in nursing,
midwifery, social work, medicine, paediatrics, and dentistry.
The benefits of good social determinant coding are many
and diverse. Firstly, for primary care professionals, record-
ing of social determinants optimises consultation time and
helps identify the reason for consultation. It also facilitates
therapeutic conciliation and continuity of care between
professionals and services, optimising tests and treatments
and promoting interventions based on the assets for health
model.3 Secondly, for the patient’s part, it reduces the
overdiagnosis and pharmacological overtreatment4 of some
social ailments presented in consultations. These patients
could benefit from a different approach to their clinical
disease with community interventions with a salutogenic
perspective5 and/or social prescriptions,6 which help peo-
ple to take better control of their health, improve their
social support network and reduce the need for medication.
Finally, coding social diagnoses enables the most prevalent
social determinants of health in the community to be visu-
alised, so as to make health diagnoses and assist health
roundtables, promoting the creation of a social vulnerability
map to identify and prioritise the areas where intervention
is most needed.7
To conclude, despite the availability and usefulness of
these ICD-10 Z codes, they have not been widely adopted by
primary health care professionals, by nurses in particular. In
our opinion, their adoption has been limited due to a lack of
awareness of these codes, and due to a lack of clarity as to
who can document a patient’s social needs. We believe that
primary care nurses can take this lead given their knowledge
and dedication to the patient and the community.
Funding
The authors declare that they have received no funding for
this research.
ENFCLE-1947; No. of Pages 2
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ARTICLE IN PRESS
B. Rodoreda Pallàs and J. Vidal-Alaball
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Berta Rodoreda Pallàs a,b,∗ , Josep Vidal-Alaball a,c
a
Grup de Recerca Promoció de la Salut en l’Àmbit Rural,
Gerència Territorial de la Catalunya Central, Institut
Català de la Salut, Sant fruitós de Bages, Barcelona, Spain
b
Centre Atenció Primària Santpedor, EAP Sant
Fruitós-Santpedor-Navarcles, Gerència Territorial de la
Catalunya Central, Institut Català de la Salut, Barcelona,
Spain
c
Unitat de Suport a la Recerca de la Catalunya Central,
Fundació Institut Universitari per a la recerca a l’Atenció
Primària de Salut Jordi Gol i Gurina, Sant Fruitós de
Bages, Spain
∗
Corresponding author.
E-mail address: brodoreda.cc.ics@gencat.cat
(B. Rodoreda Pallàs).