Assessment and Documentation of Social Determinants of Health Among Health Care Providers: Qualitative Study.

BACKGROUND: Research clearly demonstrates social determinants of health (SDOH) impact health outcomes. Provider consideration of patient SDOH in prevention and treatment planning is critical for improved health care quality and health equity. Despite awareness of the connections between SDOH and improved population health, research demonstrates few providers document patient SDOH. OBJECTIVE: This qualitative study aimed to better understand the barriers and facilitators of SDOH assessment, documentation, and referral in different health care settings and roles. METHODS: Individual semistructured interviews were conducted with practicing health care providers in South Carolina between August 25, 2022, and September 2, 2022. Participants were recruited via community partners' web-based newsletters or listservs using a purposive sampling design. An interview guide with 19 questions was used to explore the following research question: How do SDOH impact patient health and what are the facilitators and barriers experienced by multidisciplinary health care providers assessing and documenting patient SDOH? RESULTS: Participants (N=5) included a neonatal intensive care unit registered nurse, a nurse practitioner, a certified nurse midwife, a family and preventive medicine physician, and a counselor (licensed clinical social worker) with careers spanning 12 to 32 years. Participant responses are presented according to the following 5 themes: participants' understanding of SDOH for the patient population, assessment and documentation practices, referrals to other providers and community-based resources, barriers and facilitators of SDOH assessment and documentation, and SDOH assessment and documentation training preferences. Overall, participants were aware of the importance of including patient SDOH in assessment and intervention but noted a variety of institutional and interpersonal barriers to assessment and documentation, including time constraints, perceptions of stigma around discussion of SDOH, and limited referral protocols. CONCLUSIONS: Incentivizing inclusion of patient SDOH in health care must be facilitated from the top down, so assessment and documentation can be universally implemented in a pragmatic way that works for providers in a variety of roles and settings for the betterment of health care quality, health equity, and improved population health outcomes. Partnering with community organizations can serve to augment health care organizations' resource and referral availability for addressing patients' social needs.

The Role of Understanding, Trust, and Access in Public Engagement with Environmental Activities and Decision Making: A Qualitative Study with Water Quality Practitioners.

Advancing environmental health literacy in support of environmental management requires inclusive science communication, especially with environmental justice communities. In order to understand experiences of environmental practitioners in the realm of science communication, the Center for Oceans and Human Health and Climate Change Interactions at the University of South Carolina conducted two studies on science communication and research translation with the center's researchers and partners. This qualitative case study follows up with a select group of environmental practitioners on emergent themes from the initial work. It explores the specific topics of understanding, trust, and access and how those can become barriers or facilitators of public engagement with environmental activities and decision making. The authors conducted seven in-depth qualitative interviews with center partners whose work focuses on environmental water quality and impacts on human and environmental health. Key results indicate that the public may have limited understanding of scientific processes, establishing trust takes time, and access should be incorporated into the design of programs and activities to ensure broader reach. Findings from this research are relevant to other partner-engaged work and environmental management initiatives and provide insights on experiences, practices, and actions for equitable and effective stakeholder engagement and collaborative partnerships.

Elements for successful implementation of a clinic-based health literacy intervention.

Improving health literacy is a national public health priority. Given the context of the COVID-19 pandemic, it is even more critical for health and medical information to be clear and understandable for patients and their families. Clinic-based programs to improve health literacy need to be pragmatic, feasible, and helpful for the implementing clinic and patients. This paper describes the development, implementation, and evaluation of a pragmatic, clinic-based health literacy intervention in a safety-net clinic that serves uninsured and indigent patients. Study methods are guided by a previous pilot study and components recommended for pragmatic interventions. An electronic readiness assessment was distributed to out-patient clinics affiliated with a statewide hospital association. The AskMe3 tool was used for the intervention as it is evidence informed and relatively easy to implement. Implementation included ongoing dialogue between the clinic and the academic research team. Within the implementing clinic, data collected from patients via verbally administered questionnaires was analyzed using descriptive statistics and chi-squares. Interview data collected from the clinic director was analyzed qualitatively for themes. The implementing clinic had some of the lowest average scores of the 34 clinics who participated in the initial readiness assessment. Despite this, they were able to successfully implement the health literacy intervention during a global pandemic. Eighty-eight participants completed patient questionnaires at this clinic. Most patients (96%) agreed the AskMe3 questions helped them talk with the doctor or nurse at their current appointment. Most (99%) also perceived the AskMe3 tool to be very helpful when used in a clinical setting. The clinic director offered that the staff initially thought the intervention would be difficult to implement. However, implementation by clinic volunteers with encouragement and prioritization of health literacy by the clinic director contributed to success. When considering interventions for clinical settings, a pragmatic approach can help with selection and implementation of a program that fits with the realities on the ground. Further, frequent technical assistance can help resolve implementation barriers. Interventions utilizing tools such as AskMe3, because of their simplicity, allow creative solutions to capacity issues for clinics who see a need for health literacy improvements.

Examining Social Determinants of Health During a Pandemic: Clinical Application of Z Codes Before and During COVID-19.

Recognition of the impact of social determinants of health (SDoH) on healthcare outcomes, healthcare service utilization, and population health has prompted a global shift in focus to patient social needs and lived experiences in assessment and treatment. The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) provides a list of non-billable "Z codes" specific to SDoH for use in electronic health records. Using population-level analysis, this study aims to examine clinical application of Z codes in South Carolina before and during the COVID-19 pandemic. The study population consists of South Carolina residents who had a healthcare visit and had their COVID-19 test result reported to the state's Department of Health and Environmental Control before January 14, 2021. Of the 1,190,531 individuals in the overall sample, Z codes were used only for 14,665 (1.23%) of the patients, including 2,536 (0.97%) COVID-positive patients and 12,129 (1.30%) COVID-negative patients. Compared with hospitals that did not use Z codes, those that did were significantly more likely to have higher bed capacity (p = 0.017) and to be teaching hospitals (p = 0.03), although this was significant only among COVID-19 positive individuals. Those at inpatient visits were most likely to receive Z codes (OR: 5.26; 95% CI: 5.14, 5.38; p < 0.0001) compared to those at outpatient visits (OR: 0.07; 95%CI: 0.06, 0.07; p < 0.0001). There was a slight increase of Z code use from 2019 to 2020 (OR: 1.33, 95% CI: 1.30, 1.36; p < 0.0001), which was still significant when stratified by facility type across time. As one of the first studies to examine Z code use among a large patient population, findings clearly indicate underutilization by providers. Additional study is needed to understand the potentially long-lasting health effects related to SDoH among underserved populations.

Social Determinants of Health and Depression among African American Adults: A Scoping Review of Current Research.

Depression in the United States (US) is increasing across all races and ethnicities and is attributed to multiple social determinants of health (SDOH). For members of historically marginalized races and ethnicities, depression is often underreported and undertreated, and can present as more severe. Limited research explores multiple SDOH and depression among African American adults in the US. Guided by Healthy People (HP) 2030, and using cross-disciplinary mental health terminology, we conducted a comprehensive search to capture studies specific to African American adults in the US published after 2016. We applied known scoping review methodology and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. From 12,315 initial results, 60 studies were included in our final sample. Most studies explored the HP 2030 Social and Community Context domain, with a heavy focus on discrimination and social support; no studies examined Health Care Access and Quality. Researchers typically utilized cross-sectional, secondary datasets; no qualitative studies were included. We recommend research that comprehensively examines mental health risk and protective factors over the life course within, not just between, populations to inform tailored health promotion and public policy interventions for improving SDOH and reducing racial and ethnic health disparities.

How Do African-American Community Members' Perceptions About Environmental Risks of Breast Cancer Compare with the Current State of the Science?

African-American (AA) women experience higher mortality from breast cancer than any other racial group. Understanding community-held perceptions of environmental contaminants as risk factors for breast cancer can inform the development of tailored prevention and education efforts for improve health outcomes. Six focus groups were conducted with AA participants in two counties in South Carolina, and themes were identified using open and axial coding. Perceived environmental risks for breast cancer most frequently discussed by participants were compared to findings from published systematic reviews. Frequently discussed environmental risk factors by participants were deodorants containing aluminum, plastics, pesticides, and air and water pollution. While perceptions of aluminum and air pollution as risk factors did not align with the state of the science, perceived risk factors of chemicals in plastics and pesticides were found to be in alignment. There is some congruence between perceived environmental risks for breast cancer within the AA community and the current state of the science; however, there is a need to communicate information that reflects current science regarding commonly held misconceptions. Development of evidence-based, clear, and culturally appropriate messaging that reflects the current state of the science is warranted.

"Talk About Cancer and Build Healthy Communities": How Visuals Are Starting the Conversation About Breast Cancer Within African-American Communities.

African-American (AA) women are at higher risk of breast cancer mortality than women of other races. Factors influencing breast cancer risk, including exogenous environmental exposures, and debate around timing of exposure and dose-response relationship, can cause misunderstanding. Collaboration with priority populations encourages culturally relevant health messaging that imparts source reliability, influences message adoption, and improves understanding. Through six focus groups with AA individuals in rural and urban counties in the southeastern United States, this study used a community-engaged participatory approach to design an innovative visual tool for disseminating breast cancer information. Results demonstrated that participants were generally aware of environmental breast cancer risks and were willing to share new knowledge with families and community members. Recommended communication channels included pastors, healthcare providers, social media, and the Internet. Participants agreed that a collaboratively designed visual tool serves as a tangible, focused "conversation starter" to promote community prevention and education efforts.

Development of a Clinical-Academic-Community Collaboration to Improve Health Literacy.

Limited health literacy is associated with poor patient health outcomes and increased hospitalization rates. Patient-provider communication plays an important role in patient health literacy and the understanding of medical terminology. This study demonstrates how a collaboration between clinical, academic, and community partners was instrumental in the design and implementation of a clinic readiness assessment and a clinic-based pilot intervention to encourage patient-provider communication and improve patient health literacy. A state hospital association, academic research team, and community adult literacy center director collaborated to develop a 60-item clinic readiness assessment and an evidence-informed pilot intervention. The clinic readiness assessment captured clinics' motivation and capacity for pilot implementation and providers' current communication strategies. The intervention centered around AskMe3™ educational materials and involved 2 patient visits (initial and follow-up visits). Data collection instruments for the intervention were administered verbally and included questions about patient demographics and communication needs, and a single-item health literacy measure. Descriptive statistics (frequencies/percentages) were used to analyze results from the clinic readiness assessment and pilot intervention. Establishment of the partnership, and collaborative, iterative development of the clinic readiness assessment and pilot intervention are described. This pilot project resulted in important lessons learned which led to critical modifications that will inform future expansion of the intervention. Collaboration between healthcare leaders, researchers, and community partners is recommended for developing clinic-based health literacy initiatives.

"You Gotta Choose Your Words Carefully": Findings from Interviews with Environmental Health Scientists about Their Research Translation Perceptions and Training Needs.

Scientists are trained to communicate research in a technical manner but often lack the skills to communicate scientific findings to the general public. Effective communication and research translation are increasingly important competencies for researchers and have broader benefits to scientists and society. The aim of the study was to assess the perceptions, experiences, and training needs relative to science communication and research translation of project investigators associated with the Center for Oceans and Human Health and Climate Change Interactions at the University of South Carolina. In-depth, semi-structured interviews were conducted with the Center's investigators. Interview transcripts were coded and analyzed for emergent themes related to science communication and research translation. Investigator descriptions of their research varied in length, and researchers mentioned multiple target audiences. Most investigators preferred in-person and written communication channels and felt "comfortable" communicating uncertain findings to the public despite no formal science communication training. Investigators suggested training focused on plain language development for target communities, assessment of audience needs, and formatting research findings for various groups. Working with multiple target audiences that have preferred communication channels necessitates a comprehensive approach to science communication training to enhance two-way communication between scientists and stakeholders.

Review of the Content and Quality of Mobile Applications About Alzheimer's Disease and Related Dementias.

This study reviewed the content of mobile applications (apps) providing Alzheimer's disease or related dementias (ADRD) information and assessed quality of the apps. Characteristics, content, and technical aspects of 36 apps in the U.S. Google Play Store and App Store were coded, and quality of the apps was evaluated using the Mobile Application Rating Scale. Caregiving (62.1%) and disease management (55.6%) content was frequently provided. Few apps had an app community (8.3%) or a reminder function (8.3%). Overall, quality of the apps was acceptable; apps by health care-related developers had higher quality scores than those by non-health care-related developers. This analysis showed that ADRD-related apps provide a range of content and have potential to benefit caregivers, individuals with ADRD, health care providers, and the general public. Collaboration of ADRD experts and technology experts is needed to provide evidence-based information using effective technical functions that make apps to meet users' needs.

Prostate Cancer Information Available in Health-Care Provider Offices: An Analysis of Content, Readability, and Cultural Sensitivity.

Prostate cancer (PrCA) is the most common cancer affecting men in the United States, and African American men have the highest incidence among men in the United States. Little is known about the PrCA-related educational materials being provided to patients in health-care settings. Content, readability, and cultural sensitivity of materials available in providers' practices in South Carolina were examined. A total of 44 educational materials about PrCA and associated sexual dysfunction was collected from 16 general and specialty practices. The content of the materials was coded, and cultural sensitivity was assessed using the Cultural Sensitivity Assessment Tool. Flesch Reading Ease, Flesch-Kincaid Grade Level, and the Simple Measure of Gobbledygook were used to assess readability. Communication with health-care providers (52.3%), side effects of PrCA treatment (40.9%), sexual dysfunction and its treatment (38.6%), and treatment options (34.1%) were frequently presented. All materials had acceptable cultural sensitivity scores; however, 2.3% and 15.9% of materials demonstrated unacceptable cultural sensitivity regarding format and visual messages, respectively. Readability of the materials varied. More than half of the materials were written above a high-school reading level. PrCA-related materials available in health-care practices may not meet patients' needs regarding content, cultural sensitivity, and readability. A wide range of educational materials that address various aspects of PrCA, including treatment options and side effects, should be presented in plain language and be culturally sensitive.