Utilizing social determinants of health to identify most vulnerable neighborhoods-Latent class analysis and GIS map.

OBJECTIVES: Public Health officials are often challenged to effectively allocate limited resources. Social determinants of health (SDOH) may cluster in areas to cause unique profiles related to various adverse life events. The authors use the framework of unintended teen pregnancies to illustrate how to identify the most vulnerable neighborhoods. METHODS: This study used data from the U.S. American Community Survey, Princeton Eviction Lab, and Connecticut Office of Vital Records. Census tracts are small statistical subdivisions of a county. Latent class analysis (LCA) was employed to separate the 832 Connecticut census tracts into four distinct latent classes based on SDOH, and GIS mapping was utilized to visualize the distribution of the most vulnerable neighborhoods. GEE Poisson regression model was used to assess whether latent classes were related to the outcome. Data were analyzed in May 2021. RESULTS: LCA's results showed that class 1 (non-minority non-disadvantaged tracts) had the least diversity and lowest poverty of the four classes. Compared to class 1, class 2 (minority non-disadvantaged tracts) had more households with no health insurance and with single parents; and class 3 (non-minority disadvantaged tracts) had more households with no vehicle available, that had moved from another place in the past year, were low income, and living in renter-occupied housing. Class 4 (minority disadvantaged tracts) had the lowest socioeconomic characteristics. CONCLUSIONS: LCA can identify unique profiles for neighborhoods vulnerable to adverse events, setting up the potential for differential intervention strategies for communities with varying risk profiles. Our approach may be generalizable to other areas or other programs. KEY MESSAGES: What is already known on this topic Public health practitioners struggle to develop interventions that are universally effective. The teen birth rates vary tremendously by race and ethnicity. Unplanned teen pregnancy rates are related to multiple social determinants and behaviors. Latent class analysis has been applied successfully to address public health problems. What this study adds While it is the pregnancy that is not planned rather than the birth, access to pregnancy intention data is not available resulting in a dependency on teen birth data for developing public health strategies. Using teen birth rates to identify at-risk neighborhoods will not directly represent the teens at risk for pregnancy but rather those who delivered a live birth. Since teen birth rates often fluctuate due to small numbers, especially for small neighborhoods, LCA may avoid some of the limitations associated with direct rate comparisons. The authors illustrate how practitioners can use publicly available SDOH from the Census Bureau to identify distinct SDOH profiles for teen births at the census tract level. How this study might affect research, practice or policy These profiles of classes that are at heightened risk potentially can be used to tailor intervention plans for reducing unintended teen pregnancy. The approach may be adapted to other programs and other states to prioritize the allocation of limited resources.

Food Insecurity and Health Inequities in Food Allergy.

PURPOSE OF REVIEW: The intersection of food insecurity among those with food allergy is a growing public health concern. Both food allergy and food insecurity have profound implications on health, social, and economic outcomes. The interaction of social determinants of health, poverty, racism, housing insecurity, and access to care has direct impact on individuals with food allergy. RECENT FINDINGS: There is increasing evidence that universal screening for food insecurity is vital in the routine care of patients with food allergy. Individuals with food allergy who are also burdened by food insecurity face unique challenges related to the need to maintain dietary modifications often with expensive specialized diets, which are difficult to access. This may lead to limited dietary options, malnutrition, increased financial burden, and social isolation. While there are available resources and support systems that can assist individuals with food allergies in managing food insecurity, there is an increasing need for advocacy and inclusivity in policy frameworks involving multiple stakeholders. Multi-sector efforts involving healthcare providers and advocacy and government agencies are necessary to support policy changes that protect the rights and well-being of individuals affected by food allergy and food insecurity. By increasing awareness, improving access to safe, affordable, allergen-free food, and advocating for policy change, we can work toward ensuring universal access to safe, nutritious food for all individuals, regardless of their food allergy status or socioeconomic background.

Improving Pathways to Care for Ethnic Minority Communities.

It is well established that the COVID-19 pandemic has had a substantial impact on ethnic minority communities and has worsened existing health inequalities experienced by these populations globally. Individuals from ethnic minority backgrounds have not only been more likely to become infected with COVID-19 throughout the pandemic, but they have also higher risk of adverse symptoms and death following infection. Factors responsible for these discrepancies are wide reaching and encompass all aspects of the social determinants of health (SDoH). Although always an area of concern among healthcare professionals, barriers to health care experienced by ethnic minority populations became a more pertinent issue during the COVID-19 pandemic when all individuals required sufficient and sustained access to a healthcare system (whether this be for COVID-19 testing, vaccination or treatment). These healthcare barriers exacerbated the increased COVID-19 burden experienced by minority populations and will continue to detrimentally impact the health of these populations during future COVID-19 waves or indeed, future novel pandemics. This chapter aims to summarise the major healthcare barriers experienced by minority populations throughout the COVID-19 pandemic, including COVID-19 prevention, vaccine rollout, care during hospitalisation and post-COVID care for long COVID patients. To end, this chapter will summarise lessons learned and future directions that need to be taken to improve health disparities and healthcare access for minority populations in relation to the COVID pandemic and beyond.

Disparities in Cardiovascular Disease-Related Outcomes Among Cancer Survivors in the United States: A Systematic Review of the Literature.

BACKGROUND: Cancer and cardiovascular disease (CVD) are major causes of morbidity and mortality in the United States (US). Cancer survivors have increased risks for CVD and CVD-related mortality due to multiple factors including cancer treatment-related cardiotoxicity. Disparities are rooted in differential exposure to risk factors and social determinants of health (SDOH), including systemic racism. This review aimed to assess SDOH's role in disparities, document CVD-related disparities among US cancer survivors, and identify literature gaps for future research. METHODS: Following the Peer Review of Electronic Search Strategies (PRESS) guidelines, MEDLINE, PsycINFO, and Scopus were searched on March 15, 2021, with an update conducted on September 26, 2023. Articles screening was performed using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, a pre-defined Population, Exposure, Comparison, Outcomes, and Settings (PECOS) framework, and the Rayyan platform. A modified version of the Newcastle-Ottawa Scale was used to assess the risk of bias, and RAW Graphs for alluvial charts. This review is registered with PROSPERO under ID #CRD42021236460. RESULTS: Out of 7,719 retrieved articles, 24 were included, and discussed diverse SDOH that contribute to CVD-related disparities among cancer survivors. The 24 included studies had a large combined total sample size (n=7,704,645; median=19,707). While various disparities have been investigated, including rural-urban, sex, socioeconomic status, and age, a notable observation is that non-Hispanic Black cancer survivors experience disproportionately adverse CVD outcomes when compared to non-Hispanic White survivors. This underscores historical racism and discrimination against non-Hispanic Black individuals as fundamental drivers of CVD-related disparities. CONCLUSIONS: Stakeholders should work to eliminate the root causes of disparities. Clinicians should increase screening for risk factors that exacerbate CVD-related disparities among cancer survivors. Researchers should prioritise the investigation of systemic factors driving disparities in cancer and CVD and develop innovative interventions to mitigate risk in cancer survivors.

[In matters of health we should all be equal : unfortunately some are more equal than others ]. / Face à la COVID-19. En matière de santé nous devrions tous être égaux : malheureusement certains sont plus égaux que d'autres .

In 1978, at Alma Ata, it was clearly claimed that inequities in health are simply not acceptable. Each individual should be able to achieve the highest possible level of health (in its holistic definition). This should be considered as a fundamental human right. However, this latter is largely undermined by the unequal distribution of power, money and resources. The gap separating advantaged from disadvantaged people has clearly been highlighted, and even accentuated, during the recent health care crisis due to COVID-19. This schism is widely present, both at the international level but also within the boundaries of each country, rich or poor. In the interest of society in general, it will be mandatory to address - rapidly - these social determinants of health (the causes of the causes), because the health inequity is not the illustration of a system failure. It is the result of the organization and operationalization of the system itself.

À Alma Ata en 1978, il est clairement établi que les iniquités ne sont pas acceptables en matière de santé. Le concept que chaque individu doit pouvoir atteindre le plus haut niveau de santé possible (dans sa définition holistique) est considéré comme un droit fondamental humain. Toutefois, ce dernier est largement battu en brèche par la distribution non équitable de la puissance, de l'argent, et des ressources. Le fossé qui sépare les favorisés des défavorisés a clairement été mis en lumière, voire même accentué, à l'occasion de la récente crise sanitaire due à la COVID-19. Ce schisme est largement présent au niveau international, mais également à l'intérieur de chaque pays, riche ou pauvre. Dans l'intérêt sociétal général, il faudra s'attaquer ­ rapidement ­ aux déterminants sociaux de la santé (les causes des causes). En effet, cette iniquité en santé n'est pas l'illustration d'une défaillance d'un système, c'est le résultat de l'organisation et l'opérationnalisation même du système.

[Promoting Equity, Diversity, and Inclusion in Healthcare: An Example of the COVID-19 Pandemic].

Healthcare systems must embody equity, diversity, and inclusion (EDI) and, in the event of unfairness, appropriate policies / countermeasures should be enacted. The healthcare system response to the COVID-19 pandemic not only highlighted how socioeconomic disparities affect mortality risk but also posed significant challenges to the successful practice of EDI in healthcare. In light of this, this article was written to provide an overview of EDI, analyze the international efforts to promote it, and suggest strategies for promoting EDI in infectious disease healthcare using COVID-19 as an example. In healthcare settings, equity centers on ensuring patients receive fair treatment regardless of race, gender, age, or socioeconomic status; diversity centers on healthcare providers understanding the uniqueness of patients from different cultural backgrounds and the health barriers they face; and inclusion centers on ensuring patients are treated with respect and given the attention they deserve. During pandemics, social determinants of health (SDOH) greatly impact patient health outcomes and hinder the practice of EDI. Reflecting on the impact of COVID-19, healthcare systems can actively apply EDI in clinical practice to provide to all patients equitable access to healthcare opportunities and outcomes. Practical strategies include establishing EDI committees within healthcare systems, monitoring relevant data, conducting staff training, and continuously addressing the SDOH and needs of marginalized groups to achieve EDI in healthcare.

The Effect of Social Determinants of Health on Psychological Health Among Older Adults in Ghana.

This study examines the effects of various factors, including socioeconomic status, built environment, access to healthcare, educational level, social participation, and economic stability, on older adults' psychological health. The current study analyzed a nationally representative sub-sample of 2,577 respondents aged 50 and above from the World Health Organization's Study on Global AGEing and Adult Health (WHO SAGE) Wave 2. WHO SAGE Wave 2 is cross-sectional data collected via in-person structured interviews. Ordinal least square (OLS) was used to measure the average effect of social determinants of health (SDoH), and quantile regression analysis was used to determine the effects of SDoH on older adults' psychological health at different quantiles, specifically 10th, 50th, and 90th percentiles. Significant determinants of psychological health across all quantiles included age, healthcare access, marital status, economic stability, and neighborhood and built environment. However, the degrees of significance for residence, gender, educational level, chronic diseases, and social participation varied between quantiles, showing differing effects on older adults with high or low psychological health. Religion was insignificant across all quantiles. This study highlights the need for governments and public health agencies to develop targeted interventions and strategies that support the psychological well-being of older adults in the country.

Racial and Ethnic Disparities in Acute Care Utilization Among Patients With Glomerular Disease.

RATIONALE & OBJECTIVE: The effects of race, ethnicity, socioeconomic status (SES), and disease severity on acute care utilization in patients with glomerular disease are unknown. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 1,456 adults and 768 children with biopsy-proven glomerular disease enrolled in the Cure Glomerulonephropathy (CureGN) cohort. EXPOSURE: Race and ethnicity as a participant-reported social factor. OUTCOME: Acute care utilization defined as hospitalizations or emergency department visits. ANALYTICAL APPROACH: Multivariable recurrent event proportional rate models were used to estimate associations between race and ethnicity and acute care utilization. RESULTS: Black or Hispanic participants had lower SES and more severe glomerular disease than White or Asian participants. Acute care utilization rates were 45.6, 29.5, 25.8, and 19.2 per 100 person-years in Black, Hispanic, White, and Asian adults, respectively, and 55.8, 42.5, 40.8, and 13.0, respectively, for children. Compared with the White race (reference group), Black race was significantly associated with acute care utilization in adults (rate ratio [RR], 1.76 [95% CI, 1.37-2.27]), although this finding was attenuated after multivariable adjustment (RR, 1.31 [95% CI, 1.03-1.68]). Black race was not significantly associated with acute care utilization in children; Asian race was significantly associated with lower acute care utilization in children (RR, 0.32 [95% CI 0.14-0.70]); no significant associations between Hispanic ethnicity and acute care utilization were identified. LIMITATIONS: We used proxies for SES and lacked direct information on income, household unemployment, or disability. CONCLUSIONS: Significant differences in acute care utilization rates were observed across racial and ethnic groups in persons with prevalent glomerular disease, although many of these difference were explained by differences in SES and disease severity. Measures to combat socioeconomic disadvantage in Black patients and to more effectively prevent and treat glomerular disease are needed to reduce disparities in acute care utilization, improve patient wellbeing, and reduce health care costs.

Mortality differences by race over 20 years in individuals with peripheral artery disease.

INTRODUCTION: Racial disparities exist in patients with peripheral artery disease (PAD), with Black individuals having worse PAD-specific outcomes. However, mortality risk in this population has been mixed. As such, we sought to evaluate all-cause mortality by race among individuals with PAD. METHODS: We analyzed data from the National Health and Nutrition Examination Survey (NHANES). Baseline data were obtained from 1999 to 2004. Patients with PAD were grouped according to self-reported race. Multivariable Cox proportional hazards regression was performed to calculate adjusted hazard ratios (HR) by race. A separate analysis was performed to study the effect of burden of social determinants of health (SDoH) on all-cause mortality. RESULTS: Of 647 individuals identified, 130 were Black and 323 were White. Black individuals had more premature PAD (30% vs 20%, p < 0.001) and a higher burden of SDoH compared to White individuals. Crude mortality rates were higher in Black individuals in the 40-49-year and 50-69-year age groups compared to White individuals (6.7% vs 6.1% and 8.8% vs 7.8%, respectively). Multivariable analysis demonstrated that Black individuals with both PAD and coronary artery disease (CAD) had a 30% higher hazard of death over 20 years compared to White individuals (HR = 1.3, 95% CI: 1.0-2.1). The cumulative burden of SDoH marginally (10-20%) increased the risk of all-cause mortality. CONCLUSIONS: In a nationally representative sample, Black individuals with PAD and CAD had higher rates of mortality compared to their White counterparts. These findings add further proof to the ongoing racial disparities among Black individuals with PAD and highlight the necessity to identify ways to mitigate these differences.

Addressing Social Determinants of Health to Reduce Disparities Among Individuals with Cancer: Insights for Rehabilitation Professionals.

PURPOSE OF REVIEW: This report aims to provide a framework for cancer rehabilitation professionals to assess social determinants of health in individuals with cancer and discuss strategies that can be implemented in practice to overcome barriers to care. RECENT FINDINGS: There has been an increased focus in improving patient conditions that can affect access to cancer rehabilitation. Along with government and world health organization initiatives, healthcare professionals and institutions continue to work towards decreasing disparities. Several disparities exist in healthcare and education access and quality, patients' social and community context, neighborhood and built environments, and economic stability. The authors emphasized the challenges that patients who require cancer rehabilitation face that healthcare providers, institutions, and governments can mitigate with outlined strategies. Education and collaboration are essential to make true progress in decreasing disparities in the populations most in need.

Screening for Social Determinants of Health Among Medicare Beneficiaries in Primary Care During the Covid-19 Pandemic in Prince George's County, Maryland.

Primary care providers in Prince George's County, Maryland reported inconsistencies in their ability to identify and refer patients with social care needs. This project aimed to improve health outcomes of Medicare beneficiaries by implementing social determinant of health (SDOH) screening to identify unmet needs and improve rates of referral to appropriate services. Buy-in was achieved from providers and frontline staff via stakeholder meetings at a private primary care group practice. The Health Leads questionnaire was modified and integrated into the electronic health record. Medical assistants (MA) were trained to conduct screening and initiate care plan referrals prior to visits with the medical provider. During implementation, 96.25% of patients (n = 231) agreed to screening. Of these, 13.42% (n = 31) screened positive for at least one SDOH need, and 48.39% (n = 15) reported multiple social needs. Top needs included social isolation (26.23%), literacy (16.39%), and financial concerns (14.75%). All patients screening positive for one or more social needs were provided referral resources. Patients who identified as being of Mixed or Other race had significantly higher rates of positive screens (p = 0.032) compared to Caucasians, African Americans, and Asians. Patients were more likely to report SDOH needs during in-person visits (17.22%) compared to telehealth visits (p = 0.020). Screening for SDOH needs is feasible and sustainable and can improve the identification of SDOH needs and resource referrals. A limitation of this project was the lack of follow-up to determine whether patients with positive SDOH screens had been successfully linked to resources after initial referral.

A mixed methods study to inform and evaluate a longitudinal nurse practitioner/community health worker intervention to address social determinants of health and chronic obstructive pulmonary disease self-management.

BACKGROUND: Individuals with low socioeconomic status experience higher prevalence and worse outcomes of chronic obstructive pulmonary disease (COPD). We undertook a quality improvement initiative at our safety net hospital in which a nurse practitioner (NP)/community health worker (CHW) team followed patients with COPD, frequent admissions, and unmet SDOH needs from hospitalization through one month post-discharge. We report our mixed methods approach to inform development and preliminary evaluation of this intervention. METHODS: We first assessed characteristics of patients admitted with COPD in 2018 (n = 1811), performing multivariable logistic regression to identify factors associated with ≥ 2 admissions per year. We then tested a standardized tool to screen for unmet SDOH needs in a convenience sample of 51 frequently hospitalized patients with COPD. From January-July 2019, we pilot tested the NP/CHW intervention with 57 patients, reviewed NP/CHW logs, and conducted qualitative interviews with 16 patient participants to explore impressions of the intervention. RESULTS: Patients with Medicaid insurance, mental health disorders, cardiac disease, and substance use disorder had increased odds of having ≥ 2 admissions. COPD severity, comorbidities, and unmet SDOH needs made COPD self-management challenging. Seventy-four percent of frequently admitted patients with COPD completing SDOH screening had unmet SDOH needs. Patients perceived that the NP/CHW intervention addressed these barriers by connecting them to resources and providing emotional support. CONCLUSIONS: Many patients with COPD admitted at our safety-net hospital experience unmet SDOH needs that impede COPD self-management. A longitudinal NP/CHW intervention to address unmet SDOH needs following discharge appears feasible and acceptable.

The relationship between Social Determinants of Health (SDoH) and death from cardiovascular disease or opioid use in counties across the United States (2009-2018).

BACKGROUND: Death from cardiovascular disease (CVD) has been a longstanding public health challenge in the US, whereas death from opioid use is a recent, growing public health crisis. While population-level approaches to reducing CVD risk are known to be effective in preventing CVD deaths, more targeted approaches in high-risk communities are known to work better for reducing risk of opioid overdose. For communities to plan effectively in addressing both public health challenges, they need information on significant community-level (vs individual-level) predictors of death from CVD or opioid use. This study addresses this need by examining the relationship between 1) county-level social determinants of health (SDoH) and CVD deaths and 2) county-level SDoH and opioid-use deaths in the US, over a ten-year period (2009-2018). METHODS: A single national county-level ten-year 'SDoH Database' is analyzed, to address study objectives. Fixed-effects panel-data regression analysis, including county, year, and state-by-year fixed effects, is used to examine the relationship between 1) SDoH and CVD death-rate and 2) SDoH and opioid-use death-rate. Eighteen independent (SDoH) variables are included, spanning three contexts: socio-economic (e.g., race/ethnicity, income); healthcare (e.g., system-characteristics); and physical-infrastructure (e.g., housing). RESULTS: After adjusting for county, year, and state-by-year fixed effects, the significant county-level positive SDoH predictors for CVD death rate were, median age and percentage of civilian population in armed forces. The only significant negative predictor was percentage of population reporting White race. On the other hand, the four significant negative predictors of opioid use death rate were median age, median household income, percent of population reporting Hispanic ethnicity and percentage of civilian population consisting of veterans. Notably, a dollar increase in median household income, was estimated to decrease sample mean opioid death rate by 0.0015% based on coefficient value, and by 20.05% based on effect size. CONCLUSIONS: The study provides several practice and policy implications for addressing SDoH barriers at the county level, including population-based approaches to reduce CVD mortality risk among people in military service, and policy-based interventions to increase household income (e.g., by raising county minimum wage), to reduce mortality risk from opioid overdoses.

Neighborhood Socioeconomic Status and Identification of Patients With CKD Using Electronic Health Records.

RATIONALE & OBJECTIVE: Screening for chronic kidney disease (CKD) is recommended for patients with diabetes and hypertension as stated by the respective professional societies. However, CKD, a silent disease usually detected at later stages, is associated with low socioeconomic status (SES). We assessed whether adding census tract SES status to the standard screening approach improves our ability to identify patients with CKD. STUDY DESIGN: Screening test analysis. SETTINGS & PARTICIPANTS: Electronic health records (EHR) of 256,162 patients seen at a health care system in the 7-county Minneapolis/St. Paul area and linked census tract data. EXPOSURE: The first quartile of census tract SES (median value of owner-occupied housing units <$165,200; average household income <$35,935; percentage of residents >25 years of age with a bachelor's degree or higher <20.4%), hypertension, and diabetes. OUTCOMES: CKD (eGFR <60 mL/min/1.73 m2, or urinary albumin-creatinine ratio >30mg/g, or urinary protein-creatinine ratio >150mg/g, or urinary analysis [albuminuria] >30 mg/d). ANALYTICAL APPROACH: Sensitivity, specificity, and number needed to screen (NNS) to detect CKD if we screened patients who had hypertension and/or diabetes and/or who lived in low-SES tracts (belonging to the first quartile of any of the 3 measures of tract SES) versus the standard approach. RESULTS: CKD was prevalent in 13% of our cohort. Sensitivity, specificity, and NNS of detecting CKD after adding tract SES to the screening approach were 67% (95% CI, 66.2%-67.2%), 61% (95% CI, 61.1%-61.5%), and 5, respectively. With the standard approach, sensitivity of detecting CKD was 60% (95% CI, 59.4%-60.4%), specificity was 73% (95% CI, 72.4%-72.7%), and NNS was 4. LIMITATIONS: One health care system and selection bias. CONCLUSIONS: Leveraging patients' addresses from the EHR and adding tract-level SES to the standard screening approach modestly increases the sensitivity of detecting patients with CKD at a cost of decreased specificity. Identifying further factors that improve CKD detection at an early stage are needed to slow the progression of CKD and prevent cardiovascular complications.

Impact of Racial Discrimination on the Mental Health of Minoritized Youth.

PURPOSE OF REVIEW: The impacts of racism and discrimination on developing minoritized youth are increasingly shown as having the potential to create long-lasting adverse outcomes on children's developmental trajectories. RECENT FINDINGS: From the quality of the schools they attend, to the level and amount of toxicants in the air they breathe, to equitable access to health care, and within interpersonal relationships and experiences with their peers, multiple forms of racism, systemic/structural, interpersonal/personally mediated, and internalized shape the health status of Black, Indigenous, and people of color (BIPoC) youth. Accordingly, it is exceedingly important to use a developmental lens to distinguish the various outcomes these multiple forms of racism have on the health of minoritized youth. Critically, the time is now for rapid identification of these harms in all of the mediums and spaces in which they present followed by prevention and intervention strategies that are effective in equitably ensuring the healthy development for all of America's children.

Social Determinants of Health: the Impact of Racism on Early Childhood Mental Health.

PURPOSE OF REVIEW: Despite increased literature on the impact of racism in the past decades, relatively few studies have focused on the effects of racism on younger children. This article reviews research from the past 5 years focusing on the impact of racism on infant and early childhood mental health and socioemotional development. RECENT FINDINGS: Longitudinal studies provide evidence that very young children are highly influenced by exposure to multiple and interconnecting levels of racism and discrimination. These forms of exposure (structural and personally mediated, which can be further divided into direct and indirect exposure) are particularly nefarious to young children's socioemotional development and have implications for adolescent and adult mental health with lasting sequelae. Furthermore, the effects of racism on parenting practices and maternal/caregiver mental health appear to indicate mechanisms through which racism affects young children. Although more studies are needed in this area, recent literature indicates that racism is a social determinant of health that adversely impacts infant and early childhood socioemotional, and behavioral development. Future studies should focus on understanding the mechanisms through which racism impacts early childhood development and health, and interventions to prevent and mitigate the effects of racism.

Factors Related to Providers Screening Children for Behavioral Health Risks in Primary Care Settings.

PURPOSE: To provide information from a large sample of pediatric and family medicine primary care providers on practices in screening children for behavioral health risks. DESIGN AND METHODS: Participants were a sample of physicians (n=319) and nurse practitioners (n=292) from across the U.S. who completed a confidential online survey about screening practices through a computer-assisted self-interview. RESULTS: Almost all respondents (89%) reported screening children for depression/anxiety and behavior problems. Child substance use (82%), family social support (74%), significant household changes (73%), bullying (72%), child abuse (62%) and domestic violence (52%) were also asked about regularly, although with high rates of informal screening methods. Caregiver mental health (49%), caregiver substance use (35%), family financial strain (33%) and transportation difficulties (27%) were screened less frequently. Screening was associated with higher rates of referral for risk-related problems, and was more likely when providers reported greater confidence providing support to clients, perceived community resource availability as higher, and worked in systems with integrated primary care and behavioral health. CONCLUSIONS: Findings suggest a great amount of diversity in how providers screen for behavioral health risks. There is reluctance to screen when options for addressing the problems are seen as limited. Research is needed to better guide healthcare providers in determining the right context and methods for screening social risks. PRACTICE IMPLICATIONS: Protocols for screening adverse childhood events (ACES) and other social risk factors should be accompanied by adequate training and efforts to improve community resource and support networks.

Moving Diabetes Upstream: the Social Determinants of Diabetes Management and Control Among Immigrants in the US.

PURPOSE OF REVIEW: Relative to the US-born population, immigrants are less likely to successfully manage and control their diabetes, leading to a host of diabetes-related complications. This review draws on the social determinants of health framework (SDoH) to summarize the multilevel factors that shape diabetes care and management among immigrants in the USA. RECENT FINDINGS: While the diabetes literature is replete with research on individual-level risk factors and health behaviors, empirical literature linking the SDoH to diabetes management among immigrants is limited. However, housing precarity, food insecurity, poverty, uninsurance and underinsurance, and limited support for immigrants in healthcare systems are consistently shown to deter diabetes management and care. Immigrants with diabetes face a multitude of structural constraints to managing their diabetes. More research that theorizes the role of SDoH in diabetes management along with empirical qualitative and quantitative studies are needed. Interventions to address diabetes also require a more upstream approach in order to mitigate the drivers of diabetes disparities among immigrants.

Child Poverty, Toxic Stress, and Social Determinants of Health: Screening and Care Coordination.

Social determinants of health (SDOH) refer to the social, economic, and physical conditions in which people live that may affect their health. Poverty, which affects nearly 15 million children in the United States, has far-reaching effects on children's physical and mental health. Although it is difficult to change a family's economic circumstances, nurses can play a critical role to address SDOH through screening and effective coordination of care. As nurses, our role is to minimize the effects of SDOH, including poverty, on child health and well-being through our practice, research, and professional education. We present three exemplars of child poverty to demonstrate the impact on child health and well-being and propose a model of care for nurses to assess and address SDOH in the pediatric clinical setting.