Understanding individual health-related social needs in the context of area-level social determinants of health: The case for granularity.

Introduction: Screening for health-related social needs (HRSNs) within health systems is a widely accepted recommendation, however challenging to implement. Aggregate area-level metrics of social determinants of health (SDoH) are easily accessible and have been used as proxies in the interim. However, gaps remain in our understanding of the relationships between these measurement methodologies. This study assesses the relationships between three area-level SDoH measures, Area Deprivation Index (ADI), Social Deprivation Index (SDI) and Social Vulnerability Index (SVI), and individual HRSNs among patients within one large urban health system. Methods: Patients screened for HRSNs between 2018 and 2019 (N = 45,312) were included in the analysis. Multivariable logistic regression models assessed the association between area-level SDoH scores and individual HRSNs. Bivariate choropleth maps displayed the intersection of area-level SDoH and individual HRSNs, and the sensitivity, specificity, and positive and negative predictive values of the three area-level metrics were assessed in relation to individual HRSNs. Results: The SDI and SVI were significantly associated with HRSNs in areas with high SDoH scores, with strong specificity and positive predictive values (∼83% and ∼78%) but poor sensitivity and negative predictive values (∼54% and 62%). The strength of these associations and predictive values was poor in areas with low SDoH scores. Conclusions: While limitations exist in utilizing area-level SDoH metrics as proxies for individual social risk, understanding where and how these data can be useful in combination is critical both for meeting the immediate needs of individuals and for strengthening the advocacy platform needed for resource allocation across communities.

Advancing social care integration in health systems with community health workers: an implementation evaluation based in Bronx, New York.

BACKGROUND: In recent years, health systems have expanded the focus on health equity to include health-related social needs (HRSNs) screening. Community health workers (CHWs) are positioned to address HRSNs by serving as linkages between health systems, social services, and the community. This study describes a health system's 12-month experience integrating CHWs to navigate HRSNs among primary care patients in Bronx County, NY. METHODS: We organized process and outcome measures using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation framework domains to evaluate a CHW intervention of the Community Health Worker Institute (CHWI). We used descriptive and inferential statistics to assess RE-AIM outcomes and socio-demographic characteristics of patients who self-reported at least 1 HRSN and were referred to and contacted by CHWs between October 2022 and September 2023. RESULTS: There were 4,420 patients who self-reported HRSNs in the standardized screening tool between October 2022 and September 2023. Of these patients, 1,245 were referred to a CHW who completed the first outreach attempt during the study period. An additional 1,559 patients self-reported HRSNs directly to a clinician or CHW without being screened and were referred to and contacted by a CHW. Of the 2,804 total patients referred, 1,939 (69.2%) were successfully contacted and consented to work with a CHW for HRSN navigation. Overall, 78.1% (n = 1,515) of patients reported receiving social services. Adoption of the CHW clinician champion varied by clinical team (median 22.2%; IQR 13.3-39.0%); however, there was no difference in referral rates between those with and without a clinician champion (p = 0.50). Implementation of CHW referrals via an electronic referral order appeared successful (73.2%) and timely (median 11 days; IQR 2-26 days) compared to standard CHWI practices. Median annual cost per household per CHW for the intervention was determined to be $184.02 (IQR $134.72 - $202.12). CONCLUSIONS: We observed a significant proportion of patients reporting successful receipt of social services following engagement with an integrated CHW model. There are additional implementation factors that require further inquiry and research to understand barriers and enabling factors to integrate CHWs within clinical teams.

Children With Chronic Health Conditions and Social Needs: Investigating Outcomes to Drive Health System Improvements.

Children with chronic health conditions (CHCs) are a high-resource population, and further data are needed to identify associations between CHC diagnoses and social needs to optimize health outcomes. In this cross-sectional study of 19 779 pediatric patients screened for social needs in an urban health system, we used logistic regression to evaluate CHC diagnoses and social need. Our independent variables were CHC diagnoses. Our dependent variable was the presence of social need. In the study, 2247 of 11 071 (20%) children with CHCs identified need. Children with CHCs were more likely to have a social need than children without CHCs (adjusted odds ratio: 1.56; 95% confidence interval: 1.44-1.68). Children with autism/developmental delay were most likely to have a social need. Children with autism/developmental delay, anxiety/depression, and asthma were most likely to report specific social needs. Health systems should screen for these families' needs to improve health outcomes.

Factors Influencing the Referral of Patients with Prediabetes to a Diabetes Prevention Program in the Bronx, New York.

INTRODUCTION: Disparate engagement in the Diabetes Prevention Program (DPP) may occur as early as the point of referral for certain subgroups, including Black and Hispanic men. We aimed to determine patient demographic and provider characteristics associated with referrals to a health system DPP in the Bronx, New York. METHODS: Patient and health system characteristics for DPP-eligible patients seen in primary care between July 1, 2015, and December 31, 2017, were obtained through the electronic health record. Generalized mixed-effects modeling was used to test the association between referral rate and clinical and sociodemographic variables. RESULTS: Of 26,727 eligible patients, 66% were female, 46% were Hispanic, and 39% were non-Hispanic Black. Only 10% (n = 2,785) of eligible patients were referred to DPP. In the adjusted analyses, lower odds of referral were observed for men versus women (OR = 0.60; 95% CI, 0.52-0.66), for non-Hispanic White versus Hispanic patients (OR = 0.53; 95% CI, 0.40-0.71), and for uninsured patients versus Medicaid patients (OR = 0.66; 95% CI, 0.54-0.80). The odds were higher for patients in the highest versus lowest hemoglobin A1c (OR = 2.49; 95% CI, 2.27-2.72) category; for those in the highest versus lowest body mass index categories (OR = 1.61; 95% CI, 1.45-1.79); for middle-aged patients (aged 45-64 y) versus those aged 18-26 y (OR =1.63; 95% CI, 1.33-2.00); and for patients being seen by a family versus an internal medicine physician (OR = 1.65; 95% CI, 1.22-2.22). CONCLUSION: We identified under-referral for men and highlighted other patient and health system factors associated with referral rates. Interventions to address bias in referrals and increase referrals for men at high risk for diabetes, not typically represented in DPP, are recommended.

Unmet Social Needs and Pediatric Asthma Severity in an Urban Primary Care Setting.

OBJECTIVE: Community-level social determinants of health impact asthma outcomes among children; however, individual patient's priorities are not often included in designing social care interventions. Identifying connections between patient-prioritized unmet social needs and asthma severity status may allow for improved patient-centered approaches to asthma management. In this analysis, we examined the association between unmet social needs and asthma severity in an urban population of children. We hypothesized that those with a greater number of unmet social needs would report a more severe asthma status. METHODS: We conducted a secondary analysis of 4887 patients screened for unmet social needs and asthma severity status. Bivariate associations and adjusted logistic regression modeling were used to assess the association between unmet social needs and asthma severity. RESULTS: Persistent asthma severity status was associated with several unmet social needs, including housing quality and stability, lack of money for food, transportation, and healthcare costs. In the multivariable analysis, having 3 or more unmet social needs was associated with a 59% greater odds of persistent asthma status (CI, 1.18-2.14; P = .002), and having 2 unmet social needs was associated with a 33% greater odds of persistent asthma status (CI, 1.00-1.78; P = .05). CONCLUSIONS: Unmet social needs were associated with asthma severity status, with a greater number of unmet social needs associated with greater odds of severe asthma status. Additional studies are warranted to further evaluate the temporal relationship between unmet social needs and how they may compound one another in their relationship with asthma severity.

Micro-scale pedestrian streetscapes and physical activity in Hispanic/Latino adults: Results from HCHS/SOL.

We examined associations of micro-scale environment attributes (e.g., sidewalks, street crossings) with three physical activity (PA) measures among Hispanic/Latino adults (n = 1776) living in San Diego County, CA. Systematic observation was used to quantify micro-scale environment attributes near each participant's home. Total PA was assessed with accelerometers, and PA for transportation and recreation were assessed by validated self-report. Although several statistically significant interactions between individual and neighborhood characteristics were identified, there was little evidence micro-scale attributes were related to PA. An important limitation was restricted environmental variability for this sample which lived in a small area of a single county.

Health Care Worker Burnout and Perceived Capacity to Address Social Needs.

Health care organizations are increasingly incorporating social care programs into medical care delivery models. Recent studies have identified burnout as a potential unintended consequence of this expansion. Successful implementation of these programs requires investment in the health care team, although understanding the impact of this expansion on nonphysician team members remains limited. Utilizing a theory-informed model for organizational behavior change, the authors aim to characterize the perceived elements of capacity to address patients' social needs within a heterogenous group of health care workers, and to examine the association of these behavioral conditions with burnout. A cross-sectional analysis was conducted of a survey of ∼1900 health care staff from 46 organizations in a large delivery system. Exploratory factor analysis identified factors contributing to the "Perceived Capacity to Address Social Needs" domain; Motivation, Organizational Reinforcement, and 3 task-specific capacities (Identification of social needs, Providing care for patients with social needs, and Linkage to social needs resources). Logistic regression found both a lower sense of motivation (OR 0.71, 95% CI 0.59-0.86), and organizational reinforcement (OR 0.51, 95% CI 0.42-0.62) associated with a higher rate of burnout. These associations with burnout differed by organizational role, suggesting role-specific relationships between these behavioral conditions. As health care has evolved into team-based interventions, staff across the care spectrum are now tasked with addressing larger social issues that affect their patients. A systems approach, aligning organizational priorities and staff motivations, in addition to task-specific skill sets is likely necessary to prevent burnout in this setting.

Assessing the Health and Economic Impact of a Potential Menthol Cigarette Ban in New York City: a Modeling Study.

Menthol in cigarettes increases nicotine dependence and decreases the chances of successful smoking cessation. In New York City (NYC), nearly half of current smokers usually smoke menthol cigarettes. Female and non-Latino Black individuals were more likely to smoke menthol-flavored cigarettes compared to males and other races and ethnicities. Although the US Food and Drug Administration recently announced that it will ban menthol cigarettes, it is unclear how the policy would affect population health and health disparities in NYC. To inform potential policymaking, we used a microsimulation model of cardiovascular disease (CVD) to project the long-term health and economic impact of a potential menthol ban in NYC. Our model projected that there could be 57,232 (95% CI: 51,967-62,497) myocardial infarction (MI) cases and 52,195 (95% CI: 47,446-56,945) stroke cases per 1 million adult smokers in NYC over a 20-year period without the menthol ban policy. With the menthol ban policy, 2,862 MI cases and 1,983 stroke cases per 1 million adults could be averted over a 20-year period. The model also projected that an average of $1,836 in healthcare costs per person, or $1.62 billion among all adult smokers, could be saved over a 20-year period due to the implementation of a menthol ban policy. Results from subgroup analyses showed that women, particularly Black women, would have more reductions in adverse CVD outcomes from the potential implementation of the menthol ban policy compared to males and other racial and ethnic subgroups, which implies that the policy could reduce sex and racial and ethnic CVD disparities. Findings from our study provide policymakers with evidence to support policies that limit access to menthol cigarettes and potentially address racial and ethnic disparities in smoking-related disease burden.

The association between social needs and chronic conditions in a large, urban primary care population.

There is consensus that social needs influence health outcomes, but less is known about the relationships between certain needs and chronic health conditions in large, diverse populations. This study sought to understand the association between social needs and specific chronic conditions using social needs screening and clinical data from Electronic Health Records. Between April 2018-December 2019, 33,550 adult (≥18y) patients completed a 10-item social needs screener during primary care visits in Bronx and Westchester counties, NY. Generalized linear models were used to estimate prevalence ratios for eight outcomes by number and type of needs with analyses completed in Summer 2020. There was a positive, cumulative association between social needs and each of the outcomes. The relationship was strongest for elevated PHQ-2, depression, alcohol/drug use disorder, and smoking. Those with ≥3 social needs were 3.90 times more likely to have an elevated PHQ-2 than those without needs (95% CI: 3.66, 4.16). Challenges with healthcare transportation was associated with each condition and was the most strongly associated need with half of conditions in the fully-adjusted models. For example, those with transportation needs were 84% more likely to have an alcohol/drug use disorder diagnosis (95% CI: 1.59, 2.13) and 41% more likely to smoke (95% CI: 1.25, 1.58). Specific social needs may influence clinical issues in distinct ways. These findings suggest that health systems need to develop strategies that address unmet social need in order to optimize health outcomes, particularly in communities with a dual burden of poverty and chronic disease.

Chronic pediatric health conditions among youth living in public housing and receiving care in a large hospital system in Bronx, NY.

This study compared the prevalence of chronic pediatric health conditions for youth in public housing with youth not in public housing using clinical electronic health record (EHR) and housing data. Youth (ages 2-17 years) in a large urban health system were identified and categorized into two housing types-public housing (n = 10 770) and not in public housing (n = 84 883) by age (young childhood, middle childhood, young adolescence). The prevalence of some pediatric conditions was higher in public housing but varied by age. Disparities in health conditions among youth in public housing were more common in early adolescence: asthma (26.4 vs 18.6; P < .001); obesity (28.5 vs 24.6; P < .001); depression/anxiety (19.2 vs 17.3; P = .008); behavioral disorders (8.1 vs 5.3; P < .001). These results show that chronic pediatric conditions like asthma and obesity that lead to significant morbidity into adulthood are more common among youth living in public housing. However, this pattern is not consistent across all chronic conditions.

Social Risks Among Primary Care Patients in a Large Urban Health System.

INTRODUCTION: Health systems are increasingly interested in addressing the social determinants of health via social risk screening. The objective of this study is to understand the variability in the number and types of social risks overall and in population subgroups among primary care patients routinely screened in a large urban health system. METHODS: Between April and December 2018, a total of 24,633 primary care patients completed a 10-item screener across 19 ambulatory sites within a health system in the Bronx, NY. The prevalence of any social risk and specific social risks was estimated overall and for population subgroups. Wald tests were used to determine statistically significant differences by subgroup. Data were analyzed in winter/spring 2019. RESULTS: Twenty percent of patients presented with at least 1 social risk. The most frequently reported risks included housing quality (6.5%) and food insecurity (6.1%). Middle-aged (30-59 years) respondents (24.7%, 95% CI=23.6%, 25.7%) compared with those aged 18-29 years (17.7%, 95% CI=16.4%, 19.2%, p<0.001), and Medicaid patients (24.8%, 95% CI=24.0%, 25.5%) compared with commercially insured patients (11.8%, 95% CI=11.1%, 12.5%, p<0.001), were more likely to report social risks. The strongest predictor of housing quality risk was residing in public housing (15.1%, 95% CI=13.8%, 16.6%) compared with those not in public housing (5.6%, 95% CI=5.3%, 5.9%, p<0.001). Housing quality was the most frequently reported risk for children (aged <18 years) and older adults (aged ≥70 years), whereas, for middle-aged respondents (30-69 years), it was food insecurity. CONCLUSIONS: There are important differences in the prevalence of overall and individual social risks by subgroup. These findings should be considered to inform clinical care and social risk screening and interventions.

Relationship between area mortgage foreclosures, homeownership, and cardiovascular disease risk factors: The Hispanic Community Health Study/Study of Latinos.

BACKGROUND: The risk of mortgage foreclosure disproportionately burdens Hispanic/Latino populations perpetuating racial disparities in health. In this study, we examined the relationship between area-level mortgage foreclosure risk, homeownership, and the prevalence of cardiovascular disease risk factors among participants of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). METHODS: HCHS/SOL participants were age 18-74 years when recruited from four U.S. metropolitan areas. Mortgage foreclosure risk was obtained from the U.S. Department of Housing and Urban Development. Homeownership, sociodemographic factors, and cardiovascular disease risk factors were measured at baseline interview between 2008 and 2011. There were 13,856 individuals contributing to the analysis (median age 39 years old, 53% female). RESULTS: Renters in high foreclosure risk areas had a higher prevalence of hypertension and hypercholesterolemia but no association with smoking status compared to renters in low foreclosure risk areas. Renters were more likely to smoke cigarettes than homeowners. CONCLUSION: Among US Hispanic/Latinos in urban cities, area foreclosure and homeownership have implications for risk of cardiovascular disease.

Factors in Placement and Enrollment of Primary Care Patients in YMCA's Diabetes Prevention Program, Bronx, New York, 2010-2015.

INTRODUCTION: The reach of the New York State YMCA's Diabetes Prevention Program (DPP) to at-risk populations may be increased through integration with primary care settings. Although considerable effort has been made in the referral and retention of patients, little is known about the factors associated with the placement of potential participants into YMCA's DPP. METHODS: Among Montefiore Health System (MHS) patients referred to YMCA's DPP (n = 1,249) from July 10, 2010, through November 11, 2015, we identified demographic factors (eg, age, preferred language) and primary care practice-level factors (eg, time between referral and start of session, session season) associated with placement into a session and subsequent drop-out. We also evaluated factors associated with weight loss. RESULTS: Patients were predominantly female (71%) and aged 45 years or older (71%). Patients preferring sessions in Spanish were less often placed in sessions. Patients aged 18 to 44 years were less often placed (P = .01) and enrolled (P = .001) than patients aged 60 years or older. Sessions conducted in the summer and spring had higher enrollment than fall and winter months. Patients who started the YMCA's DPP within 2 months of their referral date were more often enrolled (54.4%) than patients who waited 4 or more months (21.6%) to start their sessions. Patients aged 45 to 59 years lost marginally less weight than those aged 60 years or older (-3.1% vs -3.8%; P = .07). CONCLUSION: Although this evaluation gives some insight into the barriers to placement and enrollment in YMCA's DPP, challenges remain. Efforts are under way to increase referral of patients to community-based DPPs.

Depressive Symptomology and Hostile Affect among Latinos Using Housing Rental Assistance: the AHOME Study.

Studies show that those residing in households subsidized with federal housing vouchers exhibit fewer mental health problems than residents of public housing. The role of housing conditions and neighborhood quality in this relationship is unclear. This study investigated the relationship between rental assistance, housing and neighborhood conditions, and the risk of depressive symptomology and hostile affect among low-income Latino adults living in the Bronx, NY. Latino adults participating in the Affordable Housing as an Obesity Mediating Environment (AHOME) study were used for analysis. All AHOME participants were eligible for federal low-income housing rental assistance (n = 385) and living in the Bronx, New York (2010-2012). Housing (crowding and structural deficiencies) and neighborhood (physical disorder and social cohesion) were measured by questionnaire during in-home interview. Depressive symptomology was measured using the Center for Epidemiologic Studies Depression Scale Short Form, CES-D 10 (score ≥10). Hostile affect was measured using items from the Cook-Medley Hostility Scale (score ≥ 4). Results suggest residents of Section 8 housing have similar levels of depressive symptomology and hostility compared to residents in public housing or those receiving no federal housing assistance. However, depressive symptomology was significantly associated with maintenance deficiencies [OR = 1.17; CI 1.02, 1.35] and social cohesion [OR = 0.71; CI 0.55, 0.93]. Hostility was significantly associated with perceived crowding [OR = 1.18; CI 1.16, 2.85], neighborhood physical disorder [OR = 1.94; CI 1.12, 3.40], and social cohesion [OR = 0.70; CI 0.50, 0.98]. Low-income housing assistance did not have an independent effect on mental health outcomes. However, characteristics of the housing and neighborhood environments were associated with depressive symptomology and hostility.

Accelerometer-measured sedentary time among Hispanic adults: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

Excessive sedentary behavior is associated with negative health outcomes independent of physical activity. Objective estimates of time spent in sedentary behaviors are lacking among adults from diverse Hispanic/Latino backgrounds. The objective of this study was to describe accelerometer-assessed sedentary time in a large, representative sample of Hispanic/Latino adults living in the United States, and compare sedentary estimates by Hispanic/Latino background, sociodemographic characteristics and weight categories. This study utilized baseline data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) that included adults aged 18-74 years from four metropolitan areas (N = 16,415). Measured with the Actical accelerometer over 6 days, 76.9% (n = 12,631) of participants had > 10 h/day and > 3 days of data. Participants spent 11.9 h/day (SD 3.0), or 74% of their monitored time in sedentary behaviors. Adjusting for differences in wear time, adults of Mexican background were the least (11.6 h/day), whereas adults of Dominican background were the most (12.3 h/day), sedentary. Women were more sedentary than men, and older adults were more sedentary than younger adults. Household income was positively associated, whereas employment was negatively associated, with sedentary time. There were no differences in sedentary time by weight categories, marital status, or proxies of acculturation. To reduce sedentariness among these populations, future research should examine how the accumulation of various sedentary behaviors differs by background and region, and which sedentary behaviors are amenable to intervention.

Cardiovascular health outcomes of Latinos in the Affordable Housing as an Obesity Mediating Environment (AHOME) study: a study of rental assistance use.

Studies have shown that households subsidized with vouchers live in higher quality units and exhibit fewer physical, mental, and social problems than do their peers living in public housing. However, none of these studies have included cardiovascular outcomes. The objective of this study was to assess if use/type of rental assistance is independently associated with poor cardiovascular health among Latino adults (ages ≥ 18) who are eligible for federal low-income rental assistance and living in the Bronx, NY. Data from the cross-sectional, Affordable Housing as an Obesity Mediating Environment study, collected over 18 months (January 2011 to August 2012) were used. The prevalence of cardiovascular disease (CVD) outcomes was determined by measured high blood pressure and self-reported heart attack and/or stroke. Type of housing status was defined as: public housing units, units subsidized by section 8 vouchers, and units unassisted by either federal program. Statistical techniques used were analysis of variance and multivariate logistic regression. The prevalence of CVD was significantly higher among public housing residents than unassisted participants even in the presence of all individual level covariates. Public housing residents also have higher levels of CVD than do section 8 participants. The prevalence of CVD was similar for unassisted and section 8 participants. These findings point to the potential for health benefits arising from housing voucher use even within a fairly delimited geographic area.

Maternal education and excessive gestational weight gain in New York city, 1999-2001: the effect of race/ethnicity and neighborhood socioeconomic status.

To examine the association between maternal education and excessive gestational weight gain (EGWG) and whether this association differs by maternal race/ethnicity and neighborhood socio-economic status (SES). A sample of 56,911 New York City births between 1999 and 2001 was used. Self-reported EGWG was defined as gaining >40 pounds. Maternal education and race/ethnicity were obtained from birth record data. Neighborhood SES was determined from 2000 US Census data. Women with a high school [prevalence ratio (PR) = 1.21; 95 % CI 1.10-1.32] and some college (PR = 1.33; 95 % CI 1.21-1.47) education were more likely to gain excessive weight during pregnancy than their counterparts with less than a high school education. Having a college or more education was associated with a decreased EGWG for non-Hispanic white women (PR = 0.81; 95 % CI 0.67-0.96) but an increased EGWG for Hispanic women (PR = 1.25; 95 % CI 1.12-1.44). EGWG increased for women with a college or more education in medium and low SES neighborhoods (1.26; 95 % CI 1.04-1.53 and 1.20; 95 % CI 1.10-1.30, respectively); whereas a college or more education was not significant in the high SES neighborhoods. Our findings suggest that maternal education is associated with EGWG. However, this association depends on race/ethnicity and SES of the neighborhood of residence.

Physical characteristics of the environment and BMI of young urban children and their mothers.

The study examined whether characteristics of the urban physical environment are associated with child and maternal body mass index (BMI) in a sample of 3 year-old children and their mothers from 18 US cities (N=1997 dyads). BMI was determined based on measured height and weight. Characteristics of the interior and exterior physical environment, assessed and rated by trained interviewers, were related to child BMI at age 3 and to their mother's BMI. Negative aspects of the physical environment were more strongly related to maternal BMI among whites than among African-Americans or Hispanics.