Patient and Care Team Perspectives on Social Determinants of Health Screening in Primary Care: A Qualitative Study.

Importance: Health systems in the US are increasingly screening for social determinants of health (SDOH). However, guidance incorporating stakeholder feedback is limited. Objective: To examine patient and care team experiences in early implementation of SDOH screening in primary care. Design, Setting, and Participants: This qualitative study included cross-sectional analysis of SDOH screenings during primary care visits from February 22 to May 10, 2022, primary care team member interviews from July 6, 2022, to March 8, 2023, and patient stakeholder engagement on June 30, 2022. The setting was a large southeastern US health care system. Eligible patients were aged 18 years or older with completed visits in primary care. Exposure: Screening for SDOH in primary care. Main outcomes and Measures: Multivariable logistic regression evaluated patient (eg, age, race and ethnicity) and care team characteristics (eg, practice type), and screening completeness. Interviews contextualized the quantitative analysis. Results: There were 78 928 visits in practices conducting any SDOH screening. The population with visits had a mean (SD) age of 57.6 (18.1) years; 48 086 (60.9%) were female, 12 569 (15.9%) Black, 60 578 (76.8%) White, and 3088 (3.9%) Hispanic. A total of 54 611 visits (69.2%) were with a doctor of medicine and 13 035 (16.5%) with a nurse practitioner. Most had no SDOH questions answered (75 298 [95.4%]) followed by all questions (2976 [3.77%]). Logistic regression analysis found that clinician type, patient race, and primary payer were associated with screening likelihood: for clinician type, nurse practitioner (odds ratio [OR], 0.13; 95% CI, 0.03-0.62; P = .01) and physician assistant (OR, 3.11; 95% CI, 1.19-8.10; P = .02); for patient race, Asian (OR, 1.69; 95% CI, 1.25-2.28; P = .001); Black (OR, 1.49; 95% CI, 1.10-2.01; P = .009); or 2 or more races (OR, 1.48; 95% CI, 1.12-1.94; P = .006); and for primary payer, Medicaid (OR, 0.62; 95% CI, 0.48-0.80; P < .001); managed care (OR, 1.17; 95% CI, 1.07-1.29; P = .001); uninsured or with Access Health (OR, 0.26; 95% CI, 0.10-0.67; P = .005), and Tricare (OR, 0.71; 95% CI, 0.55-0.92; P = .01). Interview themes included barriers (patient hesitancy, time and resources for screening and referrals, and number of questions/content overlap) and facilitators (communication, practice champions, and support for patient needs). Conclusions and Relevance: This qualitative study presents potential guidance regarding factors that could improve SDOH screening within busy clinical workflows.

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.

Patient attitudes and beliefs associated with self-referral to physical therapy for musculoskeletal complaints: a qualitative study.

BACKGROUND: Non-pharmacologic treatments such as physical therapy (PT) are advocated for musculoskeletal pain. Early access to PT through self-referral has been shown to decrease costs and improve outcomes. Although self-referral is permitted in most U.S. states and supported by some health insurance plans, patients' utilization of self-referral remains low. OBJECTIVE: To identify factors, beyond legislative policies and health insurance, associated with patients' decisions to access physical therapy through self-referral or provider-referral. METHODS: We recruited 26 females and 6 males whose employer-sponsored insurance benefits included financial incentives for self-referral to physical therapy. Between August 2017 and March 2018, participants completed semi-structured interviews about their beliefs about physical therapy and reasons for choosing self-referral (15 participants) or provider referral (17 participants) for accessing physical therapy. Grounded theory approach was employed to identify themes in the data. RESULTS: Patients selecting self-referral reported major thematic differences compared to the provider-referral patients including knowledge of the direct access program, attitudes and beliefs about physical therapy and pharmacologic treatment, and prior experiences with physical therapy. Self-referral patients were aware that their plan benefits included reduced cost for self-referral and felt confident in selecting that pathway. They also had negative beliefs about the effectiveness of pharmacological treatments and surgery, and previously had positive direct or indirect experiences with physical therapy. CONCLUSION: Knowledge of the ability to self-refer, attitudes and beliefs about treatment, and prior experience with physical therapy were associated with self-referral to physical therapy. Interventions aimed at improving knowledge and changing attitudes toward self-referral to physical therapy to increase utilization appear warranted.

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.

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.

Examining demographic characteristics and food access indicators from the location of vegan soul food restaurants in the south.

Objective: There have been a number of soul food restaurants serving exclusively vegan meals opening up across the country to appeal to African Americans and others interested in eating healthier soul foods. This study determined the number of restaurants serving vegan soul foods in the South and identified the locations of these restaurants in order to understand the characteristics of the surrounding communities that they serve.Design: Two reviewers identified restaurants using standardized search criteria for menu items in the 16 states (and the District of Columbia) that are categorized as being in the South from the Census Bureau. Mean percentage of African Americans, poverty rates, and obesity rates by county where restaurants were located were collected via census data. Restaurants were classified as being in or out of a food desert zone using the United States Department of Agriculture's (USDA) food atlas map (0.5- and 1.0-mile radius). T-tests were conducted to test for differences in the census data between the restaurants that were considered to be in and out of a food desert zone.Results: Overall, 45 restaurants met the inclusion criteria. Counties where restaurants were located had a mean African American population of 36.5 ± 18.5%, mean poverty rate of 15.5 ± 3.85% and mean obesity rate of 26.8 ± 4.8%. More than one third (n = 18, 40.0%) of the restaurants were considered to be in a food desert zone. There were no significant differences in the mean population, obesity, and poverty rates between restaurants classified in a food desert zone and restaurants not located in a food desert zone.Conclusion: A significant number of restaurants were classified in food desert zones, implying their potential to provide healthier meals by serving vegan soul foods to residents in the surrounding neighborhoods. Future work should assess how these restaurants might influence healthier eating habits in their communities.

Should We Worry About Setting? Association of Program Fidelity with Youths' Satisfaction and Intention to Practice Safer Sex.

PURPOSE: To examine whether deviation from fidelity in the implementation of an evidence-based program on safer sex education affected youth satisfaction and intention to avoid risky sexual behaviors. DESIGN: Implementation evaluation. SETTING: In-school and out-of-school settings in South Carolina. PARTICIPANTS: Three thousand seventy-three youths aged 10 to 14 years. INTERVENTION: Making Proud Choices. MEASURES: Fidelity variables were implementation setting, program length, class size, gender composition, and curriculum adaptations. Outcome variables were youth program satisfaction and intentions to remain abstinent or avoid risky sexual behaviors postintervention. ANALYSIS: Chi-square and t tests tested in-school and out-of-school comparisons. Multiple linear regression examined predictors of youth program satisfaction and intention to avoid risky behaviors. RESULTS: Program duration (B = .002), class size (B = .074), program completion rate (B = .004), gender (B = .223), and race (B = .263) predicted program satisfaction (P < .05; R2 = 0.094). Longer program duration was negatively associated with planned abstinence (B = -.002), contraception use (B = -.004), and condom use (B = -.002). Participants in single-gender classes (B = .387) and females (B = .256) were more likely to practice safer sex. Low R2 showed limited impact on intention to practice safer sex (R2 = .030 and.015) and remaining abstinent (R2 = .033). CONCLUSION: Although fidelity deviations do impact youth satisfaction and intentions, the impact is not large. Implementations adapted to fit local settings can still be beneficial.

Concordance and Discordance of the Knowledge, Understanding, and Description of Children's Experience of Food Insecurity Among Hispanic Adults and Children.

Food insecurity is highly detrimental for children, who experience food insecurity differently than do adults. We aimed to understand concordance and discordance of adults' and children's knowledge, understanding, and description of children's experience of food insecurity. In-depth interviews were conducted with the primary caregiver, another caregiver, and a child 9 to 16 years of age in 16 Hispanic families at risk of food insecurity in South Carolina. Adults often lacked knowledge of the food insecurity experiences of their children, which presents challenges for adults with roles as caregivers, educators, or policy makers to recognize and address these experiences.

Sexual Behaviors, Mobile Technology Use, and Sexting Among College Students in the American South.

PURPOSE: To examine sexual, mobile technology, and sexting behaviors of college students. DESIGN: A cross-sectional study design was employed. SETTING: Study sites were 2 universities in the southern United States. SUBJECTS: Data were collected from 254 participants via online survey of college students. MEASURES: The survey included 268 items inclusive of measures from previously validated sources. Variables for this study included technology ownership/use, online/mobile dating site use, sexting behaviors/attitudes, and sexual behaviors. In particular, the Sexting Attitudes Scale has been previously validated with other researchers providing comparative data. ANALYSIS: Chi-square and Mann-Whitney tests were used for group comparisons. Logistic regression analysis was used to examine predictors of sexting behavior. RESULTS: Of the 254 participants, over 80% had ever had sex, and participants were more likely to use condoms with partners who they were not in a committed relationship compared to those to whom they were committed (χ2 = 27.324, P = .0001). Seventy percent had ever sexted, and sexting attitudes ranged from approximately 80% agreeing that sexting is "risky" or can leave one "vulnerable" compared to 43% agreeing that sexting is "fun." Sexting was associated with having multiple sexual partners (odds ratio [OR] = 2.47, 95% confidence interval [CI]: 1.36-4.47) and sexually transmitted infection testing history (OR = 2.08, 95% CI: 1.03-4.18). CONCLUSION: Study findings should be considered as interventionists plan sexual health and risk prevention programs for college students.

A Good Idea May Not Be Good Enough: Stakeholder Buy In to QuitConnect, a National Smokers' Registry.

PURPOSE: To examine interest and concerns among those who fund and operate state-run smoking cessation helplines (quitlines) about the concept of creating a centralized smokers' registry that could be used to reengage smokers after they receive initial quitline support services. DESIGN: We conducted 3, hour-long focus groups with stakeholders, covering the perceived benefits and barriers to creating a smokers' registry. SETTING: The focus groups were conducted via telephone. PARTICIPANTS: Three groups participated: quitline service providers (n = 14), quitline funders (n = 9), and national quitline partners (n = 8). METHOD: Data collection: Focus groups were recorded, transcribed, and coded for major relevant themes. Analysis Strategies: We used a grounded theory approach. RESULTS: Stakeholders were generally positive about the concept of a centralized smokers' registry (ie, QuitConnect), especially with its potential to link relapsed smokers to ongoing research studies designed to help smokers achieve abstinence from tobacco. However, stakeholders expressed concern about QuitConnect duplicating services already offered by state quitlines. CONCLUSION: Despite a common goal, many state quitline stakeholders had strong reservations about the creation of a centralized smokers' registry unless they could see clear evidence that the registry added value and was not duplicative of their existing services.

Policy-Relevant Context of Waterpipe Tobacco Smoking among University Students in Six Countries Across the Eastern Mediterranean Region: A Qualitative Study

Background: Waterpipe tobacco smoking rates in the Eastern Mediterranean region are some of the highest worldwide, especially among young people. This study aimed to improve our knowledge of the policy-relevant context of waterpipe smoking among six countries in the Eastern Mediterranean region. Methods: In-depth interviews were conducted in Bahrain, Egypt, Jordan, Lebanon, Palestine, and the United Arab Emirates. Participants were young adult university students (18-29 years) from both genders who had ever smoked the waterpipe, recruited from universities participating in this study. Directed content analysis was used to analyze the transcripts. Results: A total of 53 in-depth interviews were conducted in Arabic in 2016. Findings were organized around 5 themes: waterpipe product characteristics; patterns of waterpipe smoking; the waterpipe café setting; perceived health consequences; and health warning labels. Waterpipe smoking was commonly perceived as a safe alternative to cigarettes. Waterpipe tobacco was reported to be widely accessible and affordable to young participants. There is a lack of knowledge among waterpipe smokers about the associated health effects. Warning labels are effective at communicating health risks associated with waterpipe smoking. Conclusions: Regulatory frameworks for waterpipe tobacco smoking should be developed and enforced, including waterpipe-specific health warning labels that elucidate the harmful effects of waterpipe smoking.

Condom use with serious and casual heterosexual partners: findings from a community venue-based survey of young adults.

Given the racial/ethnic disparities that characterize STI trends and recent increases in heterosexually transmitted HIV infection in the US, an understanding of factors underlying condom use among young adults in minority communities is vitally important. To this end, this paper presents findings from a community venue-based survey examining the influence of motivations, heuristics, and relationship factors on condom behaviors with serious and casual heterosexual partners in a sample of urban African American and Puerto Rican males and females ages 18-25 (n = 380). Condom use rates at time of last sex were considerably higher with casual partners (n = 87) than with serious (n = 313) partners, 77.9% vs. 38.7%. While dual pregnancy/STI prevention was the most frequently cited reason for use at last sex with casual partners, pregnancy prevention was the most frequently cited reason for use with serious partners. Bivariate conditional logistic regression analyses found two factors to be associated with condom use at last sex with casual partners: use at first sex with the partner and belief that neighborhood peers worried some/a lot about HIV. In contrast, such factors as condom heuristics (e.g., nonuse symbolizes trust), contraceptive status, and markers of emotional intimacy were associated with condom use with serious partners in both bivariate and multivariable analyses.

A cultural model of infidelity among African American and Puerto Rican young adults.

Having concurrent sexual partners is a risk factor for STIs and HIV/AIDS, yet few studies have investigated the cultural meanings and functions of concurrency. A multi-method qualitative/quantitative study of sexual ideas, attitudes, and behaviors among inner-city Puerto Rican and African American emergent adults (age 18-25) in Hartford, Connecticut, USA, suggests that having concurrent partners is common in this population. Using data from 12 focus groups and 40 participants in systematic data collection techniques (e.g., pile sorts), the underlying cognitive structure of concurrency and cheating/infidelity are explored. Results suggest that participants are less tolerant of multiple partners in more committed relationships, but that very few relationships can be considered committed. Furthermore, participants see cheating as inevitable even in committed relationships. Sexual transgressions are considered the most severe form of cheating. Having an outside partner for emotional reasons or to have access to one's child were seen as more acceptable/forgivable than doing so for sexual satisfaction, social status or material goods. Multiple partnerships must be seen in the context of the inner city where resources and opportunities are scarce and young adults attempt to protect themselves from emotional injury. Documenting new and changing social constructions of infidelity is important for understanding the social context of sexual behavior in our global world and for designing culturally appropriate health interventions.

Long-term Lyme disease antibiotic therapy beliefs among New England residents.

Most physicians prescribe Lyme disease antibiotic therapy regimens that are recommended by the Centers for Disease Control and Prevention, the Infectious Disease Society of America, and the National Institutes of Health. An alternative approach by some physicians consists of prolonged antibiotic treatment for >2 months because they believe that Lyme disease often results in persistent Borrelia burgdorferi infection. Understanding how patients perceive the disease is important for effective doctor-patient communication. We conducted interviews and surveys on Block Island, Rhode Island, and Storrs, Connecticut, to explore the public perception of persistent symptoms following Lyme disease and the need for long-term treatment. Most of our participants believed that symptoms and the Lyme disease bacteria can persist after antimicrobial therapy for Lyme disease. When asked about the value of continuing antibiotic treatment for >2 months, about half thought that it was sometimes useful and about a quarter thought it was always useful. Almost all of the respondents stated that they knew people who had experienced Lyme disease, and these personal observations were more frequently cited as an important source of Lyme disease information than official sources such as medical professionals. We conclude that healthcare workers should review the scientific literature regarding appropriate therapy for Lyme disease, discuss such information with their patients, and identify sources of information that their patients can review. Medical societies, private foundations, and State and Federal Health agencies should increase efforts to educate physicians and the general public about the standard diagnosis and treatment of Lyme disease and provide additional funding to determine why some people experience persistent symptoms following this infection.

"And let me see them damn papers!" The role of STI/AIDS screening among urban African American and Puerto Rican youth in the transition to sex without a condom.

Common strategies employed in preventing STI/AIDS transmission among young adults in America include abstinence, monogamy and safer sex. These strategies require a high level of vigilance and responsibility and, according to inner city participants in Project PHRESH.comm, neither option is always desirable, available, or rational in the context of their lived experiences. This article reports findings from Project PHRESH.comm, a mixed-method, ethnographic study incorporating data from focus group discussions, semi-structured interviews, coital diaries, systematic cultural assessments and a structured survey designed to explore concepts of risk and decision making about condom use among at risk African American and Puerto Rican young adults aged 18-25 years in Hartford, CT. We found that many young adults from our study population rely on a strategy of using clinic-sponsored STI/AIDS screening when wanting to discontinue condom use with a partner. While our data suggest that screening is a common strategy used by many couples to transition to having sex without a condom, the data also show that most youth do not maintain monogamy even in long-term, serious relationships. Thus, sharing test results may provide a false sense of security in the sexual culture of inner city, minority youth.