Do healthcare providers consider the social determinants of health? Results from a nationwide cross-sectional study in the United States.

BACKGROUND: While the social determinants of health (SDOH) have a greater impact on individual health outcomes than the healthcare services a person receives, healthcare providers face barriers to addressing these factors in clinical settings. Previous studies have shown that providers often lack the necessary knowledge and resources to adequately screen for and otherwise assist patients with unmet social needs. This study explores the perceptions and behaviors related to SDOH among healthcare providers in the United States (US). METHODS: This cross-sectional study analyzed data from a 22-item online survey using Reaction Data's research platform of healthcare professionals in the US. Survey items included demographic questions as well as Likert scale questions about healthcare providers' perceptions and behaviors related to SDOH. Descriptive statistics were calculated, and further analyses were conducted using t-tests and analysis of variance. RESULTS: A total of 563 respondents completed the survey, with the majority being male (72.6%), White (81%), and located in urban areas (82.2%). In terms of perceptions, most providers agreed or strongly agreed that SDOH affect the health outcomes of all patients (68.5%), while only 24.1% agreed or strongly agreed that their healthcare setting was set up to address SDOH. In terms of behavior, fewer than half currently screened for SDOH (48.6%) or addressed (42.7%) SDOH in other ways. Most providers (55.7%) wanted additional resources to focus on SDOH. Statistical analyses showed significant differences by gender, with females being more likely than males to prioritize SDOH, and by specialty, with psychiatrists, pediatricians, and family/general medicine practitioners being more likely to prioritize SDOH. CONCLUSION: Most healthcare providers understand the connection between unmet social needs and their patients' health, but they also feel limited in their ability to address these issues. Ongoing efforts to improve medical education and shift the healthcare system to allow for payment and delivery of more holistic care that considers SDOH will likely provide new opportunities for healthcare providers. In addition to what they can do at the institutional and patient levels, providers have the potential to advocate for policy and system changes at the societal level that can better address the root causes of social issues.

U.S. Physicians' Training and Experience in Providing Trauma-Informed Care in Clinical Settings.

Trauma-informed care (TIC) is a comprehensive approach that focuses on the whole individual. It acknowledges the experiences and symptoms of trauma and their impact on health. TIC prioritizes physical and emotional safety through a relationship of trust that supports patient choice and empowerment. It provides a safe and respectful healing environment that considers specific needs while promoting a greater sense of well-being, patient engagement, and partnership in the treatment process. Given the prevalence of trauma, this descriptive cross-sectional study examined the attitudes and perspectives of U.S. physicians (N = 179; 67% males; 84% White; 43% aged 56-65) in providing trauma-informed care using an anonymous 29-item online survey administered by Reaction Data. Findings showed that 16% (n = 18) of physicians estimated that >50% of their patients have a history of trauma. Commonly perceived barriers to providing TIC were resource/time/administrative constraints, provider stress, limited awareness of the right provider to refer patients who experienced trauma, and inadequate TIC emphasis in medical education/training. Expanding physicians' knowledge base of trauma through training and organizational policy/support is crucial in enhancing their TIC competence, particularly in caring for patients with complex care needs whose social determinants increase their risk of exposure to adverse experiences that carry lasting physical and psychological effects.

Investigating the Poverty-Reducing Effects of SNAP on Non-nutritional Family Outcomes: A Scoping Review.

INTRODUCTION/PURPOSE: Poverty-reduction efforts that seek to support households with children and enable healthy family functioning are vital to produce positive economic, health, developmental, and upward mobility outcomes. The Supplemental Nutrition Assistance Program (SNAP) is an effective poverty-reduction policy for individuals and families. This study investigated the non-nutritional effects that families experience when receiving SNAP benefits. METHODS: We conducted a scoping review using the PRISMA Guidelines and strategic search terms across seven databases from 01 January 2008 to 01 February 2023 (n=2456). Data extraction involved two researchers performing title-abstract reviews. Full-text articles were assessed for eligibility (n=103). Forty articles were included for data retrieval. RESULTS: SNAP positively impacts family health across the five categories of the Family Stress Model (Healthcare utilization for children and parents, Familial allocation of resources, Impact on child development and behavior, Mental health, and Abuse or neglect). DISCUSSION/CONCLUSION: SNAP is a highly effective program with growing evidence that it positively impacts family health and alleviates poverty. Four priority policy actions are discussed to overcome the unintentional barriers for SNAP: distributing benefits more than once a month; increasing SNAP benefits for recipients; softening the abrupt end of benefits when wages increase; and coordinating SNAP eligibility and enrollment with other programs.

Integrating Social Care into Healthcare: A Review on Applying the Social Determinants of Health in Clinical Settings.

Despite the substantial health and economic burdens posed by the social determinants of health (SDH), these have yet to be efficiently, sufficiently, and sustainably addressed in clinical settings-medical offices, hospitals, and healthcare systems. Our study contextualized SDH application strategies in U.S. clinical settings by exploring the reasons for integration and identifying target patients/conditions, barriers, and recommendations for clinical translation. The foremost reason for integrating SDH in clinical settings was to identify unmet social needs and link patients to community resources, particularly for vulnerable and complex care populations. This was mainly carried out through SDH screening during patient intake to collect individual-level SDH data within the context of chronic medical, mental health, or behavioral conditions. Challenges and opportunities for integration occurred at the educational, practice, and administrative/institutional levels. Gaps remain in incorporating SDH in patient workflows and EHRs for making clinical decisions and predicting health outcomes. Current strategies are largely directed at moderating individual-level social needs versus addressing community-level root causes of health inequities. Obtaining policy, funding, administrative and staff support for integration, applying a systems approach through interprofessional/intersectoral partnerships, and delivering SDH-centered medical school curricula and training are vital in helping individuals and communities achieve their best possible health.

Why Parents Say No to Having Their Children Vaccinated against Measles: A Systematic Review of the Social Determinants of Parental Perceptions on MMR Vaccine Hesitancy.

Ongoing outbreaks of measles threaten its elimination status in the United States. Its resurgence points to lower parental vaccine confidence and local pockets of unvaccinated and undervaccinated individuals. The geographic clustering of hesitancy to MMR indicates the presence of social drivers that shape parental perceptions and decisions on immunization. Through a qualitative systematic review of published literature (n = 115 articles; 7 databases), we determined major themes regarding parental reasons for MMR vaccine hesitancy, social context of MMR vaccine hesitancy, and trustworthy vaccine information sources. Fear of autism was the most cited reason for MMR hesitancy. The social drivers of vaccine hesitancy included primary care/healthcare, education, economy, and government/policy factors. Social factors, such as income and education, exerted a bidirectional influence, which facilitated or hindered vaccine compliance depending on how the social determinant was experienced. Fear of autism was the most cited reason for MMR hesitancy. Vaccine hesitancy to MMR and other childhood vaccines clustered in middle- to high-income areas among mothers with a college-level education or higher who preferred internet/social media narratives over physician-based vaccine information. They had low parental trust, low perceived disease susceptibility, and were skeptical of vaccine safety and benefits. Combating MMR vaccine misinformation and hesitancy requires intersectoral and multifaceted approaches at various socioecological levels to address the social drivers of vaccine behavior.

COVID-19 and Psychosocial Well-Being: Did COVID-19 Worsen U.S. Frontline Healthcare Workers' Burnout, Anxiety, and Depression?

Healthcare workers are highly regarded for their compassion, dedication, and composure. However, COVID-19 created unprecedented demands that rendered healthcare workers vulnerable to increased burnout, anxiety, and depression. This cross-sectional study assessed the psychosocial impact of COVID-19 on U.S. healthcare frontliners using a 38-item online survey administered by Reaction Data between September and December 2020. The survey included five validated scales to assess self-reported burnout (Maslach Summative Burnout Scale), anxiety (GAD-7), depression (PHQ-2), resilience (Brief Resilience Coping Scale), and self-efficacy (New Self-Efficacy Scale-8). We used regression to assess the relationships between demographic variables and the psychosocial scales index scores and found that COVID-19 amplified preexisting burnout (54.8%), anxiety (138.5%), and depression (166.7%), and reduced resilience (5.70%) and self-efficacy (6.5%) among 557 respondents (52.6% male, 47.5% female). High patient volume, extended work hours, staff shortages, and lack of personal protective equipment (PPE) and resources fueled burnout, anxiety, and depression. Respondents were anxious about the indefinite duration of the pandemic/uncertain return to normal (54.8%), were anxious of infecting family (48.3%), and felt conflicted about protecting themselves versus fulfilling their duty to patients (44.3%). Respondents derived strength from their capacity to perform well in tough times (74.15%), emotional support from family/friends (67.2%), and time off work (62.8%). Strategies to promote emotional well-being and job satisfaction can focus on multilevel resilience, safety, and social connectedness.

Effects of positive and negative childhood experiences on adult family health.

BACKGROUND: The objective of the study was to determine the association between adverse childhood experiences (ACEs) and positive childhood experiences (PCEs) with family health in adulthood. Prior research indicates that ACEs and PCEs affect individual physical and mental health in adulthood. However, little is known about how ACEs and PCEs affect family health. Families develop and function through patterns and routines which are often intergenerational. Therefore, a person's early experiences may influence their family's health in adulthood. METHOD: A survey was administered to 1030 adults through Qualtrics, with participants recruited using quota-sampling to reflect the demographic characteristics of U.S. adults. Participants completed a survey about their childhood experiences, four domains of family health (family social and emotional health processes, family healthy lifestyle, family health resources, and family external social supports), and demographic characteristics. Data were analyzed using structural equation modeling. RESULTS: After controlling for marriage, education, gender, race and age, ACEs were negatively associated with family social and emotional health processes and family health resources when accounting for PCEs; PCEs were positively associated with all four family health domains irrespective of ACEs. CONCLUSION: Childhood experiences affect family health in adulthood in the expected direction. Even in the presence of early adversity, positive experiences in childhood can provide a foundation for creating better family health in adulthood.

The influence of adverse and advantageous childhood experiences during adolescence on young adult health.

BACKGROUND: Research indicates that adverse childhood experiences (ACEs) can lead to poorer adult health, but less is known how advantageous childhood experiences (counter-ACEs) may neutralize the negative effects of ACEs, particularly in young adulthood. PURPOSE: We examined the independent contributions of Adverse Childhood Experiences (ACEs) and Advantageous Childhood Experiences (counter-ACEs) that occur during adolescence on five young adult health indicators: depression, anxiety, risky sexual behaviors, substance abuse, and positive body image. PARTICIPANTS AND SETTING: The sample included 489 adolescents from a large northwestern city in the United States who were 10-13 years at baseline (51 % female). METHODS: Flourishing Families Project survey data were used for this secondary analysis using structural equation modeling. Adolescents and their parents completed an annual survey. ACEs and counter-ACEs were measured over the first five years of the study. The five health indicators were measured in wave 10 when participants were 20-23 years old. RESULTS: Participants had on average 2.7 ACEs and 8.2 counter-ACEs. When both ACEs and counter-ACEs were included in the model, ACEs were not predictive of any of the health indicators and counter-ACEs were predictive of less risky sex (-.12, p < .05), substance abuse (-.12, p < .05), depression (-.11, p < .05), and a more positive body image (.15, p < .01). Higher ratios of counter-ACEs to ACEs had a particularly strong effect on improved young adult health. CONCLUSIONS: Counter-ACEs that occur in adolescence may diminish the negative effects of ACEs on young adult health and independently contribute to better health.

Predicting homelessness among individuals diagnosed with substance use disorders using local treatment records.

One in five homeless people in the United States has a substance use and/or a mental health disorder. Substance use disorders substantially impact the ability to obtain and retain appropriate housing. Professionals who provide substance use treatment are typically required to provide housing assistance by prioritizing clients according to their risk for becoming or remaining homeless; however, existing methods for prioritizing clients can be time-consuming and staff- and training-intensive. This study analyzed the potential use of variables from locally collected and readily available treatment admission records to prioritize clients needing housing assistance. This study analyzed county-level substance use treatment admission and discharge records of 1862 treatment episodes for 1642 clients in publicly funded treatment programs in Utah County, Utah. For at least one admission or discharge, 185 clients lived on the streets or in a homeless shelter. Approximately 55% of treatment episodes that ended in homelessness at discharge did not originally begin with clients being homeless, suggesting a gap in prioritizing individuals for housing assistance. Logistic regression showed statistically significant associations between eventually becoming homeless at the time of discharge and being originally homeless on admission; older age (45 years or older); methamphetamine as primary drug used; and a diagnosis of axis I/II psychiatric disorder besides substance use disorder. These findings suggest that local and routinely collected substance use treatment records may be predictive of homelessness and potentially useful in prioritizing clients for housing assistance.

The Public Health Family Impact Checklist: A Tool to Help Practitioners Think Family.

Families are an important cornerstone of individual and community health across the lifecourse. Not only do families play a role in the development of health, but the family's health is likewise influenced by individual health behaviors and outcomes. Therefore, to improve population health, public health programs must support families. Limited training in family science, as well as lack of instruments to help "think family," often result in Public Health practitioners feeling ill-equipped to develop programming that supports, targets, and/or involves a diverse range of families. Tools to help public health practitioners think family are limited. The Family Impact Checklist is one tool that may help improve the degree to which policies support families. The purpose of this study was to adapt the Family Impact Checklist specifically for use in public health programming efforts. Through a two-round Delphi approach comprised of 17 public health professionals, the Public Health Family Impact Checklist was developed. The adapted Checklist includes 14 items across four think family principles: family engagement, family responsibility, family stability and family diversity. We propose that this tool will help practitioners develop high impact, family-friendly programs that ultimately lead to improved individual and community health.

ACEs and counter-ACEs: How positive and negative childhood experiences influence adult health.

BACKGROUND: Numerous studies over the past two decades have found a link between adverse childhood experiences (ACEs) and worse adult health outcomes. Less well understood is how advantageous childhood experiences (counter-ACEs) may lead to better adult health, especially in the presence of adversity. OBJECTIVE: To examine how counter-ACEs and ACEs affect adult physical and mental health using Resiliency Theory as the theoretical framework. PARTICIPANTS AND SETTING: Participants were Amazon mTurk users ages 19-57 years (N = 246; 42% female) who completed an online survey. METHODS: We conducted a series of regression analyses to examine how counter-ACEs and ACEs predicted adult health. RESULTS: Corresponding to the Compensatory Model of Resiliency Theory, higher counter-ACEs scores were associated with improved adult health and that counter-ACEs neutralized the negative impact of ACEs on adult health. Contrary to the Protective Factors Model, there was a stronger relationship between ACEs and worse adult health among those with above average counter-ACEs scores compared to those with below average counter-ACEs scores. Consistent with the Challenge Model, counter-ACEs had a reduced positive effect on adult health among those with four or more ACEs compared to those with fewer than four ACEs. CONCLUSIONS: Overall, the findings suggest that counter-ACEs protect against poor adult health and lead to better adult wellness. When ACEs scores are moderate, counter-ACEs largely neutralize the negative effects of ACEs on adult health. Ultimately, the results demonstrate that a public health approach to promoting positive childhood experiences may promote better lifelong health.

Family-Focused Public Health: Supporting Homes and Families in Policy and Practice.

Life expectancy in the US is on the decline. Mental health issues associated with opioid abuse and suicide have been implicated for this decline necessitating new approaches and procedures. While Public Health 3.0 provides a call to action for stakeholders to work closely together to address such complex problems as these, less attention has been given to engaging and supporting the most important stakeholders and primary producers of health within the US: families and households. The idea that health begins at home is discussed from the perspective of primary, secondary, and tertiary prevention levels. Primary prevention where research provides evidence for the role of the family in healthy child development. Secondary and tertiary prevention where research offers evidence for the role of the family in caregiving. Despite this evidence, greater focus and attention must be placed on the family at all prevention levels as an often overlooked setting of public health practice and level of influence. Prevention across all levels is enhanced as public health practitioners think family when designing and implementing public health policy. Four family impact principles are presented to help guide planning and implementation decisions to nourish family engagement.

Growth in Adolescent Self-Regulation and Impact on Sexual Risk-Taking: A Curve-of-Factors Analysis.

Adolescent self-regulation is increasingly seen as an important predictor of sexual risk-taking behaviors, but little is understood about how changes in self-regulation affect later sexual risk-taking. Family financial stress may affect the development of self-regulation and later engagement in sexual risk-taking. We examined whether family financial stress influences self-regulation in early adolescence (age 13) and growth in self-regulation throughout adolescence (from age 13-17 years). We then assessed the effects of family financial stress, baseline self-regulation, and the development of self-regulation on adolescent sexual risk-taking behaviors at age 18 years. Using a curve-of-factors model, we examined these relationships in a 6-year longitudinal study of 470 adolescents (52% female) and their parents from a large northwestern city in the United States. Results indicated that family financial stress was negatively associated with baseline self-regulation but not with growth in self-regulation throughout adolescence. Both baseline self-regulation and growth in self-regulation were predictive of decreased likelihood of engaging in sexual risk-taking. Family financial stress was not predictive of later sexual risk-taking. Intervening to support the development of self-regulation in adolescence may be especially protective against later sexual risk-taking.

Family Financial Stress and Adolescent Sexual Risk-Taking: The Role of Self-Regulation.

The ability to control one's emotions, thoughts, and behaviors is known as self-regulation. Family stress and low adolescent self-regulation have been linked with increased engagement in risky sexual behaviors, which peak in late adolescence and early adulthood. The purpose of this study was to assess whether adolescent self-regulation, measured by parent and adolescent self-report and respiratory sinus arrhythmia, mediates or moderates the relationship between family financial stress and risky sexual behaviors. We assessed these relationships in a 4-year longitudinal sample of 450 adolescents (52 % female; 70 % white) and their parents using structural equation modeling. Results indicated that high family financial stress predicts engagement in risky sexual behaviors as mediated, but not moderated, by adolescent self-regulation. The results suggest that adolescent self-regulatory capacities are a mechanism through which proximal external forces influence adolescent risk-taking. Promoting adolescent self-regulation, especially in the face of external stressors, may be an important method to reduce risk-taking behaviors as adolescents transition to adulthood.

Health systems in context: a systematic review of the integration of the social determinants of health within health systems frameworks / Sistemas de salud en su contexto: revisión sistemática de la integración de los determinantes sociales de la salud en los marcos de los sistemas de salud

OBJECTIVE: To systematically review and analyze various ways that health systems frameworks interact with the social determinants of health (SDH), as well as the implications of these interactions. METHODS: This was a review of the literature conducted in 2012 using predetermined criteria to search three comprehensive databases (PubMed, the Cochrane Database for Systematic Reviews, and the World Bank E-Library) and grey literature for articles with any consideration of the SDH within health systems frameworks. Snowball sampling and expert opinion were used to include any potentially relevant articles not identified by the initial search. In total, 4 152 documents were found; of these, 27 were included in the analyses. RESULTS: Five main categories of interaction between health systems and SDH emerged: Bounded, Production, Reciprocal, Joint, and Systems models. At one end were the Bounded and Production models, which conceive the SDH to be outside the health system; at the other end, the Joint and Systems models, which visualize a continuous and dynamic interaction. CONCLUSIONS: Considering the complex and dynamic interactions among different kinds of organizations involved in and with the health system,the Joint and Systems models seem to best reflect these interactions, and should thereby guide stakeholders in planning for change.

OBJETIVO: Examinar y analizar sistemáticamente las diversas maneras en que los marcos de los sistemas de salud abordan las interacciones con los determinantes sociales de la salud (DSS), así como las implicaciones de estas interacciones. MÉTODOS: En el 2012, se llevó a cabo una revisión de la bibliografía mediante la adopción de criterios predeterminados para consultar tres bases de datos integrales (PubMed, la Base de Datos Cochrane de Revisiones Sistemáticas y la Biblioteca electrónica del Banco Mundial) y la bibliografía gris, en busca de artículos que incluyeran cualquier tipo de consideración de los DSS en los marcos de los sistemas de salud. Se utilizó el muestreo de bola de nieve y la opinión de expertos con objeto de incluir cualquier artículo potencialmente pertinente no detectado en la búsqueda inicial. En total, se encontraron 4 152 documentos; de estos, 27 se incluyeron en el análisis. RESULTADOS: Se observaron cinco categorías o modelos principales de interacción entre los sistemas de salud y los DSS: Vinculado, de Producción, Recíproco, Conjunto y de Sistemas. En un extremo se situaban los modelos Vinculado y de Producción, que contemplan los DSS como externos al sistema de salud; en el otro extremo, los modelos Conjunto y de Sistemas, que conciben una interacción continua y dinámica entre ellos. CONCLUSIONES: Si se tienen en cuentas las complejas y dinámicas interacciones entre los diferentes tipos de organizaciones involucradas en y con el sistema de salud, los modelos Conjunto y de Sistemas parecen reflejar mejor estas interacciones y, en consecuencia, son los que deberían guiar a los interesados directos en la planificación de los cambios.

Health systems in context: a systematic review of the integration of the social determinants of health within health systems frameworks.

OBJECTIVE: To systematically review and analyze various ways that health systems frameworks interact with the social determinants of health (SDH), as well as the implications of these interactions. METHODS: This was a review of the literature conducted in 2012 using predetermined criteria to search three comprehensive databases (PubMed, the Cochrane Database for Systematic Reviews, and the World Bank E-Library) and grey literature for articles with any consideration of the SDH within health systems frameworks. Snowball sampling and expert opinion were used to include any potentially relevant articles not identified by the initial search. In total, 4,152 documents were found; of these, 27 were included in the analyses. RESULTS: Five main categories of interaction between health systems and SDH emerged: Bounded, Production, Reciprocal, Joint, and Systems models. At one end were the Bounded and Production models, which conceive the SDH to be outside the health system; at the other end, the Joint and Systems models, which visualize a continuous and dynamic interaction. CONCLUSIONS: Considering the complex and dynamic interactions among different kinds of organizations involved in and with the health system,the Joint and Systems models seem to best reflect these interactions, and should thereby guide stakeholders in planning for change.

Public health perspectives on the family: an ecological approach to promoting health in the family and community.

The family, as a setting of practice, is increasingly recognized as critical to health promotion. A better understanding of the nature and process through which families take an active part in their own health can serve as the basis for designing and linking health interventions with public health programs. The integrating function of the family, viewed through an ecological context, makes it an effective entry point and central focus in health promotion.