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

BACKGROUND

Research clearly demonstrates social determinants of health (SDOH) impact health outcomes. Provider consideration of patient SDOH in prevention and treatment planning is critical for improved health care quality and health equity. Despite awareness of the connections between SDOH and improved population health, research demonstrates few providers document patient SDOH.

OBJECTIVE

This qualitative study aimed to better understand the barriers and facilitators of SDOH assessment, documentation, and referral in different health care settings and roles.

METHODS

Individual semistructured interviews were conducted with practicing health care providers in South Carolina between August 25, 2022, and September 2, 2022. Participants were recruited via community partners' web-based newsletters or listservs using a purposive sampling design. An interview guide with 19 questions was used to explore the following research question: How do SDOH impact patient health and what are the facilitators and barriers experienced by multidisciplinary health care providers assessing and documenting patient SDOH?

RESULTS

Participants (N=5) included a neonatal intensive care unit registered nurse, a nurse practitioner, a certified nurse midwife, a family and preventive medicine physician, and a counselor (licensed clinical social worker) with careers spanning 12 to 32 years. Participant responses are presented according to the following 5 themes: participants' understanding of SDOH for the patient population, assessment and documentation practices, referrals to other providers and community-based resources, barriers and facilitators of SDOH assessment and documentation, and SDOH assessment and documentation training preferences. Overall, participants were aware of the importance of including patient SDOH in assessment and intervention but noted a variety of institutional and interpersonal barriers to assessment and documentation, including time constraints, perceptions of stigma around discussion of SDOH, and limited referral protocols.

CONCLUSIONS

Incentivizing inclusion of patient SDOH in health care must be facilitated from the top down, so assessment and documentation can be universally implemented in a pragmatic way that works for providers in a variety of roles and settings for the betterment of health care quality, health equity, and improved population health outcomes. Partnering with community organizations can serve to augment health care organizations' resource and referral availability for addressing patients' social needs.

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

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

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

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

Methodologic approach to sampling and field-based data collection for a large-scale in-depth interview study: The Social Position and Family Formation (SPAFF) project

Over the past several decades there have been dramatic shifts in demographic patterns pertaining to family formation, with declining and delayed marriage and childbearing, and increased cohabitation in the United States and other Western industrialized nations. These trends in family demography have been predominantly studied using large-scale datasets, which have identified total population and subgroup trends over time, including differences by age, gender, racial/ethnic, economic, educational, religious, and other characteristics. However, there is limited knowledge and understanding of how individuals across different levels of social position, as well as other important characteristics, make decisions around forming families. This lack of qualitative data on contemporary attitudes regarding family formation has hampered our ability to more completely understand the factors driving behaviors pertaining to the large-scale (ie, international) shifts in demographic trends. The Social Position and Family Formation (SPAFF) project is an in-depth interview study that used quantitative data to guide recruitment of a large sample for qualitative interview data collection on factors influencing different aspects of family formation among heterosexual females and males (18-35 years) in the context of individuals' social position. This methodological paper describes the use of a 'quantitatively-informed' purposive sampling approach in a large metropolitan area to collect qualitative data (through in-depth interviews) from a large sample (n = 200), utilizing web-based tools for successful community-based recruitment and project management.

Exposing the Backstage: Critical Reflections on a Longitudinal Qualitative Study of Residents' Care Networks in Assisted Living

In this article, we analyze the research experiences associated with a longitudinal qualitative study of residents' care networks in assisted living. Using data from researcher meetings, field notes, and memos, we critically examine our design and decision making and accompanying methodological implications. We focus on one complete wave of data collection involving 28 residents and 114 care network members in four diverse settings followed for 2 years. We identify study features that make our research innovative, but that also represent significant challenges. They include the focus and topic; settings and participants; scope and design complexity; nature, modes, frequency, and duration of data collection; and analytic approach. Each feature has methodological implications, including benefits and challenges pertaining to recruitment, retention, data collection, quality, and management, research team work, researcher roles, ethics, and dissemination. Our analysis demonstrates the value of our approach and of reflecting on and sharing methodological processes for cumulative knowledge building.

Beliefs about promoting cognitive health among Filipino Americans who care for persons with dementia

We examined beliefs about promoting cognitive health among Filipino Americans who care for persons with dementia, their awareness of media information about cognitive health, and their suggestions for communicating such information to other caregivers. We conducted three focus groups (25 participants). The constant comparison method compared themes across focus groups. Caregivers most frequently described cognitive health benefits of social engagement and leisure; next in emphasis were benefits of healthy diets. There was less emphasis on physical activity. Participants had heard from television that avoiding smoking, alcohol, and drugs might promote cognitive health. Ways to inform others about cognitive health included information in Filipino newspapers, and handouts in Filipino languages, distributed in Filipino stores, workplaces, community organizations, and health care facilities. Findings suggest an opportunity to develop public health messages promoting cognitive health that are in-language, published in ethnic-specific media, and that are culturally appropriate for Filipino and other Asian Americans.

Promoting cognitive health: a web site review of health systems, public health departments, and senior centers

Growing evidence suggests that healthy behaviors such as being physically active, having a heart healthy diet, and being socially involved may promote cognitive health. The United States has recently begun encouraging such behaviors for that purpose. To help evaluate the diffusion of this policy, we sought to measure a baseline of activity in this area. We examined Web sites of 156 large health care systems, the health departments of all 50 states and the 20 largest US cities, and 181 nationally accredited senior centers, to identify information, products, programs, or services recommended for cognitive health. Among health care systems, 40% promoted cognitive health: 24% recommended mental activity, 20% healthy diets, 20% physical activity, and 16% social involvement. Among health departments, 30% promoted cognitive health in the same ways. Among senior centers, 21% offered strategies, primarily mental activity. Results suggest emerging activity in this area and opportunities for continued development.

It takes two to talk about prostate cancer: a qualitative assessment of African American men's and women's cancer communication practices and recommendations

Prostate cancer (PrCA) is the most commonly diagnosed nonskin cancer among men. African American (AA) men in South Carolina have a PrCA death rate 150% higher than that of European American (EA) men. This in-depth qualitative research explored AA men's and women's current practices, barriers, and recommended strategies for PrCA communication. A purposive sample of 43 AA men and 38 AA spouses/female relatives participated in focus groups (11 male groups; 11 female groups). A 19-item discussion guide was developed. Coding and analyses were driven by the data; recurrent themes within and across groups were examined. Findings revealed AA men and women agreed on key barriers to discussing PrCA; however, they had differing perspectives on which of these were most important. Findings indicate that including AA women in PrCA research and education is needed to address barriers preventing AA men from effectively communicating about PrCA risk and screening with family and health care providers.

Experiences and concerns of family caregivers providing support to people with dementia: A cross-cultural perspective

Abstract:

We examined experiences and concerns among caregivers of community-dwelling people with dementia from two ethnic groups. We conducted a thematic analysis of responses to the question, ‘What is your life like as a caregiver?’ in nine focus groups ( n = 75) with Filipino and non–Hispanic White caregivers. Constant comparison methods identified themes by ethnicity. Experiences and concerns expressed across groups were related to care recipient symptoms commonly associated with dementia, including severe memory loss and behavioral changes. Participants in both ethnic groups described strategies that help them cope, such as receiving help from family and friends, receiving respite support, and participating in support groups. Filipino caregivers more often emphasized positive aspects of caregiving, whereas Whites often expressed that others do not understand the daily experiences of caregiving. Filipinos more commonly described caregivers as a ‘good person’ or ‘saint’ and emphasized that caregiving made them stronger.

The potential influence of masculine identity on health-improving behavior in midlife and older African American men

OBJECTIVE

To gain a greater understanding of masculinity and its potential influence on health-improving behavior in midlife and older African American (AA) men.

METHODS

Forty-nine AA men aged 45-88 years completed in-depth interviews to ascertain their perspectives on masculinity, how masculine identity in this population might be influenced by age and physical activity level, or how it might impact health. Taped interviews were transcribed and organized for analysis with common themes identified by multiple researchers.

RESULTS

Most often cited attributes of someone considered "manly" included a leader of a family/household, provider, strong work ethic, and masculine physique. Terms such as responsible, principled, and man of character also described the typical man. Potential negative and positive influences of manhood on health included avoiding health care appointments and being a good example to children/others, respectively. Themes associated with age-related changes in manhood were acceptance and being more health conscious. Elements associated with how manhood was influenced by AA race included stress and perseverance.

CONCLUSIONS

Midlife and older AA men in this study primarily expressed views of masculinity that fit the traditional perception of manhood. However, the attributes revealed, such as family provider, responsibility, self-reliance, and perseverance, were viewed as having potential for both negative and positive impacts on health and health-improving behaviors. It will be essential to integrate these prevalent attributes of masculine identity into health promotion interventions such that they facilitate positive behavior change while not competing with gender role norms among this vulnerable group of men.

How do older people describe others with cognitive impairment? A multiethnic study in the United States

We studied how older people describe others with cognitive impairment. Forty-two focus groups represented African Americans, American Indians, Chinese Americans, Latinos, Vietnamese Americans, and Whites other than Latinos (Whites) (N = 396, ages 50+), in nine locations in the United States of America. Axial coding connected categories and identified themes. The constant comparison method compared themes across ethnic groups. African Americans, American Indians and Whites emphasised memory loss. African Americans, American Indians, Latinos and Whites stressed withdrawal, isolation and repetitive speech. African Americans, American Indians, Vietnamese Americans and Whites emphasised ‘slow thinking’. Only Whites described mood swings and personality changes. Many participants attributed dementia to stress. Terms describing others with dementia included ‘Alzheimer's’, ‘dementia’, ‘senile’ and ‘crazy’. Euphemisms were common (‘senior moment’, ‘old timer's disease’). Responses focused on memory, with limited mention of other cognitive functions. Differences among ethnic groups in descriptions of cognitive health and cognitive impairment underscore the need to tailor public health messages about cognitive health to ways that people construe its loss, and to their interest in maintaining it, so that messages and terms used are familiar, understandable and relevant to the groups for which they are designed. Health promotion efforts should develop ethnically sensitive ways to address the widely held misperception that even serious cognitive impairment is a normal characteristic of ageing and also to address stigma associated with cognitive impairment.

Multisite qualitative study of primary care physicians' and midlevel providers' self-reported practices and perceptions about maintaining cognitive health

INTRODUCTION

To facilitate national efforts to maintain cognitive health through public health practice, the Healthy Brain Initiative recommended examining diverse groups to identify stakeholder perspectives on cognitive health. In response, the Healthy Aging Research Network (HAN), funded by the Centers for Disease Control and Prevention (CDC), coordinated projects to document the perspectives of older adults, caregivers of people with dementia, and primary care providers (PCPs) on maintaining cognitive health. Our objective was to describe PCPs' perceptions and practices regarding cognitive health.

METHODS

HAN researchers conducted 10 focus groups and 3 interviews with physicians (N = 28) and advanced practice providers (N = 21) in Colorado, Texas, and North Carolina from June 2007 to November 2008. Data were transcribed and coded axially.

RESULTS

PCPs reported addressing cognitive health with patients only indirectly in the context of physical health or in response to observed functional changes and patient or family requests. Some providers felt evidence on the efficacy of preventive strategies for cognitive health was insufficient, but many reported suggesting activities such as games and social interaction when queried by patients. PCPs identified barriers to talking with patients about cognitive health such as lack of time and patient reactions to recommendations.

CONCLUSION

Communicating new evidence on cognitive health and engaging older adults in making lasting lifestyle changes recommended by PCPs and others may be practical ways in which public health practitioners can partner with PCPs to address cognitive health in health care settings.

African American men's perspectives on promoting physical activity: "We're not that difficult to figure out!"

African American men report poorer health than do White men and have significantly greater odds for developing chronic diseases partly because of limited physical activity. Understanding how to encourage healthy behaviors among African American men will be critical in the development of effective physical activity messages and programs. Guided by principles of cultural sensitivity and social marketing, this research examined middle-aged and older African American men's recommended strategies for promoting physical activity to African American men of their age. The authors report results from 49 interviews conducted with middle-aged (45-64 years) and older (65-84 years) African American men in South Carolina. Four groups of African American men were recruited: middle-aged active men (n = 17), middle-aged inactive men (n = 12), older active men (n = 10), older inactive men (n = 10). Themes related to marketing and recruitment strategies, message content, and spokesperson characteristics emerged and differed by age and physical activity level. Recommended marketing strategies included word of mouth; use of mass media; partnering with churches, businesses, and fraternities; strategic placement of messages; culturally appropriate message framing; and careful attention to selection of program spokespersons. Findings will help in the marketing, design, implementation, and evaluation of culturally appropriate interventions to encourage physical activity among middle-aged and older African American men in the South.

Ethnically Diverse Older Adults' Beliefs about Staying Mentally Sharp

This study examined diverse older adults' ( n = 396, ages 50+) views about how to stay mentally sharp. We conducted 42 focus groups in four languages at nine United States locations using a standardized discussion guide and methods. The groups represented African Americans, American Indians, Chinese Americans, Latinos, Whites other than Latinos, and Vietnamese Americans. All groups mentioned benefits of social interaction. All groups, especially Chinese and African Americans, mentioned benefits of community engagement. Participants in all groups expressed their belief that mental stimulation, particularly reading, promoted cognitive health; African Americans and Whites were especially likely to say that mental exercises (e.g., puzzles) were useful. Results suggest opportunities for education about potential cognitive health benefits of being socially connected through senior center activities and volunteer programs.

Older adults' concerns about cognitive health: commonalities and differences among six United States ethnic groups

We studied concerns about cognitive health among ethnically diverse groups of older adults. The study was grounded in theories of health behaviour and the representation of health and illness. We conducted 42 focus groups (N=396, ages 50+) in four languages, with African Americans, American Indians, Chinese Americans, Latinos, Whites other than Latinos (hereafter, Whites) and Vietnamese Americans, in nine United States locations. Participants discussed concerns about keeping their memory or ability to think as they age. Audio recordings were transcribed verbatim. Constant comparison methods identified themes. In findings, all ethnic groups expressed concern and fear about memory loss, losing independence, and becoming ‘a burden’. Knowing someone with Alzheimer's disease increased concern. American Indians, Chinese Americans, Latinos and Vietnamese Americans expected memory loss. American Indians, Chinese Americans and Vietnamese Americans were concerned about stigma associated with Alzheimer's disease. Only African Americans, Chinese and Whites expressed concern about genetic risks. Only African Americans and Whites expressed concern about behaviour changes. Although we asked participants for their thoughts about their ability to think as they age, they focused almost exclusively on memory. This suggests that health education promoting cognitive health should focus on memory, but should also educate the public about the importance of maintaining all aspects of cognitive health.

Older adults' perceived physical activity enablers and barriers: a multicultural perspective

This study identified perceived physical activity (PA) enablers and barriers among a racially/ethnically and geographically diverse group of older adults. Data were from 42 focus groups conducted with African Americans, American Indians, Latinos, Chinese, Vietnamese, and non-Hispanic Whites (hereafter Whites). Constant-comparison methods were used to analyze the data. Common barriers were health problems, fear of falling, and inconvenience. Common enablers were positive outcome expectations, social support, and PA program access. American Indians mentioned the built environment and lack of knowledge about PA as barriers and health benefits as an enabler more than participants in other groups. Whites and American Indians emphasized the importance of PA programs specifically designed for older adults. Findings suggest several ways to promote PA among older people, including developing exercise programs designed for older adults and health messages promoting existing places and programs older adults can use to engage in PA.

Primary care providers' sources and preferences for cognitive health information in the United States

In most countries, physicians and other health-care providers play key roles in promoting health. Accumulating scientific evidence suggests that providers may soon want to include cognitive health among the areas they promote. Cognitive health is the maintenance of cognitive abilities that enable social connectedness, foster a sense of purpose, promote independent living, allow recovery from illness or injury and promote effective coping with functional deficits. The US Centers for Disease Control and Prevention has established health promotion about cognitive health as a policy priority, with health providers included as one key group to participate in this effort. This study presents results from focus groups and interviews with primary care physicians (n = 28) and midlevel health-care providers (physician assistants and nurse practitioners, n = 21) in three states of the US. Providers were asked about their sources of information on cognitive health and for their ideas on how best to communicate with primary care providers about research on cognitive health. In results, providers cited online sources, popular media and continuing medical education as their most common sources of information about cognitive health. Popular media sources were used both proactively and reactively to respond to patient inquiries. Differences in sources of information were noted for physicians as compared with midlevel providers, and for rural and urban providers. Several potential ways to disseminate information about cognitive health were identified. Effective messaging is likely to require multiple strategies to reach diverse groups of primary care providers, and to include continuing medical education.

Gender differences in views about cognitive health and healthy lifestyle behaviors among rural older adults

PURPOSE

Research suggests that men and women often differ in knowledge and beliefs about causes and treatments of a variety of diseases. This study examines gender differences in views about cognitive health and behaviors that have been associated with its maintenance, focusing on older adults living in rural areas.

DESIGN AND METHODS

We conducted 6 focus groups in rural West Virginia. Participants included 37 women and 30 men, aged 55 years and older.

RESULTS

Men and women held similar views of cognitive decline, as well as largely similar views about causes of Alzheimer's disease (AD). However, women were more concerned about developing AD than were men. Gender differences were also noted with respect to healthy lifestyle beliefs, including diet, leisure-time physical activity, and strategies to maintain cognitive health.

IMPLICATIONS

Findings illustrate the importance of considering gender with respect to health beliefs, health behaviors, and health promotion, and emphasize the need to develop interventions designed for specific populations. Results highlight a critical need to translate research findings to the community.