Community Health Worker Intervention to Address Social Determinants of Health for Children Hospitalized With Asthma

Community health worker perspectives: examining current responsibilities and strategies for success

BACKGROUND

Community health worker (CHW) interventions have demonstrated positive impacts globally, with the COVID-19 pandemic further highlighting the potential of CHWs at the frontline to support prevention, outreach, and healthcare delivery. As the workforce expands, understanding the work and capabilities of CHWs is key to design successful interventions. This study examines the perspectives of experienced CHWs in Chicago about their current work and strategies for success.

METHODS

As part of a community-academic partnership in Chicago, semi-structured interviews were completed with individuals who held positions aligned with CHW. Interviews were conducted between January and April 2022. Questions focused on participants' work and factors contributing to their effectiveness to gain insights into workforce strategies for success to be applied in healthcare and community settings. De-identified transcripts were analyzed using inductive reasoning with codes organized into themes and subthemes under two domains identified a priori. The themes informed a logic model focused on the early stages to support the success of CHWs in their role.

RESULTS

Fourteen individuals participated in the study. The two predetermined domains in this study were: current work of CHWs and strategies for CHWs to be successful. Five themes were identified about CHWs' current work: providing services, building alliances with clients, establishing and maintaining collaborations, collecting data, and experiencing challenges in role. From their perspectives, all these responsibilities enhance client care and support workforce sustainability efforts. Five themes emerged about strategies for the success of CHWs: background of CHWs, champions to support work of CHWs, materials to perform work of CHWs, preparation for CHW role, and characteristics of CHWs. Participants described key traits CHWs should possess to be hired, individuals who can champion and advocate for their work, and specific materials needed to fulfill responsibilities. They reported that training and familiarity with the community were integral to developing and refining the qualities and skills necessary to be effective in their role.

CONCLUSION

CHWs play an increasingly important role in enhancing healthcare delivery and improving health outcomes. This study offers a framework for policymakers, communities, and organizations to utilize for preparing CHWs to succeed in their roles.

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.

Disparities in Patient Family Social Determinants of Health in a Large Urban Pediatric Health System

INTRODUCTION

This analysis sought to identify disparities in social determinants of health (SDOH) outcomes at a Texas pediatric hospital.

METHODS

This retrospective study used electronic health records of pediatric patients families surveyed August -December 2022. Outcomes for health literacy, social support, food, transportation, energy, digital, and housing insecurity, and tobacco exposure were analyzed across demographic categories.

RESULTS

Among 15,294 respondents to the survey (mean child age, 8.73 years; 43.68% Hispanic, 29.73% non-Hispanic White, 18.27% non-Hispanic Black, 6.79% other race/ethnicity; 53.95% male), 50.25% of respondents reported at least one SDOH, whereas 23.39% reported two or more SDOH. The most prevalent SDOH was lack of social support (3,456, 23.91%). Hispanic, non-Hispanic Black, and other race/ethnicity respondents, non-English speakers, and public insurance users had higher odds of reporting almost all SDOH in logistic regression models adjusted for age, race/ethnicity, language, gender, and insurance type.

DISCUSSION

Race/ethnicity, language, and insurance type disparities were identified for all SDOH.

Population-level SDOH and Pediatric Asthma Health Care Utilization: A Systematic Review

CONTEXT

Spatial analysis is a population health methodology that can determine geographic distributions of asthma outcomes and examine their relationship to place-based social determinants of health (SDOH).

OBJECTIVES

To systematically review US-based studies analyzing associations between SDOH and asthma health care utilization by geographic entities.

DATA SOURCES

Pubmed, Medline, Web of Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature.

STUDY SELECTION

Empirical, observational US-based studies were included if (1) outcomes included asthma-related emergency department visits or revisits, and hospitalizations or rehospitalizations; (2) exposures were ≥1 SDOH described by the Healthy People (HP) SDOH framework; (3) analysis occurred at the population-level using a geographic entity (eg, census-tract); (4) results were reported separately for children ≤18 years.

DATA EXTRACTION

Two reviewers collected data on study information, demographics, geographic entities, SDOH exposures, and asthma outcomes. We used the HP SDOH framework's 5 domains to organize and synthesize study findings.

RESULTS

The initial search identified 815 studies; 40 met inclusion criteria. Zip-code tabulation areas (n = 16) and census-tracts (n = 9) were frequently used geographic entities. Ten SDOH were evaluated across all HP domains. Most studies (n = 37) found significant associations between ≥1 SDOH and asthma health care utilization. Poverty and environmental conditions were the most often studied SDOH. Eight SDOH-poverty, higher education enrollment, health care access, primary care access, discrimination, environmental conditions, housing quality, and crime - had consistent significant associations with asthma health care utilization.

CONCLUSIONS

Population-level SDOH are associated with asthma health care utilization when evaluated by geographic entities. Future work using similar methodology may improve this research's quality and utility.

Effectiveness of a Community Health Worker-Driven Intervention in Improving the Quality of Life of Caregivers of Children With Disability in Rural Karnataka, India

Purpose To assess the effectiveness of a community-health-worker (CHW)-driven intervention in improving the quality of life (QOL) of caregivers of children with disability in rural Karnataka, India. Methodology A community-based quasi-experimental study with cluster randomization on the village level was done. CHWs provided structured health education and training for the intervention arm. Pre- and post-intervention, the QOL and Zarit burden scores were compared between and within the two arms. Results From baseline, the physical domain score improved from 49.66 to 53.88 (p < 0.001). The Zarit burden scores decreased from 33.27 to 28.89 (p < 0.001). On comparing the post-test QOL scores between the two arms, the physical domain scores increased from 51.68 to 56.08 (p = 0.025). The Zarit burden scores also significantly decreased from 31.50 to 26.28. Conclusion The intervention by the CHWs on the caregivers has significant improvements in the physical domain of QOL and a reduction in caregiver burden.

Community health workers' perspectives on integrating into school settings to support student health

Introduction

While schools represent key venues for supporting health, they continue to experience gaps in health resources. The integration of community health workers (CHWs) into schools has the potential to supplement these resources but has been underexplored. This study is the first to examine perspectives of experienced CHWs about how CHWs can be applied in school settings to support student health.

Methods

This qualitative study involved conducting semi-structured interviews focused on implementation of CHWs in schools with individuals who held positions aligned with the CHW scope of work. De-identified transcripts were analyzed, and codes were organized into domains and themes.

Results

Among 14 participants, seven domains emerged about the implementation of CHWs in schools: roles and responsibilities, collaborations, steps for integration, characteristics of successful CHWs, training, assessment, and potential challenges. Participants shared various potential responsibilities of school-based CHWs, including educating on health topics, addressing social determinants of health, and supporting chronic disease management. Participants emphasized the importance of CHWs building trusting relationships with the school community and identified internal and external collaborations integral to the success of CHWs. Specifically, participants indicated CHWs and schools should together determine CHWs' responsibilities, familiarize CHWs with the school population, introduce CHWs to the school community, and establish support systems for CHWs. Participants identified key characteristics of school-based CHWs, including having familiarity with the broader community, relevant work experience, essential professional skills, and specific personal qualities. Participants highlighted trainings relevant to school-based CHWs, including CHW core skills and health topics. To assess CHWs' impact, participants proposed utilizing evaluation tools, documenting interactions with students, and observing indicators of success within schools. Participants also identified challenges for school-based CHWs to overcome, including pushback from the school community and difficulties related to the scope of work.

Discussion

This study identified how CHWs can have a valuable role in supporting student health and the findings can help inform models to integrate CHWs to ensure healthy school environments.

Socioeconomic determinants of asthma health

PURPOSE OF REVIEW

The current review provides an assessment of the recent pediatric literature evaluating socioeconomic drivers of asthma incidence and morbidity. The review addresses the specific social determinants of health related to housing, indoor and outdoor environmental exposures, healthcare access and quality, and the impact of systematic racism.

RECENT FINDINGS

Many social risk factors are associated with adverse asthma outcomes. Children living in low-income, urban neighborhoods have greater exposure to both indoor and outdoor hazards, including molds, mice, second-hand smoke, chemicals, and air pollutants, all of which are associated with adverse asthma outcomes. Providing asthma education in the community - via telehealth, school-based health centers, or peer mentors - are all effective methods for improving medication adherence and asthma outcomes. The racially segregated neighborhoods created by the racist 'redlining' policies implemented decades ago, persist today as hotspots of poverty, poor housing conditions, and adverse asthma outcomes.

SUMMARY

Routine screening for social determinants of health in clinical settings is important to identify the social risk factors of pediatric patients with asthma. Interventions targeting social risk factors can improve pediatric asthma outcomes, but more studies are needed related to social risk interventions.

Social determinants of health and asthma

PURPOSE OF REVIEW

Social determinants of health play a major role in healthcare utilization and outcomes in patients with asthma. Continuing to understand how these complex and interwoven relationships interact to impact patient care will be crucial to creating innovative programmes that address these disparities.

RECENT FINDINGS

The current literature continues to support the association of substandard housing, urban and rural neighbourhoods, and race/ethnicity with poor asthma outcomes. Targeted interventions with community health workers (CHWs), telemedicine and local environmental rectifications can help improve outcomes.

SUMMARY

The link between social determinants and poor asthma outcomes continues to be supported by recent literature. These factors are both nonmodifiable and consequences of institutionalized racist policies that require innovative ideas, technologic equity and funding for groups most at risk for poorer outcomes.

Social determinants of health screening in pediatric healthcare settings

PURPOSE OF REVIEW

This article outlines updates in social determinants of health (SDOH) screening practices in pediatric healthcare and community settings. The transition to value-based care and the COVID-19 pandemic have both had significant impacts on screening practices, with implications for providers, communities, and policymakers.

RECENT FINDINGS

The COVID-19 pandemic has exacerbated social needs for vulnerable patients and families, resulting in increased recognition by healthcare teams through screening. Policy frameworks like value-based care that aim to deliver whole-child care in the community are reorienting the logistics of screening, including screening in acute-care settings and community settings. Recent studies on family and provider perspectives should be integrated into screening practices.

SUMMARY

Despite significant advances in and expansion of SDOH screening in the pediatric healthcare setting, there remain limitations and future research needs. More data is needed to evaluate social need screeners and interventions, and determine how healthcare systems, communities, and states can spread and scale such interventions based on outcomes and value measurements. Population-based social indices have the potential to augment individual patient screening, but this remains a future research need.

Social Risks and Health Care Utilization Among a National Sample of Children With Asthma

OBJECTIVES

Prior studies using single-center populations have established associations between social risks and health care utilization among children with asthma. We aimed to evaluate associations between social risks and health care utilization among a nationally representative sample of children with asthma.

STUDY DESIGN

In this cross-sectional study, we utilized the 2018-2019 National Survey of Children's Health to identify children 2 to 17 years old with asthma. Using the Healthy People (HP) 2030 social determinants of health (SDOH) framework, we identified 31 survey items assessing 18 caregiver-identified social risks as exposure variables and classified them into the 5 HP SDOH domains (Economy, Education, Health care, Community, and Environment). Primary outcome was caregiver-reported health care utilization. Associations between individual social risks and total number of SDOH domains experienced with health care utilization were assessed.

RESULTS

The weighted study population included 8.05 million children, 96% of whom reported ≥1 social risk. Fourteen social risks, spanning all 5 SDOH domains, were significantly associated with increased health care utilization. The 3 risks with the highest adjusted odds ratios (aOR) of health care utilization included: experiencing discrimination (aOR 3.26 [95% confidence interval (CI): 1.75, 6.08]); receiving free/reduced lunch (aOR 2.16, [95% CI 1.57, 2.98]); and being a victim of violence (aOR 2.11, [95% CI 1.11, 4]). Children with risks across more SDOH domains reported significantly higher health care utilization.

CONCLUSIONS

Among our national population of children with asthma, social risks are prevalent and associated with increased health care utilization, highlighting their potential contribution to pediatric asthma morbidity.

Structural Racism and the Social Determinants of Health in Asthma

Asthma prevalence and morbidity are disproportionately higher among minoritized communities in the United States. Racial and ethnic disparities in asthma result from complex interactions across biological, environmental, and social factors. Asthma is considered a complex heterogeneous disease consisting of different phenotypes, some of which may be more common in individuals impacted by the downstream effects of structural racism and lack of access to the social determinants of health. Structural racism across generations has created and reinforced inequitable systems through policies and practices which are embedded in the economic, educational, health care, and justice systems (Bailey et al., N Engl J Med 384(8):768-773, 2021; Bailey et al., Lancet 389:1453-1463, 2017; Williams et al., Annu Rev Public Health 40:105-125, 2019). This manifests in an inequitable distribution of resources and the social determinants of health affecting an individual's physical and social environment (Bailey et al., Lancet 389:1453-1463, 2017; Thakur et al., Am J Respir Crit Care Med 202:943-949, 2020; Martinez et al., J Allergy Clin Immunol 148(5):1112-1120, 2021). In this chapter, we outline how inequity in housing, zoning laws, urban planning, education, employment, healthcare access, and healthcare delivery is linked to higher asthma prevalence and morbidity. We also describe the role that chronic physiologic stress has on asthma by enhancing neuroimmune and immunologic responses to environmental exposures. Interventions aimed at addressing the physical or social environment of an individual or community have been shown to improve asthma outcomes in patients at higher risk of severe disease.

Oral community health worker-led interventions in households with average levels of psychosocial factors

Introduction

Household-level psychosocial stress levels have been linked to child tooth brushing behaviors. Community health worker (CHW) interventions that target psychosocial factors in high-risk communities have been associated with changes in health behaviors.

Aim

Observe changes in psychosocial factors over time and an association between psychosocial factors and CHW intervention dose amongst urban Chicago families.

Patients and methods

Participants (N = 420 families) were recruited from 10 community clinics and 10 Women, Infants, or Children (WIC) centers in Cook County, Illinois to participate in a clinical trial. Research staff collected participant-reported psychosocial factors (family functioning and caregiver reports of depression, anxiety, support, and social functioning) and characteristics of CHW-led oral health intervention visits (number, content, child engagement) at 0, 6, and 12 months. CHWs recorded field observations after home visits on household environment, social circumstances, stressors, and supports.

Results

Participants across the cohort reported levels of psychosocial factors consistent with average levels for the general population for nearly all measures. Psychosocial factors did not vary over time. Social functioning was the only measure reported at low levels [32.0 (6.9); 32.1 (6.7); 32.7 (6.9); mean = 50 (standard deviation)] at 0, 6, and 12 months. We did not observe a meaningful difference in social functioning scores over time by exposure to CHW-led intervention visits (control arm, 0, 1, 2, 3, and 4 visits). Field observations made by CHWs described a range of psychosocial stress related to poverty, language barriers, and immigration status.

Conclusion

The unexpectedly average and unchanging psychosocial factors over time, in the context of field observations of stress related to poverty, lack of support, immigration status, and language barriers, suggests that our study did not adequately capture the social determinants of health related to oral health behaviors or that measurement biases precluded accurate assessment. Future studies will assess psychosocial factors using a variety of instruments in an attempt to better measure psychosocial factors including social support, depression, anxiety, functioning, trauma and resilience within our urban population. We will also look at neighborhood-level factors of community distress and resilience to better apply the social ecologic model to child oral health behaviors.

Social Determinants of Emergency Department Visits in Mild Compared to Moderate and Severe Asthma

BACKGROUND

Social determinants of health (SDH) influence emergency department (ED) use among children with asthma. We aimed to examine if SDH were more strongly associated with ED use among children with moderate/severe compared to mild asthma.

METHODS

This study utilized the 2016-2019 data from the National Survey of Children's Health. Children with asthma ages 0-17 years (N = 9937) were included in the analysis. Asthma severity and all-cause ED use in the past year were reported by caregivers. The association between patient factors and ED visits was evaluated using ordinal logistic regression.

RESULTS

Based on the study sample, 29% of children with asthma had moderate/severe asthma. In the mild group, 30% visited the ED at least once in the past 12 months, compared to 49% in the moderate/severe group. SDH associated with ED visits included race/ethnicity, insurance coverage, and parental educational attainment, but the strength of these associations did not vary according to asthma severity.

CONCLUSIONS

In a nationally representative data set, SDH were equally predictive of ED use regardless of children's asthma severity. Interventions to reduce ED use among children with asthma should be considered for children with any severity of asthma, especially children in socially disadvantaged groups at higher risk of ED utilization.