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.

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.

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.

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.

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.

"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.