Social Determinants Of Health Research Articles

Documentation of social determinants of health across individuals from different racial and ethnic groups in home healthcare.

Home healthcare (HHC) enables patients to receive healthcare services within their homes to manage chronic conditions and recover from illnesses. Recent research has identified disparities in HHC based on race or ethnicity. Social determinants of health (SDOH) describe the external factors influencing a patient's health, such as access to care and social support. Individuals from racially or ethnically minoritized communities are known to be disproportionately affected by SDOH. Existing evidence suggests that SDOH are documented in clinical notes. However, no prior study has investigated the documentation of SDOH across individuals from different racial or ethnic backgrounds in the HHC setting. This study aimed to (1) describe frequencies of SDOH documented in clinical notes by race or ethnicity and (2) determine associations between race or ethnicity and SDOH documentation. Retrospective data analysis. We conducted a cross-sectional secondary data analysis of 86,866 HHC episodes representing 65,693 unique patients from one large HHC agency in New York collected between January 1, 2015, and December 31, 2017. We reported the frequency of six SDOH (physical environment, social environment, housing and economic circumstances, food insecurity, access to care, and education and literacy) documented in clinical notes across individuals reported as Asian/Pacific Islander, Black, Hispanic, multi-racial, Native American, or White. We analyzed differences in SDOH documentation by race or ethnicity using logistic regression models. Compared to patients reported as White, patients across other racial or ethnic groups had higher frequencies of SDOH documented in their clinical notes. Our results suggest that race or ethnicity is associated with SDOH documentation in HHC. As the study of SDOH in HHC continues to evolve, our results provide a foundation to evaluate social information in the HHC setting and understand how it influences the quality of care provided. The results of this exploratory study can help clinicians understand the differences in SDOH across individuals from different racial and ethnic groups and serve as a foundation for future research aimed at fostering more inclusive HHC documentation practices.

Instructing to Impact: Exploration of Doctor of Physical Therapy Education Instruction of Social Determinants of Health and Health Equity for People with Disabilities.

The aim of this study was to explore instruction of social determinants of health (SDOH) for people with disabilities (PWD) in Doctor of Physical Therapy (DPT) education programs. A sequential mixed methods study informed by a 5-member disability community advisory panel was conducted. Qualitative semi-structured interviews with educators (n = 10) across 4 DPT programs in the Midwest were conducted and analyzed thematically. The qualitative findings formed the basis of the quantitative phase. An online survey was conducted with faculty of DPT programs in the United States (n = 254) with the most knowledge of instruction of SDOH and health equity for PWD (n = 74; 29% response rate). Quantitative data were analyzed with descriptive statistics and triangulated with qualitative data. SDOH for PWD is an emerging component of instruction in DPT curricula. Five themes included: emerging instruction of SDOH for PWD; conceptual frameworks informing instruction; instructional strategies; barriers to integration of SDOH for PWD; and facilitators to integration of SDOH for PWD. Quantitative analysis revealed that 71 respondents (95.9%) included disability in health equity discussions primarily focused on health care access. Limited time (n = 49; 66.2%) was the most frequently reported barrier, and educator interest in disability health equity was the most frequently reported facilitator (n = 62; 83.7%) to inclusion of the SDOH for PWD in health equity discussions. Opportunities exist in DPT curricula to build on instructional strategies, integrate SDOH frameworks, and amplify facilitators to integration of SDOH for PWD. To meet the needs of the 67 million Americans living with disabilities, students must have the knowledge and skills to address the complex needs of this historically marginalized population. Understanding the DPT education landscape around SDOH for PWD can guide DPT educators to more fully prepare their students to recognize and ameliorate health disparities faced by PWD.

Human milk, breastfeeding, and early neurodevelopmental outcomes for infants with critical CHD.

Human milk improves neurodevelopment for preterm infants, but relationships between human milk and neurodevelopment for infants with critical CHD are unknown. We aimed to (1) explore associations between human milk/direct breastfeeding and neurodevelopment at 1-year and 2-year follow-up and (2) describe patterns of human milk (maternal, donor) and commercial formula during hospitalisation in the first year of life.This retrospective cohort study included infants who underwent surgery for CHD < 6 months old. The primary outcome was neurodevelopment via Bayley Scales of Infant Development-IV. Analysis included adjusted linear regression for associations between exclusive human milk while inpatient during the first 6 months or any direct breastfeeding while inpatient during the first year of life and 1-year Bayley-IV scores. Models were adjusted for race, insurance type, genetic diagnosis, and length of stay.Of 98 eligible infants, 40% followed up at 1 year; 27% at 2 years. There were differences in follow-up related to demographics (race, ethnicity) and social determinants of health (insurance type, distance from clinic). In adjusted models, infants who directly breastfed had 13.18 points higher cognition (95% CI: 0.84-25.53, p = 0.037); 14.04 points higher language (2.55-25.53, p = 0.018); and 15.80 points higher motor scores (3.27-28.34, p = 0.015) at 1-year follow-up. Infants fed exclusive human milk had 12.64 points higher cognition scores (-0.53-25.82, p = 0.059).Future investigation into nutrition and neurodevelopment in the context of critical CHD is warranted. As neurodevelopmental follow-up becomes standard of care in this population, efforts are needed to mitigate disparities in access to this care.

The impact of socio-environmental factors on doxycycline post-exposure prophylaxis awareness in the US: a cross-sectional study

Background We investigated awareness and use of doxycycline post-exposure prophylaxis (doxyPEP) in the US. DoxyPEP has preventative benefits for bacterial STIs among people assigned male at birth. We considered how individual, interpersonal and social determinants of health, such as state-level LGBTQ equality, impact doxyPEP awareness. Methods We conducted an online snapshot cross-sectional survey in June 2023. Survey questions included demographics, sexual and substance use behaviours, and socio-environmental factors, and provided a short explanation of doxyPEP, with questions regarding prior awareness and use. Results Among a racially diverse sample of 196 participants (median age 33 years), 94% identified as cisgender men, 26% were aware of doxyPEP, whereas only 14 (7%) had ever used it. Factors significantly associated with awareness included being college educated (OR 2.50, 95% CI 1.09–5.74), a past year bacterial STI (OR 4.20, 95% CI 1.97–8.89), having discussed HIV pre-exposure prophylaxis with a health care provider (OR 3.88, 95% CI 1.99–7.57) and having taken HIV pre-exposure prophylaxis (OR 2.29, 95% CI 1.11–4.70). Socio-environmental factors associated with doxyPEP awareness included living in a large urban city (OR 2.14, 95% CI 1.12–4.10) and living in a state with higher levels of LGBTQ policy equality (OR 2.18, 95% CI 1.07–4.44). Conclusions Considering the disproportionate impact of bacterial STIs on men who have sex with men, especially those living in lower LGBTQ equality regions, such as the Southern US, our study emphasises how socio-environmental factors may limit awareness and uptake of novel biomedical approaches that have the potential to prevent morbidity and enhance sexual health.

Characterizing "collateral damage" in men and women with metastatic breast cancer (mBC) from diverse racial and ethnic backgrounds in New York City.

Patients from diverse racial, ethnic, and socio-economic backgrounds may be particularly vulnerable to experiencing undue social and financial burdens ("collateral damage") from a metastatic breast cancer (mBC) diagnosis; however, these challenges have not been well explored in diverse populations. From May 2022 to May 2023, English- or Spanish-speaking adults with mBC treated at four New York-Presbyterian (NYP) sites were invited to complete a survey that assessed collateral damage, social determinants of health, physical and psychosocial well-being, and patient-provider communication. Fisher's exact and the Kruskal-Wallis rank-sum tests assessed differences by race and ethnicity. Of 87 respondents, 14% identified as Hispanic, 28% non-Hispanic Black (NHB), 41% non-Hispanic White (NHW), 7% Asian American Pacific Islander (AAPI), and 10% other/multiracial. While 100% of Hispanic, NHW, and AAPI participants reported stable housing, 29% of NHB participants were worried about losing housing (p = 0.002). Forty-two percent of Hispanic and 46% of NHB participants (vs. 8%, NHW and 0%, AAPI, p = 0.005) were food insecure; 18% of Hispanic and 17% of NHB adults indicated lack of reliable transportation in the last year (vs. 0%, NHW/AAPI, p = 0.033). Participants were generally satisfied with the quality of communication that they had with their healthcare providers and overall physical and mental well-being were modestly poorer relative to healthy population norms. In our study, NHB and Hispanic mBC patients reported higher levels of financial concern and were more likely to experience food and transportation insecurity compared to NHW patients. Systematically connecting patients with resources to address unmet needs should be prioritized to identify feasible approaches to support economically vulnerable patients following an mBC diagnosis.

The impact of syndemic burden, age, and sexual minority status on internalized HIV stigma among people living with HIV in South Florida.

Internalized HIV stigma has been associated with several poor mental and physical health outcomes among people living with HIV (PLWH); yet, little research has explored how internalized HIV stigma may be affected by syndemic burden. This study sought to examine the relationship between syndemic conditions and HIV stigma over and above the potential effects of two social determinants of health, age and sexual minority status, using a linear regression approach (N = 1343). Syndemic burden was significantly positively associated with internalized HIV stigma above and beyond the effects of age and sexual minority status (b = 0.23). Additionally, age (b = -0.02) and being a sexually minority (b = -0.31) were significantly negatively associated with internalized HIV stigma. Findings should inform future treatment targets for this population by specifically working to reduce internalized HIV stigma for people with a greater syndemic burden and, potentially, among young adults and heterosexual PLWH.

Bias in team decision-making for advanced heart failure therapies: model application

ABSTRACT Bias in advanced heart failure therapy allocation results in inequitable outcomes for minoritized populations. The purpose of this study was to examine how bias is introduced during group decision-making with an interprofessional team using Breathett’s Model of Heart Failure Decision-Making. This was a secondary qualitative descriptive analysis from a study focused on bias in advanced heart failure therapy allocation. Team meetings were recorded and transcribed from four heart failure centers. Breathett’s Model was applied both deductively and inductively to transcripts (n = 12). Bias was identified during discussions about patient characteristics, clinical fragility, and prior clinical decision-making. Some patients were labeled as “good citizens” or as adherent/non-adherent while others benefited from strong advocacy from interprofessional team members. Social determinants of health also impacted therapy allocation. Interprofessional collaboration with advanced heart failure therapy allocation may be enhanced with the inclusion of patient advocates and limit of clinical decision-making using subjective data.

Social Factors Associated with Congenital Syphilis in Missouri.

Congenital syphilis disproportionately affects individuals impacted by adverse social determinants of health. Understanding these determinants may help facilitate holistic care. We performed a retrospective review of mother-infant dyads with potential congenital syphilis in a Missouri hospital system. Cases were classified per Centers for Disease Control and Prevention clinical scenarios. Information was collected regarding demographics, prenatal care, substance use, and other social factors. Dyads with confirmed/highly probable or possible congenital syphilis ("congenital syphilis outcomes") were compared to those with less likely/unlikely congenital syphilis ("non-congenital syphilis outcomes") using descriptive statistics. We identified 131 dyads with infant dates of birth from 12/2015-6/2022: 74 (56%) with congenital syphilis outcomes and 56 (43%) with non-congenital syphilis outcomes. Most mothers were Black/African American (n = 84, 65%) and lived in areas with high Social Vulnerability Indices. Many had inadequate prenatal care (n = 61, 47%) and/or substance use histories (n = 55, 42%). Significant associations with congenital syphilis outcomes included limited prenatal care (OR 3.01, 95% CI 1.38-6.56), no prenatal care (OR 16.08, 95% CI 1.96-132.11), substance use (OR 3.42, 95% CI 1.61-7.25), housing instability (OR 3.42, 95% CI 1.39-8.38), and justice system interactions (OR 2.29, 95% CI 1.00-5.24). Substance use correlated with prenatal care adequacy (p < 0.001). 30% of infants with congenital syphilis outcomes were taken into protective custody. Adverse social determinants of health are common in dyads impacted by congenital syphilis. Health systems should consider interdisciplinary programming to improve testing and linkage to care. Future studies should evaluate social support for congenital syphilis prevention and management.

Cardiovascular Burden of the V142I Transthyretin Variant.

Individual cohort studies concur that the amyloidogenic V142I variant of the transthyretin (TTR) gene, present in 3% to 4% of US Black individuals, increases heart failure (HF) and mortality risk. Precisely defining carrier risk across relevant clinical outcomes and estimating population burden of disease are important given established and emerging targeted treatments. To better define the natural history of disease in carriers across mid to late life, assess variant modifiers, and estimate cardiovascular burden to the US population. A total of 23 338 self-reported Black participants initially free from HF were included in 4 large observational studies across the US (mean [SD], 15.5 [8.2] years of follow-up). Data analysis was performed between May 2023 and February 2024. V142I carrier status (n = 754, 3.2%). Hospitalizations for HF (including subtypes of reduced and preserved ejection fraction) and all-cause mortality. Outcomes were analyzed by generating 10-year hazard ratios for each age between 50 and 90 years. Using actuarial methods, mean survival by carrier status was estimated and applied to the 2022 US population using US Census data. Among the 23 338 participants, the mean (SD) age at baseline was 62 (9) years and 76.7% were women. Ten-year carrier risk increased for HF hospitalization by age 63 years, predominantly driven by HF with reduced ejection fraction, and 10-year all-cause mortality risk increased by age 72 years. Only age (but not sex or other select variables) modified risk with the variant, with estimated reductions in longevity ranging from 1.9 years (95% CI, 0.6-3.1) at age 50 to 2.8 years (95% CI, 2.0-3.6) at age 81. Based on these data, 435 851 estimated US Black carriers between ages 50 and 95 years are projected to cumulatively lose 957 505 years of life (95% CI, 534 475-1 380 535) due to the variant. Among self-reported Black individuals, male and female V142I carriers faced similar and substantial risk for HF hospitalization, predominantly with reduced ejection fraction, and death, with steep age-dependent penetrance. Delineating the individual contributions of, and complex interplay among, the V142I variant, ancestry, the social construct of race, and biological or social determinants of health to cardiovascular disease merits further investigation.

Social environment, lifestyle, and genetic predisposition with dementia risk: A long-term longitudinal study among older adults.

The role of social environment, i.e., the aggregate effect of social determinants of health (SDOHs), in determining dementia is unclear. We developed a novel polysocial risk score for dementia based on 19 SDOH among 5,199 participants in the Health and Retirement Study, US, to measure the social environmental risk. We used a survival analysis approach to assess the association between social environment and dementia risk in 2006-2020. We further studied the interaction between social environment and lifestyles, and explored racial disparities. The study participants (mean age=73.4 years, SD=8.3; 58.0% female; 11.6% African American) were followed up for an average of 6.2 years, and 1,089 participants developed dementia. Every one-point increase in the polysocial risk score (ranging from 0-10) was associated with a 21.6% higher risk (aHR=1.21, 95% CI=1.15-1.26) of developing dementia, other things being equal. Among participants with high social environmental risk, regular exercise and moderate drinking were associated with a 43-60% lower risk of developing dementia (p<0.001). In addition, African Americans were 1.3 times (aHR=2.28, 95% CI=1.96-2.66) more likely to develop dementia than European Americans, other things being equal. An adverse social environment is linked to higher dementia risk, but healthy lifestyles can partially offset the increased social environmental risk. The polysocial risk score can complement the existing risk tools to identify high-risk older populations, and guide the design of targeted social environmental interventions, particularly focusing on improving the companionship of the older people, to prevent dementia.

Social and Structural Determinants of Health Associated with COVID-19 Vaccine Hesitancy among Older Adults in the United States

State-level COVID-19 vaccination rates among older adults have been uneven in the United States. Due to the immunocompromised nature of older adults, vaccine hesitancy increases the risk of morbidity and mortality. This study aims to determine the association between the social determinants of health, the structural determinants of health, and COVID-19 vaccine hesitancy among older adults in the United States. Secondary data from the Health and Retirement Study (HRS) dataset were used. A descriptive analysis and multinomial multivariable logistic regression were performed to examine the association of the independent variables—gender, age, race, immigration status, marital status, broadband internet access, social security income, Medicare coverage, education, and frequency of religious service—with the dependent variable, vaccine hesitancy. Compared to the respondents with no vaccine hesitancy and without the specific predictor, the respondents who reported religious attendance at least once/week were more likely to be “somewhat hesitant”, divorced respondents had higher odds of being “somewhat hesitant”, and older adults aged 65–74 years were more likely to be “very hesitant” or “somewhat hesitant” about the COVID-19 vaccine. Compared to the respondents with no vaccine hesitancy and without the specific predictor, females had higher odds of being “very hesitant”, “somewhat hesitant”, or a “little hesitant”, and African Americans were more likely to be “very hesitant”, “somewhat hesitant”, or a “little hesitant” about the COVID-19 vaccine. Addressing these factors may limit the barriers to vaccine uptake reported among older adults and improve herd immunity among the immunocompromised population.

Development and validation of mortality prediction models based on the social determinants of health

BackgroundThere is no standardised approach to screening adults for social risk factors. The goal of this study was to develop mortality risk prediction models based on the social determinants of...

Social Determinants of Health and Delivery of Rehabilitation to Older Adults During ICU Hospitalization

Older adults with socioeconomic disadvantage develop a greater burden of disability after critical illness than those without socioeconomic disadvantage. The delivery of in-hospital rehabilitation that can mitigate functional decline may be influenced by social determinants of health (SDOH). Whether rehabilitation delivery differs by SDOH during critical illness hospitalization is not known. To evaluate whether SDOH are associated with the delivery of skilled rehabilitation during critical illness hospitalization among older adults. This cohort study used data from the National Health and Aging Trends Study linked with Medicare claims (2011-2018). Participants included older adults hospitalized with a stay in the intensive care unit (ICU). Data were analyzed from August 2022 to September 2023. Dual eligibility for Medicare and Medicaid, education, income, limited English proficiency (LEP), and rural residence. The primary outcome was delivery of physical therapy (PT) and/or occupational therapy (OT) during ICU hospitalization, characterized as any in-hospital PT or OT and rate of in-hospital PT or OT, calculated as total number of units divided by length of stay. In the sample of 1618 ICU hospitalizations (median [IQR] patient age, 81.0 [75.0-86.0] years; 842 [52.0%] female), 371 hospitalizations (22.9%) were among patients with dual Medicare and Medicaid eligibility, 523 hospitalizations (32.6%) were among patients with less than high school education, 320 hospitalizations (19.8%) were for patients with rural residence, and 56 hospitalizations (3.5%) were among patients with LEP. A total of 1076 hospitalized patients (68.5%) received any PT or OT, with a mean rate of 0.94 (95% CI, 0.86-1.02) units/d. After adjustment for age, sex, prehospitalization disability, mechanical ventilation, and organ dysfunction, factors associated with lower odds of receipt of PT or OT included dual Medicare and Medicaid eligibility (adjusted odds ratio, 0.70 [95% CI, 0.50-0.97]) and rural residence (adjusted odds ratio, 0.65 [95% CI, 0.48-0.87]). LEP was associated with a lower rate of PT or OT (adjusted rate ratio, 0.55 [95% CI, 0.32-0.94]). These findings highlight the need to consider SDOH in efforts to promote rehabilitation delivery during ICU hospitalization and to investigate factors underlying inequities in this practice.

National Overview of Nonprofit Hospitals' Community Benefit Programs to Address Housing.

Housing is a critical social determinant of health that can be addressed through hospital-supported community benefit programming. To explore the prevalence of hospital-based programs that address housing-related needs, categorize the specific actions taken to address housing, and determine organizational and community-level factors associated with investing in housing. This retrospective, cross-sectional study examined a nationally representative dataset of administrative documents from nonprofit hospitals that addressed social determinants of health in their federally mandated community benefit implementation plans. We conducted descriptive statistics and bivariate analyses to examine hospital and community characteristics associated with whether a hospital invested in housing programs. Using an inductive approach, we categorized housing investments into distinct categories. The main outcome measure was a dichotomous variable representing whether a hospital invested in one or more housing programs in their community. Twenty percent of hospitals invested in one or more housing programs. Hospitals that addressed housing in their implementation strategies were larger on average, less likely to be in rural communities, and more likely to be serving populations with greater housing needs. Housing programs fell into 1 of 7 categories: community partner collaboration (34%), social determinants of health screening (9%), medical respite centers (4%), community social determinants of health liaison (11%), addressing specific needs of homeless populations (16%), financial assistance (21%), and targeting high-risk populations (5%). Currently, a small subset of hospitals nationally are addressing housing. Hospitals may need additional policy support, external partnerships, and technical assistance to address housing in their communities.

Lessons learned from COVID-19: improving breast cancer care post-pandemic from the patient perspective

BackgroundSince the onset of the pandemic, breast cancer (BC) services have been disrupted in most countries. The purpose of this qualitative study is to explore the unmet needs, patient-priorities, and recommendations for improving BC healthcare post-pandemic for women with BC and to understand how they may vary based on social determinants of health (SDH), in particular socio-economic status (SES).MethodsThirty-seven women, who were purposively sampled based on SDH and previously interviewed about the impact of COVID-19 on BC, were invited to take part in follow-up semi-structured qualitative interviews in early 2023. The interviews explored their perspectives of BC care since the easing of COVID-19 government restrictions, including unmet needs, patient-priorities, and recommendations specific to BC care. Thematic analysis was conducted to synthesize each topic narratively with corresponding sub-themes. Additionally, variation by SDH was analyzed within each sub-theme.ResultsTwenty-eight women (mean age = 61.7 years, standard deviation (SD) = 12.3) participated in interviews (response rate = 76%). Thirty-nine percent (n = 11) of women were categorized as high-SES, while 61% (n = 17) of women were categorized as low-SES. Women expressed unmet needs in their BC care including routine care and mental and physical well-being care, as well as a lack of financial support to access BC care. Patient priorities included the following: developing cohesion between different aspects of BC care; communication with and between healthcare professionals; and patient empowerment within BC care. Recommendations moving forward post-pandemic included improving the transition from active to post-treatment, enhancing support resources, and implementing telemedicine where appropriate. Overall, women of low-SES experienced more severe unmet needs, which in turn resulted in varied patient priorities and recommendations.ConclusionAs health systems are recovering from the COVID-19 pandemic, the emphasis should be on restoring access to BC care and improving the quality of BC care, with a particular consideration given to those women from low-SES, to reduce health inequalities post-pandemic.

Social determinants of health and their relation to suboptimal health status in the context of 3PM: a latent profile analysis

Social determinants of health and their relation to suboptimal health status in the context of 3PM: a latent profile analysis

Blood pressure across the life course: The importance of cardiovascular health and considerations for those with adverse social determinants of health.

Blood pressure across the life course: The importance of cardiovascular health and considerations for those with adverse social determinants of health.

FlourishCare Model of Integrated Care: The Validation of the Flourish Index-Revised (FI-R)

Abstract Background and Objectives This study validates the Flourish Index–Revised (FI-R), a tool evaluating integrated health care models. The original Flourish Index (FI) was developed in 2018 (Faul et al., 2018) and has been refined to align with the FlourishCare (FC)TM Model (Model) for geriatric primary care. Research Design and Methods The Model provides integrated biopsychosocial health care to older adults. The FI-R uses 25 quality-of-care indicators and 7 contextual community indicators. The FI-R was validated with Categorial Principal Components Analysis (CATPCA) using a sample of 949 patients 50+ who were mostly female (73%), Non-Hispanic White (70%), living in urban areas (90%), and married (29%), single (22%) or divorced (19%). The mean age was 73.46 (SD=10.86) and mean years of education was 14.30 (SD=2.14). Results CATPCA showed a four-dimensional structure of biological, psychological, and two social determinants of health (SDOH) subdomains: health behaviors and community. Final selection of indicators was based on total variance accounted for &amp;gt;0.30, absolute values of item loadings &amp;gt;0.45, and not having cross loadings &amp;gt;0.45 on two factors. Internal consistency (Cronbach Alpha) for the determinants were: biological=0.75, psychological=0.76, SDOH: community=0.70, SDOH: Health Behaviors=0.50 and total FI-R=0.95. Sensitivity to change was shown for the total FI-R, psychological determinants, and SDOH:health behaviors but not for biological determinants. Discussion and Implications The validation of the FI-R shows promise for its usability to evaluate integrated health care models using existing measures in electronic health systems. More work is needed to improve the incorporation of SDOH:sociodemographics into the FI-R.

Feasibility of a Telemedicine-Based Principal Illness Navigation (PIN) Service for Complex Populations Following Hospital Discharge After Acute Stroke

Background Principal Illness Navigation (PIN) services may play an important role in helping patients through important transitions in care following acute hospitalization. We evaluated a novel PIN telemedicine approach to understand the feasibility of providing these services to diverse patient cohorts. Methods A single-arm, retrospective observational study of Kandu Health’s post-acute PIN service was conducted in patients experiencing ischemic or hemorrhagic stroke in California and New Jersey. The technology-enabled program offered remote healthcare support led by occupational therapists and licensed clinical social workers that was tailored to individual patient needs to facilitate transition to community settings post-discharge. Barriers to recovery were addressed through patient education, one-on-one guidance, and specialized referrals. Patient outcomes were assessed through in-app assessments and clinician-assessed modified Rankin Scores conducted via video consultation. Readmissions were monitored through both patient reporting and admission/discharge/transfer feeds from health information exchanges. Results A total of 111 patients were enrolled between June 22, 2022 and January 11, 2024. Patients were onboarded an average of 29 ± 40 days (median 18, IQR 8-32) after acute care hospital discharge and spent an average of 81 ± 21 days (median 90, IQR 75-90) in the program. During that time, the average enrollee spent 333 ± 156 minutes (median 350, IQR 205-435) of 1:1 time interacting with their dedicated navigator, and navigators spent an additional 113 ± 87 minutes (median 95, IQR 61-140) per patient on care coordination and curriculum curation. Patients with 5 or more social determinants of health (SDOH) needs required over 50% more navigator time than those without any SDOH needs. Within 6 weeks of hospital discharge, 8.5% experienced an inpatient hospital all-cause readmission that was not associated with race, ethnicity, or SDOH. Conclusions High rates of enrollment and extensive patient engagement in both navigator-facilitated and self-directed program elements can be achieved using the Kandu program. Our findings indicate that telemedicine facilitated, app-supported PIN is feasible to deliver following acute stroke discharge across diverse ages, races, ethnicities, functional status (mRS), and social needs.

Utilizing social determinants of health to identify most vulnerable neighborhoods–Latent class analysis and GIS map

ObjectivesPublic Health officials are often challenged to effectively allocate limited resources. Social determinants of health (SDOH) may cluster in areas to cause unique profiles related to various adverse life events. The authors use the framework of unintended teen pregnancies to illustrate how to identify the most vulnerable neighborhoods. MethodsThis study used data from the U.S. American Community Survey, Princeton Eviction Lab, and Connecticut Office of Vital Records. Census tracts are small statistical subdivisions of a county. Latent class analysis (LCA) was employed to separate the 832 Connecticut census tracts into four distinct latent classes based on SDOH, and GIS mapping was utilized to visualize the distribution of the most vulnerable neighborhoods. GEE Poisson regression model was used to assess whether latent classes were related to the outcome. Data were analyzed in May 2021. ResultsLCA's results showed that class 1 (non-minority non-disadvantaged tracts) had the least diversity and lowest poverty of the four classes. Compared to class 1, class 2 (minority non-disadvantaged tracts) had more households with no health insurance and with single parents; and class 3 (non-minority disadvantaged tracts) had more households with no vehicle available, that had moved from another place in the past year, were low income, and living in renter-occupied housing. Class 4 (minority disadvantaged tracts) had the lowest socioeconomic characteristics. ConclusionsLCA can identify unique profiles for neighborhoods vulnerable to adverse events, setting up the potential for differential intervention strategies for communities with varying risk profiles. Our approach may be generalizable to other areas or other programs. Key messagesWhat is already known on this topicPublic health practitioners struggle to develop interventions that are universally effective. The teen birth rates vary tremendously by race and ethnicity. Unplanned teen pregnancy rates are related to multiple social determinants and behaviors. Latent class analysis has been applied successfully to address public health problems.What this study addsWhile it is the pregnancy that is not planned rather than the birth, access to pregnancy intention data is not available resulting in a dependency on teen birth data for developing public health strategies. Using teen birth rates to identify at-risk neighborhoods will not directly represent the teens at risk for pregnancy but rather those who delivered a live birth. Since teen birth rates often fluctuate due to small numbers, especially for small neighborhoods, LCA may avoid some of the limitations associated with direct rate comparisons. The authors illustrate how practitioners can use publicly available SDOH from the Census Bureau to identify distinct SDOH profiles for teen births at the census tract level.How this study might affect research, practice or policyThese profiles of classes that are at heightened risk potentially can be used to tailor intervention plans for reducing unintended teen pregnancy. The approach may be adapted to other programs and other states to prioritize the allocation of limited resources.