Addressing Social Determinants of Health for Dual-Use Veterans

An estimated 40% of Veterans are eligible for community care. Veterans who access care both outside of the Veterans Health Administration (VA) and at the VA are at risk for fragmented care and adverse outcomes. These dual-use Veterans often do not receive necessary follow-up care or linkage to resources addressing social determinants of health (SDOH) post–non-VA emergency department (ED) visits. We created a social worker–led advanced care coordination (ACC) program to reduce fragmented care, enhance care coordination, and provide longitudinal case management to address SDOH for dual users who access non-VA EDs. ACC collaborated with internal and external stakeholders (ie, clinicians and staff) to enhance care and address SDOH for dual users. The ACC social worker had regular contact with stakeholders through phone calls, emails, and in-services to enhance relationships and program buy-in. Stakeholders asked each patient if they were a Veteran and informed ACC of the Veteran’s non-VA ED visit. Postdischarge, the ACC social worker called the Veteran to complete a comprehensive assessment identifying SDOH needs. The ACC social worker provided case management via phone calls and home visits to the Veteran up to 90 days addressing SDOH needs and reconnected the Veterans to their primary care team through electronic closed-loop communication. We analyzed VA claim data postimplementation to compare intervention participants with nonparticipants. Using propensity score, Veterans were matched 3 to 1 on age, gender, comorbidities, and number of hospitalization and primary care physician (PCP) visits in the past year. Dual-use Veterans who accessed non-VA EDs in Denver, Colorado, and Omaha, Nebraska, metro areas. Veterans had to be eligible to receive care through the VA. When compared to a matched control group, Veterans who received the ACC intervention had significantly lower rates in readmission to the ED within 30 days of ED discharge (16.1% vs. 30.5%, P < 0.01). ACC connected Veterans to services addressing SDOH they may not have otherwise accessed due to lack of knowledge and resources. Using our program database to evaluate Veterans enrolled in ACC since April 2018, we found they were connected to: (1) VA PCP appointments (82%), (2) VA benefits including enrollment (33%), (3) home health care (21%), (4) financial assistance (ie, food benefits, rental and utility assistance, disability benefits, 18%), (5) homeless resources including housing vouchers and shelters (9%), (6) mental health treatment (9%) and transportation assistance (9%), and (7) substance use treatment (4%). Dual-use Veterans often fall through the cracks after receiving non-VA care. ACC addressed gaps in transitions by connecting Veterans to resources addressing SDOH needs and linking Veterans back to their VA primary care teams. Gaps in care will continue as Veterans increasingly access non-VA care. ACC bridged these gaps by enhancing relationships and communication between VA and non-VA providers. ACC addressed Veteran’s SDOH by connecting them to resources post–non-VA ED discharge. Programs similar to ACC should be implemented across health care systems to assist dual-use Veterans with SDOH needs and increase linkage to resources. The study was funded by QUERI.     

Detecting the Determinants of Health in Social Media

Objective

Create an analysis pipeline that can detect the behavioral determinants of disease in the population using social media data.

Introduction

The explosive use of social media sites presents a unique opportunity for developing alternative methods for understanding the health of the public. The near ubiquity of smartphones has further increased the volume and resolution of data that is shared through these sites. The emerging field of digital epidemiology[1] has focused on methods to analyze and use this “digital exhaust” to augment traditional epidemiologic methods. When applied to the task of disease detection they often detect outbreaks 1–2 weeks earlier than their traditional counterpart [1]. Many of these approaches successfully employ data mining techniques to detect symptoms associated with influenza-like illness [2]. Others can identify the appearance of novel symptom patterns, allowing the ability to detect the emergence of a new illness in a population [3]. However, behaviors that lead to increased risk for disease have not yet received this treatment.

Methods

We have created a methodology that can detect the behavioral determinants of disease in the population. Initially we have focused on risky behaviors that can contribute to HIV transmission in a population, however, the methodology is generalizable.We collected 15 million tweets based on 32 broad keywords relating to three types of risky behaviors associated with the transmission of HIV: drug use (e.g. meth), risky sexual behaviors (e.g. bareback), and other STIs (e.g. herpes). We then hand coded a subset of 2,537 unique tweets using a crowd-sourceable “game” that can be distributed online. This hand-coded set was used to train a simple n-gram classifier, which resulted in an algorithm to select relevant tweets from the larger database. We then generated geocodes from text locations provided by the tweet author, supplemented by the ∼1% of tweets that are already geolocated. We scaled these geocodes to the state and county levels, which allowed us to compare HIV prevalence in our collected data with public health data.

Results

We present the correlation between behaviors identified in social media and the corresponding impacts on disease incidence across a large population. Hand coding revealed that 34% of tweets with one or more of the 32 initial keywords was relevant to behaviors associated with HIV transmission. Among the three categories of initial search terms, the drug category yielded 21% true positives, compared to 9% for risky behaviors, and 2% for other STIs. The n-gram classifier measured 66% sensitivity and 44% specificity on a test set. In addition, our geolocation algorithm found coordinates for 88% of text locations. Of those, a test sample of 59 text locations showed that 83% of geolocations are correctly identified. These components combine to form an analysis pipeline for detecting risky behaviors across the United States.

Conclusions

We present a surveillance methodology to help sift through the vast volumes of these data to detect behaviors and determinants of health contributing to both disease transmission and chronic illness. This effort allows for identification of at-risk communities and populations, which will facilitate targeted, primary and secondary-prevention efforts to improve public health.     

Integrated Approaches to Address the Social Determinants of Health for Reducing Health Inequity

The social and physical environments have long since been recognized as important determinants of health. People in urban settings are exposed to a variety of health hazards that are interconnected with their health effects. The Millennium Development Goals (MDGs) have underlined the multidimensional nature of poverty and the connections between health and social conditions and present an opportunity to move beyond narrow sectoral interventions and to develop comprehensive social responses and participatory processes that address the root causes of health inequity. Considering the complexity and magnitude of health, poverty, and environmental issues in cities, it is clear that improvements in health and health equity demand not only changes in the physical and social environment of cities, but also an integrated approach that takes into account the wider socioeconomic and contextual factors affecting health. Integrated or multilevel approaches should address not only the immediate, but also the underlying and particularly the fundamental causes at societal level of related health issues. The political and legal organization of the policy-making process has been identified as a major determinant of urban and global health, as a result of the role it plays in creating possibilities for participation, empowerment, and its influence on the content of public policies and the distribution of scarce resources. This paper argues that it is essential to adopt a long-term multisectoral approach to address the social determinants of health in urban settings. For comprehensive approaches to address the social determinants of health effectively and at multiple levels, they need explicitly to tackle issues of participation, governance, and the politics of power, decision making, and empowerment.     

Equity and the Social Determinants of Health in European Cities

Equity in health has been the underlying value of the World Health Organization’s (WHO) Health for All policy for 30 years. This article examines how cities have translated this principle into action. Using information designed to help evaluate phase IV (2003–2008) of the WHO European Healthy Cities Network (WHO-EHCN) plus documentation from city programs and websites, an attempt is made to assess how far the concept of equity in health is understood, the political will to tackle the issue, and types of action taken. Results show that although cities continue to focus considerable support on vulnerable groups, rather than the full social gradient, most are now making the necessary shift towards more upstream policies to tackle determinants of health such as poverty, unemployment, education, housing, and the environment, without neglecting access to care. Although local level data reflecting inequalities in health is improving, there is still a long way to go in some cities. The Healthy Cities Project is becoming an integral part of structures for long-term planning and intersectoral action for health in cities, and Health Impact Assessment is gradually being developed. Participation in the WHO-EHCN appears to allow new members to leap-frog ahead established cities. However, this evaluation also exposes barriers to effective local policies and processes to reduce health inequalities. Armed with locally generated evidence of critical success factors, the WHO-EHCN has embarked on a more rigorous and determined effort to achieve the prerequisites for equity in health. More attention will be given to evaluating the effectiveness of action taken and to dealing not only with the most vulnerable but a greater part of the gradient in socioeconomic health inequalities.     

Social Determinants of the Health of Urban Populations: Methodologic Considerations

A full understanding of the role of the urban environment in shaping the health of populations requires consideration of different features of the urban environment that may influence population health. The social environment is key to understanding the way in which cities affect the health of populations. Social determinants of health (SDH) are important, generally, yet can have different effects in different settings from urban to rural, between countries, between cities, and within cities. Failure to acknowledge, and more importantly, to understand the role of SDH in health and access to health and social services will hamper any effort to improve the health of the population. In this paper, we will briefly summarize a few key SDH and their measurement. We will also consider methodologic tools and some methodologic challenges. The concepts presented here are broadly applicable to a variety of settings: developed and developing countries, slum areas, inner cities, middle income neighborhoods, and even higher income neighborhoods. However, our focus will be on some of the more vulnerable urban populations who are most profoundly affected by SDH.     

Oral Health of Foreign Domestic Workers: Exploring the Social Determinants

Foreign domestic helpers constitute a significant proportion of migrant workers worldwide. This population subgroup provides an opportunity for understanding social determinants of oral health in immigrant community. A random sample of 122 Indonesian domestic helpers in Hong Kong completed a questionnaire on their demographic background, social characteristics (competency in local languages, immigration history, living condition, social connections, and leisure activities) and oral health behaviours (knowledge, attitudes, practice and self-efficacy). Their tooth status and periodontal health were assessed. Participants tended to start flossing after settling in Hong Kong. Favourable oral health knowledge was found in more acculturated participants, as indicated by proficiency in local languages and immigration history. Engagement in social and/or religious activities and decent living condition provided by employers were associated with favourable oral health behaviours and/or better oral health. Social determinants explained 13.2 % of variance in caries severity. Our findings support the significant impact of social circumstances on oral health of domestic workers.     

Social Determinants and COVID-19 in a Community Health Center Cohort

Associations between social determinants of health (SDOH), demographic factors including preferred language, and SARS-CoV-2 detection are not clear. We conducted a retrospective cohort study among those seeking testing for SARS-CoV-2 at a multi-site, urban community health center. Logistic regression and exact matching methods were used to identify independent predictors of SARS-CoV-2 detection among demographic, SDOH, and neighborhood-level variables. Of 1,361 included individuals, SARS-CoV-2 was detected among 266 (19.5%). Logistic regression demonstrated that SARS-CoV-2 detection was less likely in White participants relative to Hispanic participants (adjusted odds ratio [aOR] 0.18, 95% confidence interval [CI] 0.05–0.46). and more likely in patients who prefer Spanish relative to those that prefer English (aOR 2.04, 95% CI 1.43–2.96). No observed SDOH predicted SARS-CoV-2 detection in adjusted models. A robustness analysis using a matched subset of the study sample produced findings similar to those in the main analysis. Preferring to receive care in Spanish is an independent predictor of SARS-CoV-2 detection in a community health center cohort.

     

A Community Health Worker Intervention to Address the Social Determinants of Health Through Policy Change

Public policy that seeks to achieve sustainable improvements in the social determinants of health, such as income, education, housing, food security and neighborhood conditions, can create positive and sustainable health effects. This paper describes preliminary results of Acción para la Salud, a public health intervention in which Community health workers (CHWs) from five health agencies engaged their community in the process of making positive systems and environmental changes. Academic-community partners trained Acción CHWs in community advocacy and provided ongoing technical assistance in developing strategic advocacy plans. The CHWs documented community advocacy activities through encounter forms in which they identified problems, formulated solutions, and described systems and policy change efforts. Strategy maps described the steps of the advocacy plans. Findings demonstrate that CHWs worked to initiate discussions about underlying social determinants and environment-related factors that impact health, and identified solutions to improve neighborhood conditions, create community opportunities, and increase access to services.