Kim Nguyen, ScD, MPH; Jessica Fields, BA; Anupama G Cemballi, MA; Riya Desai, MPH; Anjali Gopalan, MD, MS; Tessa Cruz, BA; Aekta Shah, PhD; Antwi Akom, PhD; William Brown, PhD, DrPH; Urmimala Sarkar, MD, MPH; Courtney Rees Lyles, PhD
Corresponding Author: Kim Nguyen, ScD, MPH; University of California, San Francisco. Email: kim.nguyen2@ucsf.edu
Section: Original Research
Publication Date: July 23, 2021
Introduction: Social determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts. Methods: Varied qualitative inquiry methods – in-depth interviews, participant-led neighborhood tours, and clinic visit observations – involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco’s public healthcare delivery system). Qualitative analyses was guided by the Chronic Care Model (CCM). Results: A number of key themes emerged: First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services, that interact with patients’ self-management. Health service providers leveraged these resources to address patients’ social needs, but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated amongst many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated. Conclusion: The results contribute new evidence towards the community domain of the CCM. Healthcare systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues in order to make progress.