Linking electronic health records and in-depth interviews to inform efforts to integrate social determinants of health into health care delivery: Protocol for a qualitative research study (Preprint)

BACKGROUND Health systems are attempting to capture social determinants of health (SDoH) in electronic health records (EHR) and use these data to adjust care plans. To date, however, methods for identifying social needs, which are the SDoH prioritized by patients, have been underexplored, and there is little guidance as to how clinicians should act on SDoH data when caring for patients. Moreover, the unintended consequences of collecting and responding to SDoH are poorly understood. OBJECTIVE The objective of this study is to use two data sources, EHR data and patient interviews, to describe divergences between the EHR and patient experiences that could help identify gaps in documentation of SDoH in the EHR; highlight potential missed opportunities for addressing social needs; and identify unintended consequences of efforts to integrate SDoH into clinical care. METHODS We are conducting a qualitative study that merges discrete and free-text data from EHRs with in-depth interviews with women residing in rural, socio-economically deprived communities in the Mid-Atlantic region of the United States. Participants had to confirm that they had at least one visit with the large health system that serves the region. Interviews with the women included questions regarding health, interaction with the health system, and social needs. Next, with consent, for each participant we extracted discrete data (e.g., diagnoses; medication orders) and free-text clinician notes from this health system’s EHRs between 1996 and the year of the interview. We used a standardized protocol to create an EHR narrative, a free-text summary of the EHR data. We used NVivo to identify themes in the interviews and the EHR narratives. RESULTS To date, we have interviewed 88 women, including 51 White women, 19 Black women, 14 Latina women, 2 mixed Black and Latina women, and 2 Asian Pacific women. We have completed the EHR narratives on 66 women. The women range in age from 18 to 90. We found corresponding EHR data on all but 4 of the interview participants. Participants had contact with a wide range of clinical departments (e.g., psychiatry, neurology, infectious disease) and received care in various clinical settings (e.g., primary care clinics, emergency departments, inpatient hospitalizations). A preliminary review of the EHR narratives revealed that the clinician notes were a source of data on a range of SDoH, but did not always reflect the social needs that participants described in the interviews. CONCLUSIONS This study will provide unique insight into the demands and consequences of integrating SDoH into clinical care. This work comes at a pivotal point in time, as health systems, payors, and policy makers accelerate attempts to deliver care within the context of social needs.

Prenatal ambient air pollution and maternal depression at 12 months postpartum in the MADRES pregnancy cohort

Background Depression is the leading cause of mental health-related morbidity and affects twice as many women as men. Hispanic/Latina women in the US have unique risk factors for depression and they have lower utilization of mental health care services. Identifying modifiable risk factors for maternal depression, such as ambient air pollution, is an urgent public health priority. We aimed to determine whether prenatal exposure to ambient air pollutants was associated with maternal depression at 12 months after childbirth. Methods One hundred eighty predominantly low-income Hispanic/Latina women participating in the ongoing MADRES cohort study in Los Angeles, CA were followed from early pregnancy through 12 months postpartum through a series of phone questionnaires and in-person study visits. Daily prenatal ambient pollutant estimates of nitrogen dioxide (NO2), ozone (O3), and particulate matter (PM10 and PM2.5) were assigned to participant residences using inverse-distance squared spatial interpolation from ambient monitoring data. Exposures were averaged for each trimester and across pregnancy. The primary outcome measure was maternal depression at 12 months postpartum, as reported on the 20-item Center for Epidemiologic Studies-Depression (CES-D) scale. We classified each participant as depressed (n = 29) or not depressed (n = 151) based on the suggested cutoff of 16 or above (possible scores range from 0 to 60) and fitted logistic regression models, adjusting for potential confounders. Results We found over a two-fold increased odds of depression at 12 months postpartum associated with second trimester NO2 exposure (OR = 2.63, 95% CI: 1.41–4.89) and pregnancy average NO2 (OR = 2.04, 95% CI: 1.13–3.69). Higher second trimester PM2.5 exposure also was associated with increased depression at 12 months postpartum (OR = 1.56, 95% CI: 1.01–2.42). The effect for second trimester PM10 was similar and was borderline significant (OR = 1.58, 95% CI: 0.97–2.56). Conclusions In a low-income cohort consisting of primarily Hispanic/Latina women in urban Los Angeles, we found that prenatal ambient air pollution, especially mid-pregnancy NO2 and PM2.5, increased the risk of depression at 12 months after childbirth. These results underscore the need to better understand the contribution of modifiable environmental risk factors during potentially critical exposure periods.

Nurse-led long-term support groups for Latina women survivors of intimate partner violence

Purpose The purpose of this article is to describe the development of a Nurse-led Long-term Support Group (NLLTSG) as an intervention for Latina women survivors of intimate partner violence (IPV) as well as to discuss a process for facilitation. Design/methodology/approach Yalom’s (2005) group therapy principles guided the creation of the NLLTSGs. According to Yolam, interaction with others and sharing stories reinforces connections within group members and leads to interpersonal learning (Yalom, 2005). Findings Latina women survivors of IPV do not have adequate support post IPV relationships. In this case study, the authors describe the process for developing and facilitating a NLLTSG for Latina women survivors. Research limitations/implications The case study intervention only included Latina women living in the US Texas–Mexico border. Questions remain regarding the effectiveness of LTNLSGs with women from other cultures and geographic regions. Practical implications Nurses, nurse practitioners and other professionals can partner with community service agencies to offer this vital intervention to support and empower Latina women survivors and their families. Implications for future research include theory development and quantitative studies to measure empowerment and healing in Latina women survivors of IPV. The intervention and process should expand to include women of other cultures and geographic region. Social implications The case study established a NLLTSG as an effective intervention for initiating and maintaining a NLLTSG with Latina women survivors of IPV as well. NLLTSGs seem to be an essential intervention for recovery in this vulnerable population. Originality/value The content of this paper describes an innovative, culturally sensitive, practitioner-engaged response to intimate partner violence in Latina women survivors.