Interview Techniques
A successful CHA was performed on an overweight female (BMI=25.5) immigrant with hypertension and a history of migraines but otherwise healthy. Evidence-based interview strategies were employed to evaluate H.B.’s social determinants, including using open-ended questions, empathy, active listening, and summarization. The four techniques helped elicit useful details about the patient’s psychosocial context.
Open-ended questions were used to explore the client’s primary concerns. According to Hashim (2017), using unspecific phrases such as ‘tell me more about…’ prompts patients to express themselves freely, often revealing critical diagnostic data and evaluating the emotional burden and psychosocial effect of the disease. Empathy was expressed verbally through supportive utterances and nonverbally via respectful silence and emphatic facial cues. The goal was to show understanding and relate to H.B.’s psychosocial experience. The active listening method was used to foster open communication about her social risk factors. Head nodding, eye contact, and tactful silent pauses were used to achieve this goal (Hashim, 2017). Finally, the summarization technique was utilized to validate the information given by the patient.
Justification of Key Questions
Social risk factors impact the health of a patient and must be addressed to ensure health equity. Therefore, it is important to look beyond physical health to understand other nonmedical variables that influence the health outcomes of individuals or communities. The five social determinants assessed included “socioeconomic status, education, employment, neighborhood, and physical environment, and social support networks” (Daniel et al., 2018, p. 577). Open-ended questions were used to elicit relevant responses from H.B. To determine her socioeconomic status, she was asked about total personal/family earnings, household size, and wealth and assets. These questions were critical in assessing H.B.’s access to care. Her total annual income was below $5,000 and she lived with an unemployed spouse and two teenage children.
Questions on her education included her highest level of academic attainment and language proficiency to assess her health literacy and self-care capacity. H.B. revealed that she has an associate degree but being a recent immigrant she had difficulty communicating in English. Thus, interpretation services may be required to bolster her health literacy. Information about her employment status was also sought. The questions asked focused on current and recent jobs, hours spent working daily, workplace conditions, sick leave, and health coverage. H.B. admitted to working as a part-time store attendant for twelve-hour daily shifts, five days a week. Further, she denies previous exposure to on-the-job injuries, implying safety in the workplace. The patient is not entitled to sick leave and has limited coverage due to her immigrant status.
The neighborhood and physical environment component contained questions on living conditions, including the size of the house, access to clean water, and sports/exercise facilities available. The rationale was to determine the resources that can help promote healthy living. H.B. revealed living in a small rented apartment with her family in a low-income neighborhood with limited access to clean water, parks, and social amenities but a high concentration of fast food outlets. The questions on social support networks centered on family composition and church fellowships. The goal was to identify psychosocial resources available to her.
Responses to Key Questions
H.B.’s responses during the interview indicate that she is struggling with social challenges related to neighborhood socioeconomic disadvantage, language, and health coverage. An appropriate care plan for her will include broader interventions to promote access to fresh produce, clean water, and recreational facilities – parks or gyms. These approaches will ensure optimal nutrition and physical activity to manage her hypertension and overweight condition. A social diagnosis is often followed by referrals to the available support resources (Andermann, 2016). The patient will be referred to physical trainers and nutritionists to help her manage chronic conditions. Contacting housing agencies, safety-net institutions, English literacy programs, and psychosocial support systems in the community on behalf of the client is another intervention that will be included in the care plan.
Economic Stability
Socioeconomic Status
Social determinants contribute to health inequities and limited access to healthcare. H.B. has poor health outcomes – hypertension, overweight condition, and migraines – due to modifiable social and economic factors. She lives in a poor neighborhood that lacks clean running water, healthy food options, and parks. Further, her low income means that she struggles to support her family. Therefore, the patient’s socioeconomic disadvantage limits her access to integrated clinical care, including nutritional support by a dietician and medications, constraining healthful behaviors.
Employment Status
H.B. works part-time and does not have full health insurance cover. The long work hours and absence of sick leave make seeing a doctor difficult. Additionally, her limited health coverage means that she cannot access anti-hypertensive agents and manage the overweight condition.
Housing Instability
This measure denotes the inability to pay rent or live in crowded spaces. Housing instability is associated with poor health outcomes and high rates of morbidity, emergency department (ED) use, and readmissions (Jessup et al., 2017)). H.B. lives in a small rented apartment with her family – a spouse and two children. These conditions are bound to cause poor access to specialist care. She may use her income to pay rent and delay needed medical care and medications, leading to late diagnosis and care.
Educational Status
Education is a critical social determinant of health. Highly educated people tend to exhibit optimal use of medical services due to superior levels of health literacy, which denotes the challenges a person may experience when navigating through the health system (Jansen et al., 2018). H.B. has an associate degree, post-secondary educational attainment. Therefore, she has fundamental skills in reading and numeracy to seek and understand health information. However, the patient’s rudimentary English language proficiency may limit her capacity to appraise and use medical resources and make healthier life choices.
Individuals with chronic illnesses are expected to learn self-care strategies for better health outcomes. H.B. suffers from hypertension and is overweight. Her access and use of information on diet, exercise regimens, and pharmacological treatments would lead to a lower BMI, well-managed hypertension, and lower ED utilization. However, H.B.’s health literacy may be constrained by her low English language proficiency. According to Jansen et al. (2018), appraisal of medical information, patient engagement of nurses and doctors, and the ability to find your way through a healthcare system are associated with high primary care utilization. Thus, given that the patient interviewed has low functional literacy, she may not adequately seek out accessible primary care services and engage with providers across the healthcare continuum.
Healthcare Barriers and Opportunities
Education is related to optimal health outcomes that are linked to income, psychosocial benefits, and healthier behaviors. H.B.’s highest educational attainment is an associate degree from a foreign university. Therefore, she may not have been exposed to comprehensive school-based health programs like those in the US. One health barrier she is likely to face because of her educational status is poor nutrition resulting from a lack of appropriate knowledge on healthy diets and lifestyle behaviors (van der Heide et al., 2015). She will also encounter difficulties engaging health providers to address the risk factors due to poor language skills. However, H.B.’s educational status presents unique healthcare opportunities for favorable outcomes. First, being college-educated, she can understand basic health information. Thus, she can follow physical activity recommendations, which is a self-management opportunity to lose weight. Second, H.B.’s higher educational status will enhance her compliance with dietary guidelines on daily fruit/vegetable servings and sugar intake to achieve a lower BMI and manage hypertension.
Effect of Health on Quality of Life
H.B. is a hypertensive patient and has been diagnosed as overweight. Hypertension is a chronic condition that leads to a low quality of life (QoL) due to a high morbidity rate (Zhang et al., 2017). H.B. is likely to experience pain or discomfort, anxiety, and depression linked to complications that require regular hospitalization. Her lower physical capacity due to the overweight condition will affect mobility, self-management, self-esteem, and performance of activities of daily living (ADL) with negative impacts on QoL. H.B.’s hypertension and overweight condition may strain her family, which could cause more anxiety and stress. She is currently experiencing persistent migraines. Such mental problems would negatively affect her quality of life as well as that of family members.
Poor QoL scores may also result from lower incomes. Being hypertensive and overweight, H.B. has complex healthcare needs but her financial ability to pay for specialist care is limited. Limited health utilization increases the risk of developing life-threatening complications such as angina, nephropathy, and stroke (Zhang et al., 2017). These conditions would lead to poor ADL outcomes and physical pain, resulting in an even lower quality of life.
Health Literacy
Patients with chronic conditions are required to acquire self-care skills to manage their illnesses effectively. This kind of health literacy comprises a functional component and the capacity to act with respect to individual health and lifestyle (Rademakers & Heijmans, 2018). The critical competencies required include the capacity to access, comprehend, appraise, and apply health information to prevent or manage an illness. Therefore, health literacy goes beyond the functional dimension – basic communication or social skills – to include cognitive abilities (comprehension), behavioral characteristics (searching and using information), and self-regulation.
Both functional and behavioral attributes contribute to patient involvement in interventions that promote self-management. Health literacy is associated with optimal use of clinical services, positive experiences with care, and better self-care outcomes (Rademakers & Heijmans, 2018). It also builds individual confidence to adopt lifestyle changes, such as healthy eating and exercising. Medication adherence and utilization of professional care would be high in health-literate patients compared to those with cognitive and functional deficits. They are also likely to self-manage chronic conditions, reducing the burden on the healthcare systems, family, and friends.
Neighborhood and Environmental Impacts
Geographic differences in access to care cause poor outcomes for low-income groups. H.B.’s low-income neighborhood of residence is characterized by limited local health care supply. Thus, the adult to provider ratio is high, which may reduce her access to quality, timely care for hypertension. H.B.’s outpatient service use may be low due to limited private physician offices or clinics, leading to frequent preventable hospitalizations for her condition. Residents of poor neighborhoods depend on public transportation, which is often underdeveloped in these areas. Ryvicker and Sridharan (2018) found a link between heavy use of mass transit omnibus and high rates of missed E&M visits Therefore, H.B.’s timely healthcare use may be hindered by transport service unreliability.
Neighborhood environmental characteristics influence healthy behaviors among the residents, including nutrition and exercise. H.B.’s living environment lacks parks and walkways that would promote walkability and physical activity. People living in walkable environments – sidewalks and footpaths – are physically active, and therefore, cardiorespiratory fit (Ryvicker & Sridharan, 2018). Limited fresh produce and a high concentration of fast-food outlets in H.B.’s neighborhood affect her access to healthy food options, increasing the risk of obesity and chronic disease. Further, community nutritional programs and resources to support weight loss and dietary change are fewer in low-income environments. Therefore, H.B. may not access adequate integrated community-level services, including nutrition education, to achieve weight loss and manage her hypertension.
Healthcare Received in Low- and High-income Areas
Quality
Socioeconomic disparities lead to differences in the quality of care provided. A patient in a high-income area is likely to afford high-quality specialist care compared to an individual in a low-income place. Additionally, the supply of trained physicians and healthcare resources is often higher in upper-class regions than in poor neighborhoods. Research evidence indicates that people with low academic attainment, from low-income regions, and minorities receive low-quality care (Nguyen et al., 2019). A person from a high-income area is likely to be highly educated and working in a job with full insurance coverage and favorable sick-leave policies that guarantees him or her better quality healthcare. However, there are some similarities in healthcare quality between high- and low-income areas. First, physicians providing care in both settings undergo similar training and licensure procedures before being allowed to practice. Second, FDA-approved drugs and standard clinical guidelines are used to care delivery in low- and high-income areas.
Access
Wide geographical disparities exist in the structural aspects of the healthcare system. Healthcare accessibility is higher in provider-dense locations, which are often inhabited by affluent individuals. These areas also benefit from targeted community interventions aimed at reducing the risk of chronic disease. On the other hand, people in poor neighborhoods are likely to be unemployed or underemployed, and therefore, uninsured, limiting their access to healthcare. However, since the Affordable Care Act was adopted to address cost concerns, healthcare disparities are decreasing. Thus, both high- and low-income people are now likely to have similar access to medical care. Another similarity in healthcare between these two groups relates to nutritional health. The Supplemental Nutrition Assistant Program has ensured that low-income households access food of excellent quality like that consumed by affluent individuals.
Outcomes
Regional variations in healthcare access contribute to disparate outcomes for people from high-income and low-income areas. Neighborhood socioeconomic status is a critical determinant of health. Poverty is associated with adverse outcomes, including depressive disorders, cardiovascular risk, and mortality (Ryvicker & Sridharan, 2018). Additionally, the lack of parks, walkways, and healthier food choices in these regions may increase the risk of obesity and chronic disease. However, both high- and low-income populations have similar preventive care outcomes. Coordinated, team-based care is implemented across the country to cut costs and promote prevention and self-management.
Rural versus Urban Healthcare Access
Provider supply is likely to be higher in cities than in the countryside. According to Nguyen et al. (2019), rural populations struggle to access essential medical services compared to urban dwellers due to limited healthcare resource availability. People in the countryside face greater difficulties in attracting providers and the few that work there complain of heavy workloads and low pay compared to physicians in urban regions. Therefore, weak local delivery systems and a shortage of medical personnel are the key barriers to healthcare access by disadvantaged rural populations despite the presence of safety nets and Medicaid expansion.
Neighborhood Healthy Food Options
Socioeconomic disadvantages may constrain access to better nutrition. H.B. lives in a low-income neighborhood characterized by many fast-food outlets but fewer supermarkets. Low-income places have a higher concentration of small markets that usually carry food of low nutritional quality than chain grocery stores (Penney et al., 2015). Therefore, nutritious food, including fruits and vegetables, to support healthier dietary practices is unavailable to H.B., increasing her risk of chronic disease – hypertension and obesity. Affordability is another barrier to healthy eating patterns. H.B.’s low socioeconomic status means that she cannot afford healthier fresh produce, which is often more expensive than low nutrient density food.
Discussion of Social Determinants
Addressing the social determinants in a CHA is one that health disparities can be reduced. From the assessment, H.B. experiences unequal access to health services due to her low socioeconomic status, language skills, and neighborhood factors. Implementing supportive interventions that address environmental, work-related, and nutritional aspects can promote access to quality healthcare (Daniel et al., 2018). H.B.’s health is affected by multiple social determinants, which must be tackled through referral to various organizations and advocacy for better outcomes. Addressing these factors can improve patient health and achieve modifiable behavior changes.
Identification of Social Determinants
Identifying and addressing social factors can help alleviate adverse health outcomes. The three high-priority social determinants affecting H.B. are socioeconomic, the living environment, and access to quality food. These factors can be linked to her poor health outcomes – hypertension, overweight, and migraines.
Patient Plan of Care
Integrating the social concerns into nursing care will result in better health outcomes for H.B. Three approaches to address each social determinant identified above will be used in this plan, namely, referring H.B. to social support services, facilitating her access to integrated care, and advocating for better housing conditions. H.B. will be linked to employment agencies to help her secure a full-time job with full health insurance coverage and mortgage facilities. The next action is referring H.B. to a local clinic with integrated weight management or nutritional support programs. Advocating for better access benefits, such as low-cost houses, parks, and walkaways at the community level, will reduce the environmental or neighborhood effects on H.B.’s health (Morone, 2017). Counseling services and referrals to local social support systems will also help build resilience.
Plan Implementation
Tackling the social causes of poor health through the nursing plan developed will involve three steps. First, to address H.B.’s socioeconomic problems, she will be referred to social work services, resources, and employment agencies that support disadvantaged groups. The goal is to improve her economic status and capacity to support her family. The second step will focus on modifying the physical environment by linking H.B. to a trainer and nutritionist to help her manage chronic conditions. Third, through partnerships with community growers and store owners, greenhouses and groceries will be established to supply fresh nutritious food at low costs to the neighborhood.
Implementation Barriers
Some key constraints in implementing the nursing plan of care are anticipated. In the case of the first social determinant (socioeconomic status), H.B.’s immigrant condition and low language skills may limit access to better jobs with benefits. Barriers to improving the living environment may include financial constraints and a lack of support from local housing agencies. Additionally, the local leadership may not be receptive to the idea of increasing walkways and parks. The high density of fast-food outlets and the absence of grocery stores are some of the constraints to ensuring H.B. receives nutritious food.
Individuals Involved in Interventions
Implementing the specific components of the nursing plan of care will require different parties. The domain of socioeconomic status will require collaboration among local employers, charitable individuals, and social workers. Through this partnership, interventions will be created to uplift H.B.’s household income and economic status. Concerning the living environment, three individuals will be involved: housing providers, local planners, and healthcare practitioners. On the other hand, addressing food instability will require collaboration among the patient, nutritionists, and store owners.
Plan Effectiveness
The outcomes of the nursing plan of care will indicate its efficacy. Jones (2016) recommends using value-based purchasing measures of the experience of care, process metrics, patient outcomes, and efficiency to assess and improve interventions. H.B.’s overall rating of steps taken to address her socioeconomic status, environment, and nutrition will indicate the plan’s effectiveness. Her access to integrated care – nutritional support and exercise – in the community will be a critical process measure.
Impact of Social Determinants
Failure to address the social challenges that H.B. is facing will predispose her to poor health outcomes. Specifically, H.B.’s income level, coverage status, housing, and neighborhood are likely to affect her wellbeing. H.B.’s low socioeconomic status will limit her ability to afford healthier food options to meet the dietary recommendations for losing weight and managing hypertension. Inadequate nutritional support is a negative social determinant (Heijmans et al., 2015). Additionally, H.B. is underinsured, and thus, cannot access costly bariatric surgery to treat morbid obesity or prescriptive drugs for high blood pressure. Inadequate housing also impacts her health negatively. It inhibits her capacity to work out, meditate, or worship, affecting her quality-of-life outcomes. Neighborhoods’ effects on H.B.’s health come from a congested living environment with limited water supply to the houses, a lack of parks, and the presence of unhealthy food outlets. She is exposed to environmental hazards, such as dust and lead, which increase the risk of respiratory problems and hypertension.
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