Clinical intervention directed at social risks does not increase experiences of discrimination

A growing recognition of the health impact of social risks – such as food insecurity and homelessness – has prompted researchers, healthcare providers and policymakers to consider ways to address these risk factors as part of holistic clinical care. However, some healthcare providers worry the same interventions designed to help patients and families with social risks might also make them feel singled out or like they are otherwise stigmatized.

Now, new results of a rigorous study from the University of Chicago Medicine published October 2023 in JAMA Pediatrics suggest well-designed interventions that address social risks can be provided to parents of hospitalized children without increasing self-reported experiences of discrimination.

The researchers said they hope these new findings will have the potential to remove a roadblock that has been holding back the field of social care research.

“What encouraged us to conduct this study is the combination of data from other studies showing that addressing social risks in clinical care can improve health and wellness, and patients and their families are amenable to receiving these kinds of interventions. However, studies also find clinicians consistently express concerns about compromising satisfaction and engendering feelings of discrimination when addressing social risks in clinical practice,” said Nathaniel Glasser, MD, an internist, pediatrician and health researcher at UChicago Medicine and lead author of the paper.

In the study, caregivers of pediatric patients were randomized to receive either usual care or usual care plus CommunityRx: a low-intensity, universally-delivered program that involves providing personalized information about local resources that help address social risks, such as food insecurity or transportation difficulties. After children were discharged from inpatient units, their parents filled out standardized surveys designed to assess their satisfaction with medical care and whether or not they experienced discrimination of any kind, such as being treated with less courtesy than others, during their child’s most recent hospital stay.

The researchers were able to conclude that CommunityRx did not increase experiences of discrimination, although some caregivers did report experiencing at least one form of discrimination during a hospital visit.

The team emphasized that discrimination in healthcare settings is a pervasive and well-documented issue that must be addressed, but clarified that this particular study focused on addressing social risks with root causes that lie outside the clinical setting, but to do so without making families feel stigmatized.

“Our intervention was not specifically designed to reduce experiences of discrimination that might happen during a child’s hospitalization; it was designed to reduce social risks families had when their child was admitted to the hospital,” said senior author Jennifer Makelarski, PhD, an epidemiologist and researcher at UChicago. “We wanted to make sure we’re not causing harm – causing experiences of discrimination – by addressing social risks. With findings from this study, we are working toward an intervention that could do both.”

While parents in the study generally reported high satisfaction with medical care, the data didn’t offer a definitive conclusion about whether CommunityRx affected caregivers’ satisfaction with their experience during their child’s hospital discharge, leaving the door open for further investigation. In particular, Makelarski said an ongoing qualitative study will help researchers better understand the intricate factors contributing to satisfaction and whether or not discharge is the best time to address social risks.

Makelarski noted that policymakers have already begun responding to a growing awareness of the importance of assessing and addressing social risks. Programs such as Medicare have already begun implementing strategies to incorporate these priorities into patient care, but until now they have been doing so with very little information about potential negative impacts. Insights from the current study indicate these efforts can continue, as long as they are implemented with caution, sensitivity and careful design.

“As a researcher, I think our results are a good sign that we should keep working on interventions that address social risks during clinical care; we should keep testing different variations,” Makelarski said.

She emphasized the importance of including a wide range of collaborators in the development of these interventions, including patients and community members.

“From a clinician’s perspective, ad hoc requests for resources to address social risks come up multiple times a day, but it’s not something most clinicians are trained to provide,” added Glasser. “Our findings suggest a low-cost, highly scalable intervention can be made widely available to patients, and clinicians can have some assurance that it can be done in a way that won’t engender feelings of discrimination and stigma.”

The study, “CommunityRx-Hunger: A double-blind, randomized controlled trial examining noninferiority of a social care intervention on healthcare experiences,” was conducted with input from community advisors and published in JAMA Pediatrics in October 2023. Study co-authors include Stacy Tessler Lindau, Kristen Wroblewski, Emily M. Abramsohn, Deborah L. Burnet, Charles M. Fuller, Doriane C. Miller, Christine A. O’Malley, Eva Shiu and Elaine Waxman.