Bringing Cultural Competence to Social Determinants of Health Work

When a food security program in Dorchester, one of the boroughs of Boston, started offering up English muffins, it quickly became apparent those subsidized meals wouldn’t be fruitful. What was missing from that social determinants of health intervention was cultural competency, according to Samara Grossman, LICSW, one of the program’s leaders.

After all, Dorchester is home to a multicultural population, and the program was specifically catering to the community’s mostly Haitian immigrants, Grossman told the audience at Xtelligent Healthcare Media’s Social Determinants of Health Virtual Summit.

“Once we had identified the community we were going to work with, who was a majority Haitian immigrant community and culture, we were really able to understand that you can't just sort of throw English muffins in the box,” Grossman said. “Our other partner put English muffins in and they're like, ‘We don't eat English muffins,’ because we did an iterative feedback response. And it was like, ‘No, we actually wanted this other food.’ And so, we were able to address that, to shift.”

Social determinants of health programming, like food security or housing security interventions, have become common across the United States. As more healthcare professionals acknowledged the role that SDOH play in overall patient wellness—and, ultimately, clinical outcomes for value-based care—screening and referring for social needs like housing, food, and transportation has become important.

But as more organizations stand up interventions like the one operated by Grossman, who works at Brigham & Women’s Hospital in Boston, they will need to fine-tune the delivery.

This means recognizing that social determinants of health work is not one-size-fits-all, Karen Wilding, vice president and chief value officer at Nemours Children's Health. Nemours has successfully built an SDOH screening tool into its EHR, Wilding said during the panel discussion, but the organization has had to remain mindful that the process is not always preferable for every patient.

Depending on patient preferences and cultural norms, they might want to fill out an SDOH screening a different way, or not at all. It’s been crucial to respect patient dignity to accommodate those preferences.

“We've had a lot of lessons in engaging with patients and understanding how they want to be asked those questions,” Wilding explained. “What works for us in our EMR doesn't mean it's going to work for them. There are sometimes patients that we've received feedback from that they would prefer to have a piece of paper that they circle and check off and they do it in the privacy of their home and they bring it to us.”

Other patients want to fill out the screening tool in the patient portal as a part of patient pre-registration, while others would like to verbally complete a screening with their trusted clinician.

And even once the patient screens for social determinants, Wilding noted that the community health partnerships that organizations use to refer to social services must be varied.

“One-size-fits-all, it's really going to be an important process as we are expanding our community partnerships to meet the demands around social determinants of health, that there's a recognition of those unique needs,” Wilding said.

“The same thing is true with the community partners. So being able to have a blend of religious organizations, community organizations are so important, but also organizations that are local and in the community, and we know that is just so important.”

That level of cultural competence improves the odds a patient will stick with a certain intervention, said Stephen Brown, MSW, LCSW, the director of Preventive Emergency Medicine, senior director of Social and Behavioral Health Transformation and Advocacy, and director of the Better Health Through Housing at UI Health.

For example, UI Health’s Better Health Through Housing program, which leverages big data to identify individuals who might be housing insecure and connects them with stable housing, offers various housing environments. The program has some single-room occupancies, or SROs, in different neighborhoods within Chicago, and even in units that are primarily Spanish-speaking.

“It was from a lesson of housing a guy that lived in an encampment in a predominantly Spanish-speaking neighborhood, moving him to an SRO on the north side, and he lost his sense of community and he left,” Brown recalled. “And so, from that lesson learned, we decided we needed to think about languages spoken too.”

It also increases trust, Grossman added. In her food security program, which operated using some grant funding from the Robert Wood Johnson Foundation, she tapped high schoolers from the community and spoke the language to help operate food access.

“If you hear someone talking to you in your own language about a program that is meant to help you, you're much more likely to want to try it out,” she concluded. “And trustworthiness and transparency are really relevant for social determinants of health in general, because again, that top-down bottom-up issue. If we can build that trustworthiness and transparency by having people speak the same language or we can build it by providing food that makes sense for people.”