What are the key considerations for developing a health promotion plan addressing Social Determinants of Health (SDOH) in a low-income community?

Developing Health Promotion Plans for Low-Income Communities: A Framework for SDOH Case Study Analysis

Priority Population Focus

Your priority population should be defined by the specific SDOH domain most prominently affecting health outcomes in your case study, with particular attention to those facing multiple intersecting disadvantages. When analyzing your case study, identify whether economic instability, education access, healthcare access, neighborhood environment, or social/community context represents the primary barrier to health 1. The American Diabetes Association emphasizes that SDOH are responsible for major health inequalities worldwide, yet remain consistently unrecognized in clinical encounters 2.

Identifying Your Population

• Screen systematically for SDOH using validated tools during your case analysis—the Accountable Health Communities' 10-item screening tool assesses housing instability, food insecurity, transportation needs, utility needs, and interpersonal safety 1.
• Recognize intersectionality: racial, ethnic, and ancestral groups are not monoliths but aggregates of diverse individuals with intersecting identities including class, gender identity, educational attainment, occupation, and residential neighborhood 1.
• Avoid population-level generalizations: within SES categories, individual differences significantly modify risk, so your priority population must account for these nuances 1.

Three Critical Health Risk Factors Related to SDOH

1. Food Insecurity

• Affects one-fifth of adults with diabetes and over 18% of the general U.S. population, with higher rates in racial/ethnic minorities, low-income households, and single-mother homes 2.
• Increases diabetes risk twofold and associates with lower engagement in self-care behaviors, medication non-adherence, depression, diabetes distress, and worse glycemic management 2.
• Screen using the validated two-item tool: "Within the past 12 months, we worried whether our food would run out before we got money to buy more" and "Within the past 12 months the food we bought just didn't last, and we didn't have money to get more" (sensitivity 97%, specificity 83%) 2.

2. Cost-Related Medication Non-Adherence

• Two-thirds of patients with chronic illness who don't take medications due to cost never share this with their physician 1.
• Up to 25% of patients prescribed insulin report cost-related insulin underuse, directly impacting glycemic control and increasing morbidity 2.
• Creates bidirectional health deterioration: financial barriers lead to medication non-adherence, which worsens health outcomes, which further strains financial resources 3.

3. Transportation and Healthcare Access Barriers

• Transportation barriers among low-income and elderly populations result in delayed or missed care and worsening health outcomes 3.
• Publicly insured and low SES patients experience higher rates of adverse events, suboptimal treatment, and poorer clinical outcomes 3.
• One-third of patients hospitalized with heart failure are unemployed 12 months later, demonstrating how health conditions perpetuate socioeconomic disadvantage 1.

Health Promotion Theory/Model Application

For addressing chronic disease management in low-income populations, apply the Social Ecological Model with intensive cultural tailoring at multiple intervention levels. This model addresses the complex interplay between individual, interpersonal, organizational, community, and policy factors 4.

Why This Model Works

• The Social Ecological Model recognizes that low-income populations face hazards in both workplaces and communities, requiring integrated approaches that address combined health hazards 4.
• Evidence demonstrates that effective telehealth interventions addressing SDOH must target key social determinants at the root of entrenched health behaviors in systematic ways across multiple levels 2.
• Cultural tailoring is essential: interventions must be extensively culturally tailored during initial planning and ongoing basis to ensure cultural congruence based on norms, attitudes, behavioral preferences, and cultural values of the population served 2.

Practical Application Framework

• Individual level: Provide culturally sensitive disease education, teach self-management skills, and address health literacy barriers 2.
• Interpersonal level: Engage family members, utilize peer support, and organize initiatives within existing social groups 5.
• Organizational level: Partner with trusted intermediaries including community health workers, faith-based organizations, and schools 2.
• Community level: Build partnerships between health systems and community-based organizations to offer social services and education 2.
• Policy level: Advocate for insurance coverage expansion and reimbursement for specialty care and treatments 2.

Three Population-Level Health Promotion Strategies

1. Community-Based Partnerships Through Trusted Intermediaries

Partner with faith-based organizations, schools, and community health workers to deliver culturally tailored interventions in familiar settings. The Journal of the American College of Cardiology demonstrates that church-based positive psychological interventions for Hispanic/Latino adults with cardiovascular risk factors achieved 97% participant satisfaction and large increases in happiness and emotional vitality 2.

• Deliver services through trusted intermediaries including community health workers, nurses, and faith-based organizations to improve access and coordination of care 2.
• Provide resources within local communities such as fresh food markets, smoking cessation programs, exercise and nutrition classes, and free support groups 2.
• Schools and faith-based organizations should partner with health care facilities to provide education and access to medical care in school settings through educational sessions, telemedicine visits, and community health worker medication administration 2.

Critical caveat: Dropout rates can be high due to logistical factors—address transportation, shifting work schedules, and childcare duties proactively 2.

2. Low-Cost Technology-Based Interventions

Implement text messaging and mobile health (mHealth) interventions using standard mobile phones, as 71% of households earning less than $30,000 own smartphones. Early evidence indicates text messaging represents one of the most effective low-cost technological strategies for engaging patients in behavior change 2.

• Leverage existing technological capacities accessible to low-income populations rather than requiring new technology adoption 2.
• Culturally tailor all mHealth interventions with intensive personalization during initial planning phases and ongoing adjustments 2.
• Ensure patient-guided confidential sharing of personal information with safeguards to protect privacy 2.

3. Systematic SDOH Screening and Referral Systems

Create systems-level mechanisms to screen for SDOH using validated tools during every clinical encounter, with direct linkage to community resources. The American Diabetes Association emphasizes that SDOH often go undiscussed in clinical encounters despite affecting two-thirds of medication adherence decisions 2.

• Screen for SDOH with a nonbiased approach and address findings in office visits, providing patient education about SDOH and clinical care resources 2.
• Compile an inventory of community resources to facilitate referrals at point of care, including social service resources like findhelp.org and 211.org 2.
• Provide health care forums for community members to express concerns and health care needs to inform providers, systems, payers, and legislators 2.

Health Literacy Considerations

Address health literacy by recognizing that lower health literacy correlates with lower educational attainment and poverty where people of color are overrepresented, creating knowledge gaps that directly impact disease management. The Journal of Allergy and Clinical Immunology reports that low health literacy populations are less likely to correctly identify disease signs and triggers 2.

Specific Health Literacy Strategies

• Provide culturally sensitive education on disease for patients, recognizing that cultural factors impact how patients participate in their own care and that perceptions of disease are shaped by cultural factors and social positions 2, 1.
• Communicate openly about needs and cultural differences, as 70% of physicians have implicit preference for whites over blacks, which affects medical decision-making, communication, and nonverbal behavior 2, 1.
• Deliver interventions in familiar settings where peer support is available, initiatives are organized within existing groups, external incentives are offered, and there are options regarding times and locations 5.
• Use teach-back methods and request that patients share challenges and barriers to care openly with health care providers 2.

Critical Implementation Points

• Avoid assumptions: knowledge of local community and its socio-environmental context alongside collaborative, facilitative, and tailored approach to delivery are required for successful engagement 5.
• Recognize that failure to communicate understanding of complex lifestyle influences to local residents adversely affects service engagement and contributes to negative attitudes toward health promotion 5.
• Measure intervention durability over time, as interventions should address the entire spectrum of health care treatment from prevention and primary care to specialty care, hospitalization, and post-discharge treatment 2.