Barriers to Social Determinants of Health Screening and Low Socioeconomic Status Reinforce the Patient-provider Power Differential

Background: Social determinants of health (SDOH) screening has become more commonplace in healthcare as a means of providing resources and support to improve patient health. However, barriers to effective screening, heightened by low socioeconomic status (SES), lead to strained patient-provider relationships. This study aims to elucidate perspectives on SDOH screenings and how these, in relation to SES, can impact patient-provider relationships and provide suggestions for screening improvement.

Methods: This IRB-approved mixed methods study adopted an explanatory-sequential design. A representative sample of 244 postpartum women completed phone surveys for SDOH needs and a validated Provider Relationship scale. The relationship between these was analyzed using multiple correspondence analysis and linear regression. Twenty-three women were subsequently interviewed about their screening experiences and recommendations. Transcripts were broad coded using Atlasti and thematic analysis was completed using consensus approach.

Results: Survey participants clustered into three SDOH levels: Adequate (44.7%), On-the-edge (47.1%), Deep-poverty (8.2%). Statistical analysis revealed a stepwise relationship: the greater the SDOH risk, the worse the self-reported relationship with providers (-1.51 Beta coefficient, CI –2.31 & -0.703, p<.001), and greater provider support. In the focus groups, lower income women were 25% more likely to make negative comments regarding screening. Mothers were discouraged from seeking care for themselves and their children for fear of repercussions from SDOH screening results. Themes of stigma, vulnerability, fear of Child Protective Services, and the power differential between women and their providers emerged.

Conclusion: Barriers to effective SDOH screening, exacerbated by low SES, could be improved by building trust with providers, maintaining longitudinal care, increasing transparency, and improving follow-up. Successful patient-provider relationships can enhance effectiveness of SDOH screenings and lead to better outcomes for patients and their families.