Social determinants of health (SDH) contribute substantially to health outcomes and account for health disparities. Consequently, graduate medical education accreditation bodies have called for inclusion of social determinants of health (SDH) in medical training.1 Internal medicine (IM) physicians manage many health outcomes for which SDH have a significant impact, yet few residencies offer curricula on SDH.2

Home visits are conducive to experiential teaching of SDH; they allow insight into patients’ living conditions, social supports, and challenges living with illness and competing priorities.3 Through a home visit and reflection, residents can partake in transformative learning, where first-hand experience leads to professional identity-formation that is more enduring. Coupling home visits with neighborhood asset-mapping contextualizes patient care within the neighborhood environment and extends learning beyond individual patients.4,5 No IM program has evaluated the use of a combined home visit and neighborhood assessment of continuity clinic patients as a tool to teach SDH. We conducted a mixed-methods study to understand the impact of this curriculum on residents and identify barriers to implementation.

METHOD

All 48 second-year IM residents at the University of Pittsburgh participated in the curriculum during their ambulatory rotation, running consecutively from January to December 2018. The month-long curriculum consisted of a 1-h small-group introduction session including online resources for addressing SDH, guided virtual neighborhood assessment, half-day SDH focused neighborhood and home visit, and 1-h group debrief session.

We administered surveys prior to and immediately after the curriculum assessing residents’ attitudes and self-reported behaviors regarding SDH using a 5-point Likert-type scale, and demographics. The survey was developed de novo and piloted prior to administration. Mean pre- and post-intervention responses were compared using paired t-tests or McNemar tests (Stata v.16.0).

We conducted five, 1-h-long group interviews of 3 to 5 residents who participated in the group debrief from January to June 2018, using a semi-structured interview guide. Interviews were conducted by an independent facilitator, audio-recorded, and transcribed. We performed content and thematic analysis of transcripts through iterative inductive and deductive coding (Atlas.ti v.8.0). Consistency of themes emerging by our fifth group interview indicated thematic saturation was achieved. This study was approved by the University of Pittsburgh Quality Improvement Review Committee.

RESULTS

Forty-six residents completed the pre-intervention survey (95.8%) and 39 residents (85%) completed the post-intervention survey. Twenty-four (52%) were female; 30 (65%) self-identified as White, 11 (24%) as Hispanic, 3 (7%) as Asian, and 1 (2%) as Black; and 16 (35%) experienced a negative childhood SDH including financial, housing, or food insecurity. The curriculum improved attitudes on knowing and asking about patients’ neighborhood, and comfort asking about SDH (Table 1). Residents reported increases in incorporating SDH into plans, asking about and addressing SDH, and using online tools to identify neighborhood resources.

Table 1 Survey Results of Resident Attitudes and Self-reported Behavior
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Of 22 eligible residents, 19 participated in a group interview. Residents identified five major themes on the curriculum’s impact (Table 2). They suggested improvements in curriculum implementation, including adding more opportunities to conduct home and neighborhood visits, pairing residents, more explicit guidance asking patient permission for a home visit, and flexibility in scheduling visits.

Table 2 Qualitative Themes Related to Curriculum Impact
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DISCUSSION

Our curriculum improved resident comfort and frequency asking patients about their neighborhood, asking about and addressing SDH, and using online tools to identify neighborhood resources. Qualitative findings support prior research that home visits improve the patient-physician relationship and impact clinical management.6 Our findings also indicate that neighborhood and home visits can reduce bias by encouraging identification of SDH that positively impact health thereby challenging preconceived notions. They offer transferable skills when used for the teaching of SDH, such as identifying neighborhood resources and inquiring about neighborhood and SDH of other clinic patients. Understanding neighborhood context is key to community-centered clinician identity-formation.

Our study was conducted at a single institution with a small sample size, limiting generalizability. Behavioral outcomes were obtained via self-report, which are subject to recall or social desirability bias. Despite these limitations, this study represents the most robust curriculum evaluation of combined neighborhood and home visits in non-homebound patients for teaching SDH in IM residency. Future research includes identifying the patient perspective and exploring use of resources addressing SDH. Evaluation of this curriculum indicates that it has potential to positively impact residents’ attitudes and behaviors regarding SDH, provide transferable skills, and promote practice of community-oriented care, without increasing bias against marginalized populations.