Introduction: Social determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts. Methods: Varied qualitative inquiry methods – in-depth interviews, participant-led neighborhood tours, and clinic visit observations – involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco's public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM). Results: Several key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients' self-management. Health service providers leveraged these resources to address patients' social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated. Conclusion: The results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress.

中文翻译：

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社区组织在改善安全网人群长期护理方面的作用

简介：健康的社会决定因素 (SDoH) 会影响健康结果并导致弱势群体慢性病的差异。为了告知卫生系统战略以解决 SDoH，我们进行了一项多方利益相关者定性研究，以捕捉对生活在社会经济贫困环境中的人们的健康的多层次影响。方法：多种定性调查方法——深度访谈、参与者主导的社区参观和门诊观察——共涉及 23 名参与者（10 名旧金山慢性病高发社区的慢性病患者，10 名服务于社区的社区领袖相同的社区，以及来自旧金山公共医疗服务系统的 3 家提供者）。定性分析由慢性护理模型 (CCM) 指导。结果：这项研究出现了几个关键主题。首先，我们列举了大量的社区资源，例如食品分发处、公园/绿地，以及与患者自我管理相互作用的经济援助服务。卫生服务提供者利用这些资源来满足患者的社会需求，但明确表示需要扩大这项工作。其次，分析揭示了基于社区的组织 (CBO) 提供和浏览许多邻里卫生资源（包括社会支持和文化一致性知识）的多种基本机制。最后，阐明了制度性种族主义、交通和住房不平等等结构性问题如何与健康和社会服务交付交织在一起的许多例子。结论：结果为 CCM 的社区领域提供了新的证据。医疗保健系统必须有意识地与 CBO 合作，以解决 SDoH 问题并改善用于慢性病护理管理的社区资源，并直接解决结构性问题以取得进展。