What gets counted, counts: social risk factor screening among adults with disabilities - People with disabilities experience disparities in health outcomes, and it is likely that social risk factors contribute. Addressing social risk factors, or the specific, patient-level expressions of adverse social conditions, is increasingly recognized by healthcare systems as a leading method for reducing health disparities. Examples of social risk factors include housing instability, transportation barriers, and food insecurity. Social risks can be addressed only if they are identified. Routine screenings by healthcare systems provide actionable data upon which to intervene at individual and community levels (social care interventions). An example of an individual-level social care intervention is clinicians providing patients with a referral to a food bank to address food insecurity. An example of an institutional-level social care intervention is a health system using aggregated social risk data to inform investments in community resources; for example, supporting community investments to build affordable homes. Health systems allocate these individual and community-level resources based on data they collect from social risk screenings. However, screenings may systematically miss certain disability groups, leading to a lack of representation. Our preliminary findings show that disability groups are less likely to answer screening questions than people without disabilities, suggesting there may be barriers unique to disability that limit screening. Furthermore, there is a paucity of up-to-date evidence on the national prevalence of the three most measured social risk factors (housing instability, unreliable transportation, and food insecurity) amongst people with disabilities. In this proposal, we will measure the national prevalence of people with disabilities experiencing social risks and assess systematic gaps in the data. We will do this through the following aims: Aim 1: Using pooled data from the National Health Interview Survey (NHIS), 2020-2024, assess the association of having a disability with social risk factors. Aim 2: Using an explanatory mixed methods approach, describe patient-level barriers to completing social risk screening. Quantitative Aim 2a: Compare the characteristics of those who do and do not respond to social risk screening questions on the NHIS, by disability type and functional severity. Qualitative Aim 2b: Conduct semi-structured interviews of adults with disabilities (and caregivers) least likely to be screened (based on Aim 2a), on their perceptions of barriers to screening, and inclusive adaptations to screening questions and practices. Aim 1 will produce nationally representative comparisons of social risk prevalence among adults with and without disability. Aim 2 will identify the disability populations not included in current social risk data and provide potential explanations for nonresponse. This will elucidate disability-related biases in social risk data from the perspectives of people with disabilities. These findings will be used to create and test inclusive screening methods in a future implementation trial.
