# Project 2: Addressing Social Determinants of Health in Primary Care

> **NIH NIH U54** · FRED HUTCHINSON CANCER RESEARCH CENTER · 2020 · $80,790

## Abstract

Title: Addressing Social Determinants of Health in Primary Care
Project Leaders: Mary Alice Scott, Ivan de la Rosa, NMSU; Rachel Ceballos, Fred Hutch
[The content of this Pilot Proposal is identical in the NMSU and Fred Hutch proposals]
PROECT SUMMARY/ABSTRACT
Social determinants of health (SDH), such as low food security, personal safety, employment, housing, and
access to health care, are strongly associated with poor health outcomes and cancer health disparities.
Recognizing the importance of SDH to health outcomes, including cancer prevention and control, state and
federal agencies have issued recommendations for clinical settings to implement collection of SDH data in
electronic medical records (EMR) as part of their clinical care. However, a major gap exists between
recommendations for use of SDH screening tools and knowledge about how to implement SDH screening tools
in a clinical setting. Current efforts to implement a SDH screening tool in a New Mexico primary care practice in
a primary care residency program that serves a high need population, offers a unique opportunity to examine
the tool’s implementation process, consider methods of educating medical providers about use of the tool, and
explore patient and physicians’ perceptions of the tool’s usefulness. Using multiple methods to ensure high
scientific rigor, the proposed project will gather the formative data needed as a step toward development of an
educational intervention for medical providers. We will conduct an assessment using the PRECEDE
(Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation)
portion of the PRECEDE-PROCEED intervention development model in a medical facility that has
implemented use of the screening tool for all patient appointments. The study’s specific aims are to: 1)
identify PRECEDE factors that contribute to the patient-centered use of the SDH screening tool and
subsequent referrals by primary care providers in a community health clinic serving predominantly Latino
patients and 2) calculate the rate of utilization of the SDH screening tool and rate of patient-centered referrals
to appropriate social services by primary care providers. These specific aims will be achieved using several
data collection methods: 1) qualitative interviews and clinical observations to identify predisposing, enabling,
and reinforcing factors that can affect the behavior, attitude and environment (including administration and
policies) of primary care provider implementation of the screening tool; 2) chart review to record documentation
of referrals in patient EMR; 3) qualitative interviews with providers to document uncharted discussions and/or
referrals; and 4) qualitative interviews with patients to document patient experience with the screening tool use.
This project will contribute critical descriptions of SDH screening tool implementation processes, gaps, and
successes to the larger scientific literature and lead to deve...

## Key facts

- **NIH application ID:** 10003218
- **Project number:** 5U54CA132381-13
- **Recipient organization:** FRED HUTCHINSON CANCER RESEARCH CENTER
- **Principal Investigator:** Rachel M. Ceballos
- **Activity code:** U54 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $80,790
- **Award type:** 5
- **Project period:** 2007-09-30 → 2023-08-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10003218

## Citation

> US National Institutes of Health, RePORTER application 10003218, Project 2: Addressing Social Determinants of Health in Primary Care (5U54CA132381-13). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10003218. Licensed CC0.

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