COVID-19 Testing and Social Determinants of Health Among Disadvantaged Baltimore Neighborhoods: A Community Mobile Health Clinic Outreach Model

Abstract

The objective was to summarize data on coronavirus disease 2019 (COVID-19) testing uptake, social determinants of health, and patient satisfaction with mobile health clinic services within underserved minority and low-income communities. This COVID-19 pilot project was conducted during June and July 2020 in low-income residential neighborhoods in West Baltimore, Maryland. Quantitative data were collected and assessed cross-sectionally. Demographically, 85% of the patients identified as Black or African American (n = 265) and 58.2% as female (n = 184). The COVID-19 test was administered by the registered nurse to 78.2% (n = 288) of the patients. More than 90% of patients confirmed high levels of satisfaction with the services they received from the community mobile health clinic. Social determinants were assessed and females reported significantly worse health literacy than their male counterparts (P < 0.05). Study findings suggest that the community mobile health clinic model was effective in attracting hard-to-reach and marginalized individuals, who otherwise may have gone untested or undiagnosed. This care delivery model can be one solution to disparities by improving access to COVID-19 testing and primary care for communities with higher vulnerability to COVID-19 complications.

Introduction

The US health care system has historically struggled with high costs, barriers to accessing appropriate health care, and disproportionate rates in the incidence, mortality, and an ever-increasing prevalence of chronic diseases.^1,2 Pervasive negative health outcomes track with systemic disparities that had a disproportionate impact on certain marginalized groups, including racial and ethnic minorities, sexual and gender minority groups, uninsured individuals, individuals of lower socioeconomic status, and people living in impoverished neighborhoods.^3–5

These social and structural inequities vary markedly at the neighborhood level and require systematic effort to address these underappreciated drivers of this pandemic's transmission and survival rates. The coronavirus disease 2019 (COVID-19) pandemic is highlighting that place and zip codes matter; they may determine the rate of disease transmission, access to testing resources, the level of care an individual receives, and whether a patient survives long enough to tell the tale. Williams and Cooper poignantly redefine “herd immunity” in a recent Journal of the American Medical Association article to include treating and markedly reducing the spread of adverse social determinants of health across all racial, ethnic, and social classes, thereby creating a satisfactorily greater proportion of our nation who will be “immune” to adverse health outcomes.⁶

The pandemic is exposing the myriad of health disparities that have historically and pervasively affected the most vulnerable and underserved in our society. It is becoming increasingly clear that additional medical, social, and policy-level efforts are needed to achieve greater equity of health care within geographic locations that are experiencing underlying health disparities because of structural and complex determinants of health such as economic disadvantages, poor access to health care services, and a higher proportion of racial and ethnic minorities.⁷ In order to reduce excess mortality relating to COVID-19 among marginalized communities, public health and clinically-focused interventions are necessary to address the higher rates of medical comorbidities that place members of these communities at higher risk, including cardiovascular disease, diabetes, asthma, and kidney disease.⁷ Structural determinants of health within minority groups–such as poverty, crowded dwellings in urban settings, lack of equitable access to health care, differential distribution of COVID-19 testing resources, and unaddressed housing and food insecurity–make it more difficult to implement recommended guidelines of social distancing.⁷ As many scholars have stated and initial pandemic data support, social distancing is a privilege that many marginalized communities cannot afford or do not have the means to implement appropriately.^7,8

Impact of COVID-19

To date, COVID-19 has caused more than 500,000 deaths in the United States.⁹ It became apparent early in the pandemic that COVID-19 incidence and mortality rates were disproportionately higher for Black and Latino populations across all age groups and many geographical regions.^7,10 Oppel Jr. and colleagues reported that Latinos and African Americans are 3 times more likely to contract and twice as likely to die from the COVID-19 virus than their White counterparts.¹⁰ Other groups identified as experiencing higher rates of adverse health outcomes and/or death related to COVID-19 include those with medical comorbidities, the elderly, and individuals with obesity and diabetes.^7,11 Additionally, it is known that high population density and living in close quarters elevate COVID-19 vulnerability.¹¹ The differential effects of the COVID-19 virus necessitate a focal reduction in a range of nonfinancial barriers to care–lack of care coordination, transportation difficulties, inability to receive approved time off work–to address social determinants of health and start to level the playing field for groups experiencing the greatest burden and risk.^2,10,12

Role of community mobile health clinics (CMHCs)

A mobile health clinic is a vehicle that travels to underserved communities to provide a wide array of health care services and address barriers to health care that the traditional health care system cannot. CMHCs–often staffed with a combination of nurses, physicians, community health workers, and other health professionals–are used to meet marginalized communities where they are and increase favorable health outcomes by reducing travel time, increasing geographical accessibility, and improving trust.¹³ Many mobile health clinics incorporate the principles of the Institute of Medicine's Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, such as: (1) hiring community health workers; (2) focusing on patient-centered care, education, and empowerment; (3) training diverse and culturally competent staff; and (4) providing consistent service within the communities of focus.^13,14 All of these points have been shown to improve communication, trust, and empowerment among targeted communities. Mobile health clinics provide necessary services to people who may not have the time, motivation, or financial resources to travel to conventional clinics for care. CMHCs therefore provide streamlined care at a patient's doorstep without extra fees or administrative paperwork.^15–17 Previous qualitative studies have shown patients' appreciation for the geographical convenience and the elimination of logistical barriers such as long waiting times, transportation issues, and difficulty with scheduling appointments.^18,19

Increasing health care access

A recent study assessing the mobile health sector in the United States showed a yearly average of 3491 visits.¹³ A comprehensive analysis of the mobile clinic care delivery model found that mobile health clinics were able to reach predominantly those who are younger than age 18 years (41%; n = 183), followed by clients who are ages 45–64 years (31%; n = 183). The lowest utilization was found in those who are older than age 65 years, with an average percentage of 11%.¹³ In terms of racial demographics, 35% are African American, 42% are White, and 27% are Latino (n = 186).¹³ Many of the mobile health clinics aimed to provide preventive services, primary care, and dental care for groups including low-income, homeless, LGBTQ, employees, schools, individuals living in public housing, people living in rural communities, migrants, and veterans.¹³ Computing nationwide annual visits to mobile health clinics using the median number of visits (3491) and approximately 2000 mobile health clinics that are providing services across the United States, it is estimated that 5.2 to 7 million people nationwide are served by mobile health clinics annually.¹³ CMHCs are an innovative health care delivery model that can help alleviate some of the health disparity gaps that make individuals who experience these inequities especially vulnerable to COVID-19 by delivering testing, cost-effective preventive health screenings, offering urgent care, and linking patients with primary care providers through telehealth technology.^19,20

Mobile health clinics can play a critical role in addressing some of the social determinants of health during the COVID-19 pandemic.²¹ However, based on survey data from Harvard Medical School's Mobile Health Map assessing current COVID-19-related efforts, only 19% of mobile health clinics surveyed reported that they were providing care as usual and only 10% of mobile health clinics reported they were providing testing in an effort to respond to the virus, compounding the problem of limited access to health care in vulnerable communities.²¹ To date, there has been a lack of evaluation studies and dissemination of data on CMHCs, which has lessened their visibility within the health care field.²² The aim of this pilot study is to describe the role CMHCs can play in identifying and addressing the disproportionate share of social determinants of health and inequities impacting residents of dense Baltimore neighborhoods during the COVID-19 pandemic. This article details the pilot study's approach and results with the aim of sharing a replicable model of care for other health systems. This article discusses how CMHC staff identified and connected with communities and individuals most at risk for COVID-19 transmission and severe complications. Data on COVID-19 testing uptake, self-identified social determinants of health, proportion of patients with chronic medical conditions, and patient satisfaction with mobile health clinic services provided are summarized.

Methods

This pilot aimed to assess uptake, social determinants of health, and patient satisfaction with a CMHC care delivery model by using a nonrandomized exploratory study design in residential neighborhoods in Baltimore, MD. The LifeBridge Health Institutional Review Board reviewed and approved this study. At the start of the pandemic, Maryland's Department of Health and Socially Determined, Inc. collaborated to create and make available to Maryland health care systems a COVID-19 Vulnerability Index for Medicare beneficiaries attributed to Maryland primary care practices. The index stratified Medicare beneficiaries by their estimated risk for complications if exposed to COVID-19 by assessing neighborhood-level social determinants of health and Medicare claims data. LifeBridge Health used the Vulnerability Index as a starting point to identify its highest risk community members by location. It determined the neighborhoods with the largest proportion of vulnerable individuals and then contacted individuals and organized a mobile clinic pilot program to bring COVID-19 polymerase chain reaction (PCR) testing, screening for social determinants of health, and access to clinical services to these people where they lived. This mobile health clinic consisted of 2 vans, each with a driver, a registered nurse, and a community health worker, all linked to clinicians at LifeBridge's “virtual hospital,” a provider-staffed triage and care support arm of the health system.

Using the COVID-19 Vulnerability Index, the CMHC pilot targeted poorer, predominantly African American communities near LifeBridge hospitals in West Baltimore. The primary outcomes assessed in this study were the proportion of patients who consented to receive COVID-19 testing, self-identified social determinants of health, proportion of patients with chronic medical conditions, and patient satisfaction with mobile health clinic services provided.

Design

A descriptive exploratory design was used for this study. Quantitative data were collected, such as number of patients seen, COVID-19 testing completed and results, sociodemographic information, patients' documented social needs (eg, financial services, housing, mental health, food, transportation), presence of chronic conditions, and encounter cancellations.

Setting and mobile clinic overview

According to the 2014–2018 American Community Survey 5-year data profile, the total population in Baltimore City is 614,700, with 53% of the population being female and 62.5% identifying as Black or African American. The study sample consists of primarily Medicare patients classified as high risk based on neighborhood factors and clinical history who accepted invitations to participate in a mobile clinic visit between June-August 2020 (n = 343). LifeBridge Health, a 4-hospital system that serves a large proportion of individuals living in marginalized and underserved areas in central Maryland, implemented a CMHC within low-income, densely-populated residential neighborhoods in order to address the disproportionate threat that COVID-19 poses to these individuals. Since the start of the pandemic, studies have shown that a higher burden of cases and deaths fall on members of racial and ethnic minority groups, particularly those who live in dense communities and who experience barriers to health care access and other inequities.^6,23 Two mobile vans staffed with a registered nurse and a community health worker, both wearing personal protective equipment when seeing patients, were deployed to residential areas to see patients identified to have higher risk for severe COVID-19-related outcomes. After completion of COVID-19 testing, the health system's virtual hospital called the individuals with their results. Patients who tested positive were monitored with help from an automated daily check-in system that allowed the virtual hospital's physician assistants to monitor and intervene proactively before any complications escalated.

Data sources and analytical strategy

All major statistical analysis for patients who visited the CMHC from June-July 2020 were analyzed using Stata Statistical Software: Release 15.0 (StataCorp LLC, College Station, TX). Differences across gender were assessed using the Mann-Whitney U statistical test. Descriptive statistics were used to examine clinic attendance, patient demographics, COVID-19 testing results, patient-described needs and social determinants of health, and patient satisfaction with the mobile clinic services provided.

Results

A total of 316 patient were assessed in the mobile clinic and 288 COVID-19 PCR tests were administered during the 6-week pilot time frame in June and July 2020. Demographically, 83.9% of the patients identified as Black or African American (n = 265) and 58.2% as female (n = 184), with 12.5% deciding not to disclose their race or gender (n = 41). The cancellation rate was low, with only 8.5% of patients cancelling their appointments (Table 1). A large proportion of the patients reported a diagnosis of hypertension as a chronic condition, followed by diabetes, asthma, behavioral health conditions, chronic obstructive pulmonary disease, heart failure, and chronic kidney disease. The COVID-19 test was administered by the registered nurse to more than 78% of the patients who participated in this pilot project (Table 1).

Table 1.

Sociodemographic and Health Characteristics of Patients in the Pilot Study (n = 316) from June-July 2020

	n(%)
Age (median, min/max)	73 (29, 102)
Gender
Male	91 (28.8%)
Female	184 (58.2%)
Non-binary	0
Prefer not to say	0
Race
White or Caucasian	5 (1.6%)
Black or African American	265 (83.9%)
Not Documented	46 (14.5%)
Chronic Conditions
Hypertension	222 (70.3%)
Diabetes	108 (34.2%)
Behavioral health	40 (12.7%)
Asthma	38 (12.0%)
Chronic obstructive pulmonary disease	33 (10.4%)
Heart failure	22 (7.0%)
Chronic kidney disease/end-stage renal disease	12 (3.8%)
COVID-19 Test uptake	247 (78.2%)

Not all percentages equal 100% because of missing data. Other conditions reported by patients but not documented in table: hyperlipidemia, coronary artery disease, gastroesophageal reflux disease, gout, arthritis, sickle cell disease, cancers, bronchitis, anemia, among others.

Patient satisfaction

Two months after the pilot program's completion, the study team contacted a sample of 59 participants to assess their satisfaction with the community mobile clinic. Descriptive statistics were performed on participants' basic characteristics and survey responses. The degree of satisfaction was considered to be associated with the success of the CHMC model. The survey completers were predominantly female (n = 43, 72.9%) and identified as Black or African American (n = 57, 96.6%). As noted in Table 2, when the extent to which patients were satisfied with the services they received from the CMHC was examined, 93.1% of patients reported being “very satisfied” or “satisfied.” They were further asked if the services they needed were explained in an understandable manner and 93.2% of the patients reported “very satisfied” or “satisfied” with the way the services were explained; ∼5% reported “adequate” satisfaction and <2% reported “dissatisfaction.” When asked if patients would likely recommend the CMHC to a friend or colleague, a cumulative percentage of 91.5% (comprising “very likely” and “likely” responses) of patients endorsed likelihood of recommendation based on their complete experience with the services (Table 2).

Table 2.

Patient Satisfaction and Social Determinants of Health Factors for n = 59 Patients Sampled Two Months Post Program Completion

	Participants	Percent (%)	SE
Health Functional
General Health Status
Excellent	3	5.1	2.86
Very Good	10	28.8	5.89
Good	25	42.4	6.43
Fair	17	6.8	3.27
Poor	4	16.9	4.88
Patient Satisfaction
Overall Satisfaction with CMHC services
Very Satisfied	40	69	6.1
Satisfied	14	24.1	5.61
Adequate	4	6.9	6.07
Dissatisfied	0	__	__
Very Dissatisfied	0	__	__
Services explained in understandable manner
Very Satisfied	41	69.5	5.99
Satisfied	14	23.7	5.53
Adequate	3	5.1	2.86
Dissatisfied	1	1.7	1.68
Very Dissatisfied	0	__	__
Likely to recommend us to friend/colleague
Very Likely	38	64.4	6.23
Likely	16	27.1	5.78
Neither Likely nor Unlikely	3	5.1	2.86
Unlikely	0	__	__
Very Unlikely	2	3.4	2.35
Social Determinants of Health
Trouble getting medications
Not at all Hard	49	83.1	4.88
Somewhat Hard	9	15.3	4.68
Very Hard	0	__	__
Not Applicable	1	1.6	4.68
Health Literacy
Never	37	62.7	6.29
Rarely	12	20.3	5.24
Sometimes	7	11.9	4.21
Often	2	3.4	2.36
Always	1	1.7	1.68
Health Confidence
Very Confident	47	79.7	5.24
Somewhat Confident	11	18.6	5.07
Not Confident	1	1.7	1.68

CMHC, community mobile health clinic; SE, standard error.

Social determinants of health

Prevalence of social determinants of health was assessed through questions about trouble getting medications, health literacy, and health confidence. Participants were asked how hard was it for them to get their medications and medical supplies when they needed them in the past year, and >15% described some difficulty (Table 2). The level and impact of health literacy was assessed by asking whether and how often the patient needed to ask for help to read medical or health-related instructions, pamphlets, or other written materials from their physician or pharmacy. More than one third of patient respondents reported health literacy difficulty ranging from rarely to always. Finally, health confidence was assessed with regard to daily management of health conditions. In the present study sample, >20% of patient respondents noted feeling somewhat confident or not confident at all with daily management of their current medical conditions (Table 2).

Gender differences in social determinants of health and patient satisfaction

Male and female participants' levels of satisfaction were compared using the Mann-Whitney U test and findings are presented in Table 3. Patients who identified as female reported significantly worse health literacy than their male counterparts, when asked “how often do you need to have someone help you when you read instructions, pamphlets, or other written materials from your doctor or pharmacy?” (P < 0.05). There were no statistically significant differences across gender in reported social determinants of health such as trouble getting medication and health confidence in daily management of current medical conditions (P = 0.48 and P = 0.94, respectively). Similarly, there were no statistically significant differences across gender in general patient satisfaction with the services received from the CMHC and explanation of the services (P = 0.18 and P = 0.19, respectively).

Table 3.

Gender Differences in Patient Satisfaction and Social Determinants of Health Using the Mann-Whitney U Test (n = 59)

Domains	Gender	N	Mean rank	Sum of ranks	Mann-Whitney U	P value
Health Status	Male	16	480	428.5	3078.61	0.35
	Female	43	1290	1341.5
Patient Satisfaction
Overall satisfaction with CMHC services	Male	16	472	535	2173.33	0.18
	Female	42	1239	1176
Services explained in understandable manner	Male	16	480	541.5	2239.82	0.19
	Female	43	1290	1228.5
Likely to recommend us to friend/colleague	Male	16	480	445.5	2452.43	0.49
	Female	43	1290	1324.5
Social Determinants of Health
Trouble getting medications	Male	16	480	507	1457.63	0.48
	Female	43	1290	1263
Health literacy	Male	16	480	596.5	2557.48	0.02**
	Female	43	1290	1173.5
Health confidence	Male	16	480	483	1679.19	0.94
	Female	43	1290	1287

^** Signifies P < 0.05.

CMHC, community mobile health clinic.

Discussion

Epidemiological data indicate that the COVID-19 virus poses the greatest health risk to those living with chronic medical conditions.²⁴ This pilot initiative found that multiple participants suffered the burden of multiple chronic diseases, with 70% suffering from hypertension. Such individuals need rapid identification and better coordination of clinical and social services to prevent potential adverse consequences of delayed primary and preventive health services, as well as help to minimize sustained exposure to social determinants of health.²⁵ The mobile clinic was able to increase COVID-19 testing and enhance health care access for an under-resourced urban neighborhood, where residents are largely African American. The descriptive results reflect the feasibility and positive uptake of this model to effectively reach individuals at high risk for poor health outcomes. Incorporating outreach strategies that help surmount health care challenges built into the current structure of the US health system and experienced disproportionately by underserved communities can help address health inequities.

Patient satisfaction has often been used as an outcome proxy measure for quality of care delivery.²⁶ Study staff contacted a subsample of the pilot study's patients to evaluate their satisfaction with the CMHC services across 3 pertinent domains. More than 90% of the patients confirmed high levels of satisfaction with the services they received from the CMHC, reported that the services they needed were explained in an understandable manner, and endorsed likelihood of recommending the clinic services to a friend or colleague based on their complete experience with the care delivery at the CMHC.²⁶ Previous studies have linked high patient satisfaction with care with compliance with treatment, health status, and continuity of care. Present study findings are in alignment with previous patient satisfaction assessments using mobile health clinic delivery models, both domestically and internationally.^27–29 Similar to present study findings, they found high overall satisfaction along with more than 90% of their mobile clinic clients rating high satisfaction with the structure and types of services provided.²⁷ Mobile health clinics aid in removing barriers related to financial issues, logistical constraints, and COVID-19-related factors.²⁶ There is a need for more evaluative studies to enhance the body of literature regarding the use of CMHCs and their impact on patients' health over time, long-term patient satisfaction in underserved communities, their role in successful referrals, and data on patient follow-up.

The present study found gender differences in health literacy, with females reporting worse health literacy than their male counterparts. Interestingly, past research studies have reported gender differences in health literacy; however, Kutner et al reported higher average of health literacy scores for women compared to men.³⁰ Because of the homogeneity of the present study's racial demographic, racial and ethnic differences in health literacy could not be assessed. However, previous findings have supported that Whites and Asian/Pacific Islander tend to report higher average health literacy than Black, Hispanic, and American Indian/Alaska Natives.³⁰ Moreover, Lee et al reported higher levels of health literacy in women compared to men in their understanding of medical forms, written information offered by health providers, and directions on medication bottles.³¹ It is important to note that the gender differences in Lee's article were observed within Korean adults, while the current sample was predominantly African American. The literature on health literacy clearly demonstrates its impact on negative health outcomes and its role in health disparities.^30,31 This further establishes the importance of addressing gender differences across racial subgroups and implementing interventions to reduce these existing gaps.

Implications for practice

COVID-19 infection poses greater risk for racial and ethnic minorities, individuals with chronic diseases, and older adults.³² Evaluation of this pilot identified several strengths and limitations. Among the strengths, this pilot demonstrated the need and potential benefits of new models of health care delivery, especially in the context of a pandemic that makes social contact risky. It proved to be a feasible and successful option to connect underserved neighborhoods at high risk for COVID-19 complications to health care services, as measured by high levels of community uptake and satisfaction. Mobile health clinics such as the one described can efficiently link patients in underserved and low socioeconomic status communities to medical and social services, not only during a pandemic, but going forward.

Social determinants of health are intricately linked to the health outcomes experienced by neighborhoods. Approximately 80% of an individual's health is linked to her/his economic status, physical environment, education, and food security, with only 20% associated with clinical care.³³ Investing only in clinical care, therefore, will not eliminate excess morbidity and mortality. Because the model actively captured patient information on their social determinants of health, health literacy was able to be identified as a particular barrier–one disproportionately impacting women in the intervention. This provides an opportunity to explore and reframe how health information is communicated, especially with respect to addressing vaccine hesitancy. In the near term, this can help eradicate the COVID-19 virus more quickly. Longer term, these learnings can help improve management of chronic diseases and enhance poor health outcomes that unequally burden underserved populations.

This pilot study was limited in that it did not produce a positive return on investment during its 6-week implementation. Analysis was not able to connect the upfront costs of staffing, launching, and operating a mobile clinic with possible future downstream benefits. However, much was learned to inform future iterations of LifeBridge Health's community mobile clinic, including the relative value of stationary, community-situated screening sites and new ways to link individuals with chronic conditions to needed resources. Based on the study findings, LifeBridge has allocated additional funding to continue the mobile clinic model. Near-term plans include COVID-19 vaccination in underserved communities, improving adult chronic disease management, increasing childhood immunization rates, and supporting post-acute care facilities in their COVID-19 screening and vaccination efforts.

Mobile outreach offers a valuable mode to reach underserved communities and begin to identify and address the social factors relating to health that elevate the risk of transmission and poor health outcomes for certain communities.^34,35 To address many of the challenges impacting racial and ethnic minorities and other marginalized communities, care delivery must consider incorporating proactive mobile outreach to identify and address social barriers to health.

Conclusion

Study findings suggest that the CMHC model was effective in attracting hard-to-reach and marginalized individuals, who otherwise may have gone untested or undiagnosed. This care delivery model can be one solution to disparities by improving access to COVID-19 testing and primary care for communities with higher vulnerability to COVID-19 complications. Improving health outcomes within vulnerable communities will require more than increasing access to quality care. It necessitates a cross-sector approach that integrates medical, behavioral, and social services across the wide array of social determinants of health.³³ The role of mobile outreach in these efforts to eliminate health inequities is promising as hospitals and health systems test innovative strategies to optimally meet the needs of communities.

Authors' Contributions

Dr. Baker and Ms. Cadet conceptualized the article, contributed to the writing, and provided critical review to the manuscript during its draft and final stages. Dr. Mani had significant involvement in program design and contributed to final manuscript review. All authors contributed substantially to the authorship of this article.

Author Disclosure Statement

The authors declare that there are no conflicts of interest.

Funding Information

This research was partly supported by grants from the National Institute on Drug Abuse (T32DA007292, KC supported).