Applying a socioecological framework to chronic disease management: implications for social informatics interventions in safety-net healthcare settings

Lay Summary Marginalized patients face many types of barriers to managing their health, and we need digital health solutions that center their lived experiences. Our study completed interviews, neighborhood tours, and clinic visit observations in San Francisco to understand important influences on health and wellness for patients who have been historically and presently marginalized within society (for example, those from racial/ethnic minority groups or facing poverty). We uncovered multiple examples of how structural problems, such as housing, influence or interact with individual health behaviors in everyday life, such as medication taking. We also aggregated findings across individuals and data sources to generate more holistic personas representing these multi-level influences on health. Moving forward, we provide examples of how digital health designers and researchers might use a broader and intersectional understanding of health when developing products or programs. Objective Vulnerable populations face numerous barriers in managing chronic disease(s). As healthcare systems work toward integrating social risk factors into electronic health records and healthcare delivery, we need better understanding of the interrelated nature of social needs within patients' everyday lives to inform effective informatics interventions to advance health equity. Materials and Methods We conducted in-depth interviews, participant-led neighborhood tours, and clinic visit observations involving 10 patients with diabetes in underserved San Francisco neighborhoods and 10 community leaders serving those neighborhoods. We coded health barriers and facilitators using a socioecological framework. We also linked these qualitative data with early persona development, focusing on patients' experiences in these communities and within the healthcare system, as a starting place for our future informatics design. Results We identified social risk and protective factors across almost every socioecological domain and level-from physical disability to household context to neighborhood environment. We then detailed the complex interplay across domains and levels within two critical aspects of patients' lives: housing and food. Finally, from these data we generated 3 personas that capture the intersectional nature of these determinants. Conclusion Drawing from different disciplines, our study provides a socioecological approach to understanding health promotion for patients with chronic disease in a safety-net healthcare system, using multiple methodologies. Future digital health research should center the lived experiences of marginalized patients to effectively design and implement informatics solutions for this audience.