Racial health equity and social needs interventions: Rapid review

A heightened focus on racism as an underlying cause of health inequities has led to increased calls for action to mitigate racism-related adverse health outcomes. Differential access to goods, services, opportunities, and risks (ie, structural inequities) due to racism results in differential exposure to food insecurity, housing instability, and other social drivers (determinants) of health among minoritized racial or ethnic communities. Social needs interventions often aim to improve health outcomes and mitigate inequities by addressing barriers to care, such as lack of transportation or food insecurity, but whether—and how—these studies include race or ethnicity to understand differential impacts is unclear.  Objective: To conduct a rapid review to understand how interventions addressing social needs among multiracial or multiethnic populations: (1) conceptualized race or ethnicity; (2) explored differential treatment effects by race or ethnicity; and (3) tailored or adapted interventions to address the sociocultural needs or preferences of minoritized racial or ethnic groups in recruitment, retention, or intervention design. Methods: This review is based on papers described in the Patient-Centered Outcomes Research Institute’s scoping review and evidence map of social needs interventions, which built on systematic searches of resources including PubMed and the Cochrane Library. Review dates spanned January 1995 through November 29, 2021. The scoping review was inclusive of general populations and conditions commonly seen in primary care settings (eg, asthma, heart disease, diabetes, hypertension, mental health, and substance abuse). Studies were required to report on behavioral outcomes, health outcomes, health care utilization outcomes, or harms. Studies were eligible if the participants had identified social needs or if the intervention was designed to address social needs and permitted conclusions about the effect of the social needs intervention.  In addition, for this review, eligible studies had to be conducted in multiracial or multiethnic populations and had to report an analysis that included race or ethnicity. Two reviewers independently assessed all titles, abstracts, and full text for inclusion. The review team coded studies for population characteristics, intervention characteristics, social needs addressed, race or ethnicity analyses reported, health equity considerations (if any), and outcomes. We, the review team, developed a framework to assess whether the study was conceptually thoughtful for understanding root causes of racial health inequities (ie, noted that race or ethnicity are markers of exposure to racialized social disadvantage). We also evaluated whether analyses were analytically informative for advancing racial health equity research (ie, examined differential impacts by race or ethnicity). Finally, we reviewed included studies for evidence of sociocultural tailoring or adaptation in recruitment, retention, or intervention approach and design. Results: Of the 152 studies in the evidence map conducted in multiracial or multiethnic populations, 44 included race or ethnicity variables in their evaluation of intervention effectiveness. Social needs addressed included health care services access and quality and housing stability. Interventions were most frequently provided by a community health worker (CHW)/health navigator or other medical nonprofessional. Among these 44 studies, only 4 (9%) were conceptually thoughtful about race or ethnicity—ie, only 4 noted that race and/or ethnicity are markers of exposure to racialized social disadvantage. Among all studies that could have examined whether intervention effects differed by race or ethnicity, only 14% (n = 21/152) actually did so—ie, were analytically informative for advancing racial health equity research. Only 3 studies were analytically informative and conceptually thoughtful. Among studies that included race or ethnicity in the analysis, 12 reported information about tailoring or adapting interventions based on race or ethnicity. Tailoring approaches typically included CHWs or peer mentors who shared race or ethnicity characteristics with the intervention’s targeted population. Studies frequently reported a desire to enhance trust and social connection with the target population as a reason for sociocultural tailoring. Three studies with tailored interventions reported differences in outcomes by race or ethnicity; all showed strongest impacts or reduced inequities for Black participants. Conclusions: Minoritized racial and ethnic groups disproportionately experience poor health due, in part, to structural racism that increases the burden of social needs and decreases access to health-promoting goods, services, and opportunities. Consequently, social needs interventions should address and redress health inequities by race or ethnicity. Our review shows that studies of these interventions to date were rarely conceptually thoughtful for understanding root causes of racial health inequities and rarely conducted informative analyses on intervention effectiveness by race or ethnicity. Studies infrequently tailored or adapted interventions to address the unique needs of minoritized racial or ethnic populations. Our findings point to a wide gap between expectations of these interventions’ potential to advance health equity and their design, conduct, and reporting. To advance the field of racial health equity, future work should use a theoretically sound conceptualization of how racism affects social drivers of health; this understanding should inform methodological approaches to developing, implementing, and evaluating social needs interventions.