ArticleJournal of the American Board of Family Medicine : JABFM
The Role of Community-Based Organizations in Improving Chronic Care for Safety-Net Populations.
Open access · diamondAbstract read
In one paragraph
Article in Journal of the American Board of Family Medicine : JABFM. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 29 papers, 1 of them a synthesis that pooled it.
0numbers the graph read from it
0cells of the map it votes in
29citing papers in PubMed, 1 pooled it
6.1field-weighted citation impact, top 4% of its field
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
29 citing papers in PubMed, 1 synthesis or guideline pooled it, 33 citations in OpenAlex.
- Advancing equity and value in United States healthcare: an umbrella review.International journal for equity in health · 2026Pooled it
- Characterization of Strategies to Enhance the Provision of Holistic Services Across Three Community-Based Organizations in King County, Washington, United States.Journal of the International AIDS Society · 2026Article
- Differential expression of lymphocyte markers by neighborhood opportunity among US adults: Insights from the Midlife in the United States study.Psychoneuroendocrinology · 2026Article
- The Role of Research, Quality Improvement, and Training in Achieving Medicines Security in Nigeria: A Cross-Sectional Exploration of Stakeholders' Perspectives.Health science reports · 2026Article
- Structural readiness of CBOs to address health-related social needs in chronic disease management programs.BMC health services research · 2026Review
- Barriers and Facilitators to Accessing Preventive Services for Chronic Diseases Among People From Bangladeshi and Nepalese Backgrounds Living in Sydney.Health expectations : an international journal of public participation in health care and health policy · 2026Article
- Association of Emotion Regulation, Self-Efficacy, and Health-Related Readiness to Change Among Patients with Chronic Conditions.Journal of multidisciplinary healthcare · 2026Article
- Determinants of non-communicable disease management among support staff in Putrajaya, Malaysia: The mediating role of attitude.PloS one · 2026Article
- A designathon to collaboratively develop sustainable HIV prevention services for youth with community-based organizations in Nigeria.PloS one · 2026Article
- Exploring a Digital Health Solution to Collect and Manage Health-Related Needs for Patients Who Undergo Complex Surgery: Mixed Methods Study.Journal of medical Internet research · 2025Article
- Advancing health equity and the role of digital health technologies: a scoping review.BMJ open · 2025Article
- You Need to Know: evaluation of a uterine cancer awareness campaign for Black and Asian ethnic minority women in North East London.BMJ public health · 2025Article
- Centering Health Equity in an Increasingly Digital Environment.Perspectives in biology and medicine · 2025Article
- Exploring the Roles of Trust, Attitudes, and Motivations in COVID-19 Decision-Making and Vaccination Likelihood: Insights from the Louisiana Community Engagement Alliance (LA-CEAL) Community-Academic-Public Health-Practice (CAPP) Partnership.International journal of environmental research and public health · 2024Article
- Advancing health equity and the role of digital health technologies: a scoping review protocol.BMJ open · 2024Article
- Identifying and addressing health-related social needs: a Medicaid member perspective.BMC health services research · 2024Article
- Evaluating County Health Department Infrastructure Changes Intended to Improve Access to Federal Funding for Community-Based Organizations, Maricopa County, Arizona.American journal of public health · 2024Article
- Social Deprivation and Multimorbidity Among Community-Based Health Center Patients in the United States.Preventing chronic disease · 2024Article
- Building a Client Resource and Communication Platform for Community-Based Organizations to Address Health and Social Needs: Co-Design Study.JMIR human factors · 2024Article
- Community-based organizations' perspectives on piloting health and social care integration in North Carolina.BMC public health · 2023Article
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
11 authors at 5 institutions in 1 country.
Kim Hanh NguyenFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL). kim.nguyen2@ucsf.edu.
Jessica D FieldsFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL).
Anupama G CemballiFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL).
Riya DesaiFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL).
Anjali GopalanFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL).
Tessa CruzFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL).
Aekta ShahFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL).
Antwi AkomFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL).
William BrownFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL).
Urmimala SarkarFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL).
Courtney Rees LylesFrom the Center for Vulnerable Populations, University of California, San Francisco (KHN, JDF, AGC, RD, AA, WB, US, CRL); UCSF Department of Medicine, Division of General Internal Medicine at Zuckerberg, San Francisco General Hospital, CA (KHN, JDF, AGC, US, CRL); Department of Epidemiology and Biostatistics, University of California, San Francisco (KHN, JDF, RD, US, CRL); Kaiser Permanente Northern California, Division of Research, Oakland (AG, CRL); Streetwyze, Oakland, CA (TC, AS, AA); Social Innovation and Universal Opportunity Lab (SOUL), University of California, San Francisco, San Francisco State University (TC, AS, AA); Center for AIDS Prevention Studies, University of California, San Francisco (WB); Bakar Computational Health Science Institute, University of California, San Francisco (WB, CRL).
San Francisco General Hospital · USUniversity of California, San Francisco · USSan Francisco AIDS Foundation · USSan Francisco State University · USKaiser Permanente · US
Funding
Institutional Career Development Core SupplementKL2TR001870 · NCATS · UNIVERSITY OF CALIFORNIA, SAN FRANCISCO · PI KANAYA, ALKA M., SARKAR, URMIMALA · 2016 to 2025
$19.7MUCSF Learning Health System K12 Career Development ProgramK12HS026383 · AHRQ · UNIVERSITY OF CALIFORNIA, SAN FRANCISCO · PI GONZALES, RALPH, SARKAR, URMIMALA · 2018 to 2022
$3.6MCreating Community Driven, Personalized Health Maps for Patients with DiabetesR01LM013045 · NLM · UNIVERSITY OF CALIFORNIA, SAN FRANCISCO · PI LYLES, COURTNEY REES · 2018 to 2021
$1.5MAHRQ HHS K12 HS026383NCATS NIH HHS KL2 TR001870NLM NIH HHS R01 LM013045
Abstract
introductionSocial determinants of health (SDoH) influence health outcomes and contribute to disparities in chronic disease in vulnerable populations. To inform health system strategies to address SDoH, we conducted a multi-stakeholder qualitative study to capture the multi-level influences on health for those living in socio-economically deprived contexts.
methodsVaried qualitative inquiry methods - in-depth interviews, participant-led neighborhood tours, and clinic visit observations - involving a total of 23 participants (10 patients with chronic illnesses in San Francisco neighborhoods with high chronic disease rates, 10 community leaders serving the same neighborhoods, and 3 providers from San Francisco's public health care delivery system). Qualitative analyses were guided by the Chronic Care Model (CCM).
resultsSeveral key themes emerged from this study. First, we enumerated a large array, neighborhood resources such as food pantries, parks/green spaces, and financial assistance services that interact with patients' self-management. Health service providers leveraged these resources to address patients' social needs but suggested a clear need for expanding this work. Second, analyses uncovered multiple essential mechanisms by which community-based organizations (CBOs) provided and navigated among many neighborhood health resources, including social support and culturally aligned knowledge. Finally, many examples of how structural issues such as institutional racism, transportation, and housing inequities are intertwined with health and social service delivery were elucidated.
conclusionThe results contribute new evidence toward the community domain of the CCM. Health care systems must intentionally partner with CBOs to address SDoH and improve community resources for chronic care management, and directly address structural issues to make progress.
Indexed as
Residence CharacteristicsSocial Determinants of HealthAmbulatory CareHumansLong-Term CareSocial SupportChronic DiseaseDisease ManagementHealth ResourcesMinority HealthQualitative ResearchSan FranciscoSelf-ManagementSocial Determinants of HealthVulnerable Populations
Identifiers
What OpenQuestion holds
Textmetadata
LicenceTDM
Read underepoch 390
Registered trials
None linked
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.