Importance Of Social Determinants Research Articles

A Public Health, Whole-of-Government Approach to National Suicide Prevention Strategies

A Public Health, Whole-of-Government Approach to National Suicide Prevention Strategies

Immigrant-focused Medical Legal Partnerships: A Practical Innovation to Improve Immigrant Health and Social Well-being.

Immigration status is an important social determinant of health that can limit access to health care and related services. Few medical legal partnerships (MLPs) address immigration-related legal needs of patients. An immigrant-focused MLP (IMLP) addresses immigration legal needs and provides advice to vulnerable patient-clients and their families regarding potential legal consequences of accessing health care and other public benefits. In this article, we outline the core elements of an IMLP and provide case examples from our ongoing IMLPs. Although many of the core elements of an IMLP are similar to those of an MLP, an IMLP focuses specifically on immigration-related legal needs of patient-clients. IMLPs can complement and extend MLP services by providing legal assistance to non-citizen immigrant individuals and mixed status families. IMLPs may improve immigrant patient-clients' health and social well-being and create eligibility for public benefits. An IMLP can be a scalable innovation to improve access to health and legal services. Challenges to institutionalizing an IMLP may include limited sustainable funding, few legal service providers with immigration expertise and capacity, patient-client identification, and the politicized nature of immigration.

Exploring associations of older adults with virtual nature: a randomised factorial online survey

Abstract Loneliness and social isolation are important social determinants of wellbeing of older adults. Conversational exchanges can promote connectedness between older adults, however, conversations may not always come easy. Research shows that exposure to nature-based stimuli such as pictures and videos can stimulate social aspirations and trigger associations that could facilitate conversations, in particular when nature scenery is perceived as fascinating, mysterious, spacious and suited for social interaction. Therefore, this study investigated whether exposure to these nature characteristics (high versus low) lead to associations that could act as conversational material. A randomised factorial design, using a virtual reality-based approach for experimental control, led to 17 different virtual representations of nature (VN). In total, 150 participants (60 years and older) were recruited for an online survey. Spontaneous associations were coded on personal engagement and valence. The number of associations was measured with one multiple-choice question. VN exposure successfully triggered personally engaging and positively valenced associations and were related to multiple associations, in particular when the VN were high on mystery. Furthermore, positive effects of VN exposure was more pronounced for participants with high (rather than low) levels of nature relatedness and many (rather than few) available nature opportunities. These findings indicate that VN exposure provides fertile ground for conversations as a means to promote connectedness and social wellbeing of older adults.

Social Determinants, Cardiovascular Disease, and Health Care Cost: A Nationwide Study in the United States Using Machine Learning.

Background Existing studies on cardiovascular diseases (CVDs) often focus on individual-level behavioral risk factors, but research examining social determinants is limited. This study applies a novel machine learning approach to identify the key predictors of county-level care costs and prevalence of CVDs (including atrial fibrillation, acute myocardial infarction, congestive heart failure, and ischemic heart disease). Methods and Results We applied the extreme gradient boosting machine learning approach to a total of 3137 counties. Data are from the Interactive Atlas of Heart Disease and Stroke and a variety of national data sets. We found that although demographic composition (eg, percentages of Black people and older adults) and risk factors (eg, smoking and physical inactivity) are among the most important predictors for inpatient care costs and CVD prevalence, contextual factors such as social vulnerability and racial and ethnic segregation are particularly important for the total and outpatient care costs. Poverty and income inequality are the major contributors to the total care costs for counties that are in nonmetro areas or have high segregation or social vulnerability levels. Racial and ethnic segregation is particularly important in shaping the total care costs for counties with low poverty rates or social vulnerability level. Demographic composition, education, and social vulnerability are consistently important across different scenarios. Conclusions The findings highlight the differences in predictors for different types of CVD cost outcomes and the importance of social determinants. Interventions directed toward areas that have been economically and socially marginalized may aid in reducing the impact of CVDs.

Gender Awareness in Healthcare: Contextualization of an Arabic Version of the Nijmegen Gender Awareness in Medicine Scale (N-GAMS)

Gender is one of the important social determinants of health known to be highly associated with health status. Despite the importance of gender awareness, it has not been addressed and researched in the Arab region, including Palestine. This study aimed to contextualize an Arabic version of the Nijmegen Gender Awareness in Medicine Scale (N-GAMS) and to assess the level of gender awareness and its associated factors among primary health care providers. The N-GAMS tool was translated and adapted through a gender expert consultation and a focus group discussion. Then, it was administered online to a sample of primary health care general physicians and nurses of all health care providing actors in Ramallah and al-Bireh Governorate. The reliability of the N-GAMS subscales using Cronbach's alpha (α) was 0.681 for the gender sensitivity (GS) scale (9 items), 0.658 for the gender role ideology towards co-workers (GRIC) scale (6 items), and α = 0.848 for the gender role ideology towards patients (GRIP) scale (11 items). The results showed that participants had scored near the midpoint of the gender sensitivity subscale (M = 2.84, SD = 0.486). They also expressed moderate gender stereotypes towards patients (M = 3.11, SD = 0.624), where females held lower stereotypical thinking. Participants also expressed low to moderate stereotypes towards co-workers (M = 2.72, SD = 0.660) and females expressed less stereotypical thinking compared to males. Furthermore, the participant's age had some effect on the outcome, specifically on the GRIP subscale, while gender was associated with both GRIP and GRID subscales. The rest of the social and other variables showed no association with the gender awareness subscales. This study adds to our understanding of gender awareness. Further tests are required to confirm the psychometric qualities of the instrument.

Mortality inequalities of Black adults in Canada.

Mortality rates in Canada have been shown to vary by population group (e.g., Indigenous peoples, immigrants) and social economic status (e.g., income levels). Mortality patterns for some groups, including Black individuals, are not as well known. The objective of this study was to assess cause-specific mortality for Black adults living in Canada. Mortality inequalities between Black and White cohort members were estimated by sex using Cox proportional hazard models, based on data from the 2001, 2006 and 2011 Canadian Census Health and Environment Cohorts (CanCHECs). The CanCHEC cycles were combined and followed for mortality between Census Day and December 31, 2016 or 2019, resulting in a follow-up period of 15.6, 13.6 or 8.6 years, depending on the CanCHEC cycle. Ischemic heart disease mortality was the leading cause of death among adult Black males (12.9%) and females (9.8%), as it is for adult White males (16.4%) and females (12.4%). Despite reduced risk of all-cause mortality among Black males and females, compared with White cohort members, there was notable increased risk for some cause-specific mortality. For instance, in the age-adjusted model, among the 25 causes of death examined, Black males had an increased risk of dying from four causes (HIV/AIDS, prostate cancer, diabetes mellitus and cerebrovascular disease), compared with White males. Similarly, Black females were at an increased risk for 6 causes of death (HIV/AIDS, stomach cancer, corpus uteri cancer, lymphomas and multiple myeloma, diabetes mellitus, and endocrine disorders) out of the 27 causes of death examined. These relative increased risks persisted for most causes of death after adjustment for differences in important social determinants of health. Results showed substantial variability in the risk of dying by cause of death between Black and White cohort members. An important step in reducing health inequities is the routine identification and surveillance of different health outcomes by population groups. This study helps fill that information gap.

Validity and reliability of the arabic version of the HLS-EU-Q16 and HLS-EU-Q6 questionnaires

BackgroundHealth literacy is an important social determinant of health and affects the ability to make decisions and take action to manage one’s health. The purpose of this study was to psychometrically examine the Arabic versions of HLS-EU-Q16 and HLS-EU-Q6 and their response patterns among Arabic-speaking persons in Sweden.MethodsBy convenience sampling from a variety of settings, a total of 335 participants were invited to participate. The participants completed a self-assessment of comprehensive health literacy by answering the Ar-HLS-EU-Q16 questionnaire, also including the six items for Ar-HLS-EU-Q6. Statistical analysis was guided by The COnsensus-based Standards for the selection of health Measurement Instruments. Floor/ceiling effects, construct, structural and criterion validity, test-retest reliability and internal consistency reliability were analysed.ResultsIn total, 320 participants were included in the psychometric evaluation. Mean age was 42.1 (SD 12.5), 63% (n = 199) were females and 53% (n = 169) had at least 10 years of education. No floor or ceiling effect were found for the Ar-HLS-EU-Q16 or Ar-HLS-EU-Q6. For both instruments, construct validity was confirmed in four out of five expected correlations (weak positive correlation to educational level, self-perceived health, and years in Sweden; moderate positive correlation with higher sum score on the Arabic electronic health literacy scale, and strong positive correlation to higher Ar-HLS-EU-Q16/Ar-HLS-EU-Q6). For Ar-HLS-EU-Q16, the principal component analysis resulted in a three-factor model with all items significantly correlating to only one factor. For Ar-HLS-EU-Q6, the principal component analysis supported a one-factor solution. Criterion validity showed poor agreement between the two questionnaires with a Cohen κ 0.58 (p < 0.001). Test-retest reliability showed a substantial agreement, Cohen’s κ for Ar-HLS-EU-Q16 and Ar-HLS-EU-Q6 were both 0.89. The internal consistency of both versions was acceptable, Cronbach alpha for Arabic-HLS-EU-Q16 was 0.91 and for Arabic-HLS-EU-Q6, 0.79. Split-half reliability was 0.95 and 0.78, respectively.ConclusionThe Arabic version of HLS-EU-Q16 shows good psychometric properties, validated in a Swedish setting. The findings can further inform and guide future validation studies in other settings worldwide. Furthermore, the results of the present study did not support criterion validity of Ar-HLS-EU-Q6.

Editors' Note: Association of Self-reflection With Cognition and Brain Health in Cognitively Unimpaired Older Adults.

Dr. Demnitz-King et al. examined the association between self-reflection and markers sensitive to Alzheimer disease in 125 older adults with subjective cognitive decline and compared them with 134 cognitively unimpaired older adults in the Age-Well clinical trial. They found that self-reflection was associated with better global cognition and higher glucose metabolism in fluorodeoxyglucose positron emission tomography scans, with weak evidence that the observed associations were independent of other health and lifestyle behaviors. They concluded that longitudinal and experimental studies are needed to clarify whether self-reflection can actually help preserve cognition and cerebral glucose metabolism vs whether a lower capacity to self-reflect is a harbinger of cognitive decline and glucose hypometabolism. In response, Dr. Daly notes that the study overlooked social determinants of brain health and behaviors including those associated with self-reflection and argues that studying such determinants is potentially a higher priority for dementia research than interventional studies. Responding to these comments, the authors note that they found a higher education (an important social determinant) was associated with better self-reflection, but that the associations between self-reflection and the study outcomes remained after adjusting for education. They also report additional analyses examining the relationship between self-reflection and loneliness as well as primary occupation. They found that loneliness was associated with self-reflection, but incorporating loneliness as an additional covariate in their models did not change the associations of self-reflection with cognition and glucose metabolism. The authors counter that these findings suggest that there is utility in targeting self-reflection but agree that there may be promise in addressing such individual risk or protective factors within the broader context of social determinants of brain health. This exchange underscores the challenges of making causal inferences about protective behaviors from studies of cognitive decline or dementia-related markers, and the complexities involved in setting priorities for dementia prevention research based on such data. Dr. Demnitz-King et al. examined the association between self-reflection and markers sensitive to Alzheimer disease in 125 older adults with subjective cognitive decline and compared them with 134 cognitively unimpaired older adults in the Age-Well clinical trial. They found that self-reflection was associated with better global cognition and higher glucose metabolism in fluorodeoxyglucose positron emission tomography scans, with weak evidence that the observed associations were independent of other health and lifestyle behaviors. They concluded that longitudinal and experimental studies are needed to clarify whether self-reflection can actually help preserve cognition and cerebral glucose metabolism vs whether a lower capacity to self-reflect is a harbinger of cognitive decline and glucose hypometabolism. In response, Dr. Daly notes that the study overlooked social determinants of brain health and behaviors including those associated with self-reflection and argues that studying such determinants is potentially a higher priority for dementia research than interventional studies. Responding to these comments, the authors note that they found a higher education (an important social determinant) was associated with better self-reflection, but that the associations between self-reflection and the study outcomes remained after adjusting for education. They also report additional analyses examining the relationship between self-reflection and loneliness as well as primary occupation. They found that loneliness was associated with self-reflection, but incorporating loneliness as an additional covariate in their models did not change the associations of self-reflection with cognition and glucose metabolism. The authors counter that these findings suggest that there is utility in targeting self-reflection but agree that there may be promise in addressing such individual risk or protective factors within the broader context of social determinants of brain health. This exchange underscores the challenges of making causal inferences about protective behaviors from studies of cognitive decline or dementia-related markers, and the complexities involved in setting priorities for dementia prevention research based on such data.

Social Determinants of Cardiovascular Health: A Longitudinal Analysis of Cardiovascular Disease Mortality in US Counties From 2009 to 2018.

Background Disparities in cardiovascular disease (CVD) outcomes persist across the United States. Social determinants of health play an important role in driving these disparities. The current study aims to identify the most important social determinants associated with CVD mortality over time in US counties. Methods and Results The authors used the Agency for Healthcare Research and Quality's database on social determinants of health and linked it with CVD mortality data at the county level from 2009 to 2018. The age-standardized CVD mortality rate was measured as the number of deaths per 100 000 people. Penalized generalized estimating equations were used to select social determinants associated with county-level CVD mortality. The analytic sample included 3142 counties. The penalized generalized estimating equation identified 17 key social determinants of health including rural-urban status, county's racial composition, income, food, and housing status. Over the 10-year period, CVD mortality declined at an annual rate of 1.08 (95% CI, 0.74-1.42) deaths per 100 000 people. Rural counties and counties with a higher percentage of Black residents had a consistently higher CVD mortality rate than urban counties and counties with a lower percentage of Black residents. The rural-urban CVD mortality gap did not change significantly over the past decade, whereas the association between the percentage of Black residents and CVD mortality showed a significant diminishing trend over time. Conclusions County-level CVD mortality declined from 2009 through 2018. However, rural counties and counties with a higher percentage of Black residents continued to experience higher CVD mortality. Median income, food, and housing status consistently predicted higher CVD mortality.

Reporting of Important Social Determinants of Health in Pediatric Clinical Trials

The objective of this study was to determine the rates and trends in the reporting of preferred language, socioeconomic factors, sexual orientation, and gender identity in published pediatric clinical trials. A cross-sectional study of pediatric clinical trials conducted in the U.S. published from January 1, 2011 through December 31, 2020 in 5 general pediatric and 5 general medical journals with the highest impact factor in their respective fields was performed. Outcomes were reporting of preferred language, socioeconomic factors, sexual orientation, and gender identity. In late 2021, descriptive statistics and logistic regression to understand how reporting of preferred language and socioeconomic factors changed over time were performed. Of 612 trials, 29.6% (n=181) reported preferred language. Among these, 64.6% (n=117 of 181) exclusively enrolled participants whose preferred language was English. From 2011 to 2020, there was a relative increase in the reporting of preferred language (8.6% per year, 95% CI=1.8, 16.0). Socioeconomic factors were reported in 47.9% (n=293) of trials. There was no significant change in the reporting of socioeconomic factors (8.2% per year, 95% CI= -1.9, 15.1). Only 5.1% (9 of 179) of published trial results among adolescent participants reported any measure of sexual orientation, and 1.1% (2 of 179) reported gender identity. Preferred language, socioeconomic factors, sexual orientation, and gender identity were infrequently reported in pediatric clinical trial results despite these characteristics being increasingly recognized as social determinants of health. To achieve more inclusiveness and to reduce unmeasured disparities, these characteristics should be incorporated into routine trial registration, design, funding decisions, and reporting.

Abstract B105: Patient-reported access to telehealth: An important and unmeasured social determinant of health

Abstract Background: The recent COVID-19 pandemic expanded opportunities for remote oncology telehealth visits. However, reliable internet connectivity, digital literacy, and patient comfort with virtual medical visits may differ among patients, especially socially disadvantaged groups. The primary aim of this study was to identify patient demographics and social determinants of health (SDOH) which might limit access to remote telehealth services. Methods: First, a retrospective analysis was performed of composite administrative data of all patient visits to a large regional cancer center over the COVID-19 pandemic (3/2020-4/2022). Second, a prospective, cross-sectional study was conducted of patients with known or suspected malignancy presenting to the same center over six-months (11/2021-5/2022). Participants were asked a standard set of survey questions regarding telehealth accessibility during an in-person clinic visit. Demographics and SDOH were abstracted from the electronic health record (EHR). Results: Although Black patients comprised 43% (n=9,021) of all patient visits (n=20,953), the proportion of telehealth visits conducted among Black patients (29%; n=889) was significantly lower compared to White patients (71%, n=2,142, p&amp;lt;0.0001). Within the cross-sectional study cohort (n=149), 51% (n=76) were Black, 39% (n=58) resided in a rural county, and 8.7% (n=13) were uninsured or Medicaid-insured. Black participants were more likely to self-report lack of internet access (73.7% vs. 90.4%, p&amp;lt;0.01) and were less likely to report having access to or actively using a patient portal in the EHR compared to White patients (47.4% and 79.5%, respectively; p&amp;lt;0.001). Rates of self-reported access to video-capable devices (82.9% vs. 90.4%) and confidence in conducting video visits without assistance (59.2% vs. 68.5%) were similar among Black and White patients (p&amp;gt;0.05). The most common self-identified challenge to telehealth usage among both races was limited digital literacy. Conclusions: Black patients disproportionally under-participated in telehealth visits, suggesting underlying structural disparities in access to digital care. A greater proportion of Black participants self-reported lack of internet access and access to a patient portal to the EHR compared to White patients. Ensuring equal internet access and digital literacy will be critical to reduce further disparities in cancer care among racial minorities. Citation Format: John A. Iasiello, Arvind Rajan, Emmanuel Zervos, Alexander A. Parikh, Rebecca A. Snyder. Patient-reported access to telehealth: An important and unmeasured social determinant of health [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr B105.

Health promoted by social and community networks of low-income women

Social and community networks constitute an important social determinant of health, especially in the poorer segments of civil society and in their struggles to guarantee the right to health care. This study sought to understand the social and community networks created by women living in a low-income community and their relationship with the development of health care in this social group. Semi-structured interviews were conducted with 11 women participating in a nongovernmental organization in the community, and the data were subjected to content analysis. The analysis highlighted four categories: the community as a large network, formed by multiple interconnected dynamic networks; the network of "aunts", women with an important role in the care of the community, treated as part of the family; the conversation circles, such as the rite of periodic meeting on the sidewalks, indicated as an important space that guarantees emotional stability and quality of life; and the benzedeiras with the use of medicinal plants, they are reference care within the community, providing disease prevention, health treatment, and referral to the health care unit when necessary. We concluded that the social and community networks created by the participants are important social determinants, and health facilities registered in the territory should value such networks.

Association between diet quality and type of meal companion: the 2013-2015 Korea National Health and Nutrition Examination Survey (KNHANES).

A meal companion is an important social determinant of eating behaviors and is related to what and how much a person will eat within the social context. This study examined the difference in diet quality according to the type of dining companion. This study included 15,074 adults (6,180 men and 8,894 women, ≥ 19 years) who participated in the 6th (2013-2015) Korea National Health and Nutrition Examination Survey. Korean Healthy Eating Index (KHEI) scores were calculated using the food frequency questionnaire data. Survey multivariate linear regression analysis was used to assess the association of dining companions (ordinary type, eating with family members, eating alone, and eating with others) and the total and component scores of KHEI. People who exclusively ate with someone other than family or exclusively ate alone had lower total KHEI scores in both men (57.23 ± 0.67, 58.56 ± 0.73 vs. 62.71 ± 0.26) and women (57.6 3±0.97, 63.89±0.58 vs. 65.79±0.22) compared to people with the ordinary type (all P < 0.05). Both men and women who ate exclusively with someone other than family had lower KHEI component scores for breakfast, whole grains, and fruit, excluding juice, compared to the ordinary type and family eating group. Compared to the eating alone group, the component scores for breakfast and whole grains were lower in the eating with others group. The diet quality differed according to the meal companion type. People who always ate with someone other than family members and men who ate alone showed lower diet quality scores than the ordinary type. More research will be needed to improve their adherence to dietary recommendations.

Social Support Status of the Elderly Population in Selected Villages in a Central India District.

Social support has been considered an important social determinant of health because it assists individuals in reaching their physical and emotional needs. The current study was proposed to assess the social support status of the elderly in rural central India. This observational cross-sectional study was conducted in selected four villages in central India on 460 elderly individuals for 5 months (Aug-Dec 2021) with the use of the MSPSS (Multi-dimensional Scale Perceived Social Support) questionnaire. Univariate analysis and multivariate analysis were carried out using R software. Out of 460, 37 (8.04%) of the elderly were found to have low, 177 (38.47%) were moderate, and 246 (53.48%) were having high social support. The result showed age and education of the elderly were significantly associated with social support. Intergenerational activities, provision and strengthening of social platforms, and the addition social support components with comprehensive geriatric assessment can improve the current status.

Structural Inequity and Socioeconomic Status Link to Osteoporosis Diagnosis in a Population-Based Cohort of Middle-Older-Age Americans.

Socioeconomic status (SES) is an important social determinant of health inequities that has been linked to chronic conditions, including osteoporosis, but research tends to focus on socioeconomic disadvantage rather than how socioeconomic advantage may facilitate these inequities. This study accounts for structural inequities and assesses the relationship between early-life and later-life SES, and risk of osteoporosis diagnosis. Data come from the nationally representative, population-based cohort Health and Retirement Study and include individuals ages 50 to 90. The outcome variable is osteoporosis diagnosis. Logistic regression models of the relationship between SES and osteoporosis diagnosis are estimated, accounting for demographic, health, and childhood variables. Higher levels of childhood and adult SES link to lower odds of osteoporosis diagnosis. Structural inequities in income and underdiagnosis of osteoporosis among persons identifying as Black/African American were detected. Accounting for bone density scan access, inequities in osteoporosis diagnosis appear to stem from barriers to accessing health care due to financial constraints. The important role of SES and evidence of structural inequities leading to underdiagnosis suggest the critical importance of clinicians receiving Diversity, Equity, and Inclusion training to reduce health inequities.

A National Study of Homelessness, Social Determinants of Health, and Treatment Engagement Among Outpatient Medication for Opioid Use Disorder-Seeking Individuals in the United States.

Homelessness is an important social determinant of health (SDOH), impacting health outcomes for many medical conditions. Although homelessness is common among people with opioid use disorder (OUD), few studies systematically evaluate homelessness and other SDOH among people enrolled in standard of care treatment for OUD, medication for opioid use disorder (MOUD), or examine whether homelessness affects treatment engagement. Using data from the 2016 to 2018 U.S. Treatment Episode Dataset Discharges (TEDS-D), patient demographic, social, and clinical characteristics were compared between episodes of outpatient MOUD where homelessness was reported at treatment enrollment versus independent housing using pairwise tests adjusted for multiple testing. A logistic regression model examined the relationship between homelessness and treatment length and treatment completion while accounting for covariates. There were 188 238 eligible treatment episodes. Homelessness was reported in 17 158 episodes (8.7%). In pairwise analysis, episodes involving homelessness were significantly different from those involving independent living on most demographic, social, and clinical characteristics, with significantly greater social vulnerability in most SDOH variables (P's < .05). Homelessness was significantly and negatively associated with treatment completion (coefficient = -0.0853, P < 0.001, 95% CI = [-0.114, -0.056], OR = 0.918) and remaining in treatment for greater than 180 days (coefficient = -0.3435, P < 0.001, 95% CI = [-0.371, -0.316], OR = 0.709) after accounting for covariates. Patients reporting homelessness at treatment entry in outpatient MOUD in the U.S. represent a clinically distinct and socially vulnerable population from those not reporting homelessness. Homelessness independently predicts poorer engagement in MOUD confirming that homelessness may be an independent predictor for MOUD treatment discontinuation nationally.

Associação entre suporte social e autoavaliação de saúde na meia-idade: seriam os homens mais afetados que as mulheres?

Abstract: Social support from family and friends is recognized as an important social determinant of health, given its protective effects on individuals’ physical and mental well-being. While most studies have focused on older adults, investigating midlife health is equally crucial since middle-aged individuals are also susceptible to the harmful health outcomes of inadequate social support from friends and family. This study contributes to the debate by examining whether social support is associated with self-rated health among middle-aged Brazilian adults and how this relationship varies between men and women. Using data from the nationwide Brazilian National Health Survey conducted in 2019, logistic regression models were employed to assess differences in self-rated health, accounting for confounding factors. The sample comprised 31,926 middle-aged adults, of which 52.5% were women. The overall prevalence of poor self-rated health was 40.7%, with a significant difference between men and women. Results from this study suggest that having no friends or family members to rely on, both during good and challenging times, was associated with poorer self-rated health. However, the strength of this association differs by gender, with social support from friends playing a more critical role in women’s self-rated health. On the other hand, family support was associated with male self-rated health, particularly for men with three or more family members they can rely on. Future studies should consider cultural and contextual factors to better understand other dimensions of social support and its association with midlife health.

ASSOCIATIONS BETWEEN NEIGHBORHOOD CHARACTERISTICS AND COGNITIVE FUNCTIONING TRAJECTORIES BY RACE/ETHNICITY

Abstract Older adults living in neighborhoods with high physical disorder and low social cohesion may be especially vulnerable to experiencing declining health. However, less is known about how neighborhoods may influence age-related patterns of cognitive functioning for different racial/ethnic groups. Therefore, we examine whether perceived neighborhood characteristics (safety, cleanliness, and social cohesion) are associated with trajectories of cognitive functioning across race/ethnicity. Using data from the 2006-2016 waves of the Health and Retirement Study, our study includes 11,870 non-Hispanic White, non-Hispanic Black, and Mexican adults 65 and older. We conducted linear mixed models stratified by race/ethnicity using an age-accelerated design to understand how neighborhood characteristics are related to trajectories of cognitive functioning (measured by the Telephone Interview for Cognitive Status; range: 0-35). We also explore if sociodemographic, behavioral, and health characteristics account for this association. Analyses revealed that cognitive functioning showed a quadratic change with age. Negative neighborhood perceptions were associated with declines in cognitive functioning with increasing age for each racial/ethnic group. Among White adults, all neighborhood characteristics were negatively associated with cognitive functioning in fully adjusted models. For Black adults, perceived uncleanliness was significantly associated with trajectories of cognitive functioning. In Mexican adults, perceptions of uncleanliness and lower cohesion were significantly associated with worse cognitive functioning, but not in fully adjusted models. These findings suggest that the perceived neighborhood context is an important social determinant of cognitive health for older adults, and distinct aspects of the neighborhood may be more correlated with cognitive functioning for certain racial/ethnic groups than others.

‘I really want to work for me to feel good myself ‘: Health impacts of employment experiences for women from refugee backgrounds in Australia

Work is an important social determinant of health. However, people from refugee backgrounds face various barriers to employment and women especially have significantly lower levels of employment. Many refugees also work in jobs with poor conditions. Given the higher risk of poor health for refugees more generally, the impact of employment experiences on health is an important area of investigation. Drawing on in-depth interviews with 42 refugee women, this paper explores health effects of job seeking and employment experiences. Interviews were analysed using inductive thematic analysis. Women reported difficulties securing work and most were unemployed, which had a negative effect on mental health. Once in work, employment was found to promote wellbeing through a sense of identity and contribution, as well as extending social networks. However, almost all employed participants were working in precarious employment conditions. In terms of mental health, participants reported negative effects from exploitation and discrimination. Exposure to toxic chemicals and poor working conditions were reported as particularly detrimental to physical health. Women were reluctant to complain about poor working conditions, citing a lack of awareness of procedures, fear of losing employment, and concerns about implications for immigration status. Overall, the study highlighted significant barriers to women securing work generally, particularly work that was health promoting. The paper concludes with a discussion of the implications for policy and practice.

Pathways Linking Housing Inequalities and Health Outcomes among Migrant and Refugee Populations in High-Income Countries: A Protocol for a Mixed-Methods Systematic Review

Several high-income countries are currently experiencing an unprecedented and multifaceted housing crisis. The crisis is escalating rapidly, and its negative ramifications are shared disproportionately by migrant and refugee communities. Although housing is often cited as an important social determinant of health, the relationship between housing inequalities and health outcomes in the context of migrant and refugee populations remain under-explored, particularly in high-income countries. This paper presents a protocol for a mixed-methods systematic review which will synthesize the evidence on the key housing and health inequalities faced by migrant and refugee populations in high-income countries. It will inform the identification of pathways linking housing inequalities to health outcomes. The protocol for this systematic review was developed with guidance from the Joanna Briggs Institute (JBI) methodology for mixed-methods systematic reviews using a convergent integrated approach to synthesis and integration, and the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) statement. Quantitative, qualitative and mixed-methods studies reporting the association of housing inequalities with physical and mental health outcomes among refugee and migrant populations in high-income countries will be included. Medline, Web of Science, Embase, PsycINFO, Scopus and CINAHL will be searched for peer-reviewed literature. This will be supplemented by gray literature searches using Google Scholar, MedNar and WHOLIS. Two reviewers will independently screen and select studies, assess the methodological quality and conduct data extraction. This systematic review will elucidate the different pathways linking housing inequalities and health outcomes, which may guide the development of targeted housing and public health interventions to improve the health and wellbeing of migrant and refugee populations. The review is registered with PROSPERO (CRD42022362868).