Individual-level Determinants Research Articles

Algorithmic fairness in cardiovascular disease risk prediction: overcoming inequalities

The main purpose of prognostic risk prediction models is to identify individuals who are at risk of disease, to enable early intervention. Current prognostic cardiovascular risk prediction models, such as...

Social Determinant of Health Impact on Diabetes Device Use and Clinical Outcomes in Youth with Type 1 Diabetes

Background. Youth with Type 1 diabetes (T1D) who are Black, Hispanic, or lower socioeconomic status (SES) have lower rates of diabetes device use, higher hemoglobin A1c (HbA1c), and higher rates of diabetic ketoacidosis (DKA). However, the associations of individual-level social determinants of health (SDoH) and neighborhood-level factors with device use and clinical outcomes are unknown. Area deprivation index (ADI) is a neighborhood level measure of SES reported in deciles (range 1–10 with 10 representing most deprived neighborhood). Methods. We evaluated the association of ADI and other SDoH factors with pump/continuous glucose monitor (CGM) use, HbA1c, and DKA in 1,461 youth with T1D (50% female, age 12.8 ± 3.6 years, HbA1c 8.7 ± 2.1%, 52% pump, 70% CGM) seen between October 1, 2020 and September 30, 2021 at a large pediatric diabetes center. Multiple logistic regression and multiple linear regression analyses were used to determine statistically significant associations adjusting for potential confounders. Results. Youth were less likely to use an insulin pump if they lived in a higher ADI neighborhood, were Black or Hispanic, had Medicaid or were uninsured, or received government assistance (e.g., Supplemental Security Income, Supplemental Nutritional Assistance Program). Youth were less likely to use a CGM if they lived in a higher ADI neighborhood, were Black or Hispanic, had Medicaid or were uninsured. Youth had higher risk of DKA event in the past year if they used government assistance, whereas pump and CGM use were associated with lower DKA risk. HbA1c (%) increased by 0.09 (95% CI: 0.05, 0.13) per unit increase in ADI. HbA1c was 0.62 lower (95% CI: −0.82, −0.42) in pump users vs. nonusers and 0.78 lower (95% CI: −0.99, −0.56) in CGM users vs. nonusers. Conclusions. Interventions that tailor care plans to address SDoH in families living in deprived neighborhoods may be needed to increase successful technology uptake, optimize HbA1c, and prevent DKA.

A not-so ‘natural’ decision: impact of bureaucratic trajectories on forced migrants’ intention and ability to naturalise

ABSTRACT For forced migrants who lack unqualified state protection, citizenship acquisition serves as the only secure way to graduate from legally precarious conditions. However, despite the seemingly obvious upside, the decision to naturalise is not necessarily automatic and for those who do choose to move forward, the process is rarely straightforward. Based on 30 interviews with Syrian forced migrants in Berlin, we address why some applicants who are eligible to naturalise choose not to apply and why eligibility ‘on paper’ does not necessarily translate to ability to naturalise ‘in practice’. By combining literature on migrants’ experiences with street-level bureaucracy and individual-level determinants of naturalisation, the primary objective of this article is to advance our understanding of how citizenship and non-citizenship decisions are made. In order to do so, we build upon the two-step intention-ability framework and in particular introduce ‘bureaucratic trajectory’ as a significant determinant of one’s intention to apply and practical ability to acquire citizenship beyond eligibility. We demonstrate how perceived discretionary implementation and red tape not only constrain but also entice migrants to develop strategies to ‘enable’ access to citizenship.

Mapping Evidence on the Determinants of Postnatal Care Knowledge among Postpartum Women in sub-Saharan Africa: A Literature Review

Maternal and neonatal deaths continue to pose significant public health challenges globally. In 2020, low-to-middle-income countries accounted for over 95% of all maternal deaths. Sub-Saharan Africa (SSA) is the region most severely impacted, accounting for 70% of global maternal deaths in 2020. Most of the maternal deaths and about a third of child deaths occur in the postnatal period. These unnecessary deaths can be avoided if postpartum women have adequate knowledge about postnatal care (PNC). This literature review’s aim was to determine the factors that influence PNC knowledge among postpartum women in SSA. The methodology of this literature review was loosely guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement. Peer-reviewed articles describing determinants of PNC knowledge among postpartum women in SSA published in English between 2013 and 2023 were searched using several search engines. All the twenty-five articles used in this literature review reported on quantitative cross-sectional studies. Some of the individual-level determinants of PNC knowledge identified in this review include place of residence, age of the mother, marital status, educational status of the mother, and the socio-economic status of the woman while the health system-level determinants include distance to a healthcare facility, source of PNC information, place of delivery, and previous maternal healthcare service experience. To improve PNC knowledge of postpartum women, we recommend developing rural areas through improving transport networks, improving the socio-economic status of women, and devising strategies to increase maternal and child health services utilization.

On the determinants of anti-COVID restriction and anti-vaccine movements: the case of IoApro in Italy

Following restrictions to control the spread of COVID-19, and subsequent vaccination campaigns, sentiments against such policies were quick to arise. While individual-level determinants that led to such attitudes have drawn much attention, there are also reasons to believe that the macro context in which these movements arose may contribute to their evolution. In this study, exploiting data on business activities which supported a major Italian anti-restriction and anti-vaccine movement, IoApro, using quantitative analysis that employs both a fractional response probit and logit model and a beta regression model, we investigate the relationship between socio-economic characteristics, institutional quality, and the flourishing of this movement. Our results suggest a U-shaped relationship between income and the proliferation of the movement, meaning that support for these movements increases the greater the degree of economic decline. Our results further indicate that the share of the population between 40 and 60 years old is positively related to support for such movements, as is institutional corruption.

Using PROGRESS-plus to identify current approaches to the collection and reporting of equity-relevant data: a scoping review

ObjectivesOur objectives were to identify what and how data relating to the social determinants of health are collected and reported in equity-relevant studies and map these data to the PROGRESS-Plus framework. Study Design and SettingWe performed a scoping review. We ran two systematic searches of MEDLINE and Embase for equity-relevant studies published during 2021. We included studies in any language without limitations to participant characteristics. Included studies were required to have collected and reported at least two participant variables relevant to evaluating individual-level social determinants of health. We applied the PROGRESS-Plus framework to identify and organize these data. ResultsWe extracted data from 200 equity-relevant studies, providing 962 items defined by PROGRESS-Plus. A median of 4 (interquartile range = 2) PROGRESS-Plus items were reported in the included studies. 92% of studies reported age; 78% reported sex/gender; 65% reported educational attainment; 49% reported socioeconomic status; 45% reported race; 44% reported social capital; 33% reported occupation; 14% reported place and 9% reported religion. ConclusionOur synthesis demonstrated that researchers currently collect a limited range of equity-relevant data, but usefully provides a range of examples spanning PROGRESS-Plus to inform the development of improved, standardized practices.

Geospatial patterns of progress towards UNAIDS ‘95-95-95’ targets and community vulnerability in Zambia: insights from population-based HIV impact assessments

IntroductionIn sub-Saharan Africa, HIV/AIDS remains a leading cause of death. The UNAIDS established the ‘95-95-95’ targets to improve HIV care continuum outcomes. Using geospatial data from the Zambia Population-based HIV...

What do pedestrians consider when choosing a route? The role of safety, security, and attractiveness perceptions and the built environment during day and night walking

Increasing the use of non-motorized modes of transport, such as walking, is a worldwide objective aimed at improving the sustainability of cities. However, pedestrians may not choose to walk if the infrastructure fails to meet their needs or if they hold unfavourable perceptions regarding the built environment (BE). The current study aims to identify the significance of route attributes and perceptions of attractiveness, safety, and security at the route level, which influence pedestrians' preferences for last-mile route choices. A cross-sectional design was employed, utilizing a questionnaire comprising a stated preference (SP) experiment and a perception survey. The study considered theory-informed attributes influencing pedestrian route choice preferences, including: (1) individual-level determinants, (2) physical-level determinants, and (3) time of day. Two separate models were developed, considering the time of day, to examine the differences in trade-offs within pedestrians' route choice preferences between day and night. The results revealed that both the BE and perceptions of the BE play a crucial role in determining pedestrian route choice behaviour. Pedestrians showed a preference for routes fully encompassed by mixed or residential land uses during the daytime. The presence of vacant land along the walking route significantly decreased the likelihood of choosing a route at night. Generally, pedestrians favoured shorter walking times, lower posted speed limits, and comfortable walkway grades in their routes. Female pedestrians tended to avoid routes that were not well-lit and pleasant at night. Lowering roadway speed limits emerged as a strategy to encourage walking in suburban areas. The findings of this study hold the potential to play an essential role in the development of effective policy initiatives targeted at pedestrians in cities.

The Social Ecological Model: A Framework for Understanding COVID-19 Vaccine Uptake among Healthcare Workers-A Scoping Review.

Vaccination plays a crucial role in combating the global COVID-19 pandemic. Immunizing all healthcare workers (HCWs) is essential for increasing vaccine confidence and acceptance within the general population. Understanding the factors that hinder or facilitate vaccine uptake among HCWs is of utmost importance, considering they are among the first to be vaccinated. This review follows Arksey and O'Malley's five-stage methodological framework. We searched PubMed, Web of Science, ProQuest, WorldCat Discovery, and Google Scholar for peer-reviewed articles published from 2020 to 2023. A descriptive analysis and narrative synthesis approach were employed to collect and synthesize data. Using the social-ecological model as a framework, the literature was categorized into themes at the intrapersonal, interpersonal, organizational, community, and policy levels. We reviewed a total of fifty-three published academic articles, with the majority of studies conducted in Ethiopia and Nigeria. The intention for vaccine uptake resulted in an unsatisfactory (52%) overall uptake rate among HCWs. Individual-level determinants associated with vaccine uptake included being male, middle-aged, being a physician, having a higher level of education, and having a chronic illness. This review identified significant barriers at each level, such as safety concerns, perceived scientific uncertainty, vaccine ineffectiveness, lack of trust in stakeholders, and religious beliefs. Additionally, we identified facilitators at each level, with the most common factors promoting intention to uptake being the desire to protect oneself and others and a high perceived susceptibility to contracting COVID-19. This review highlights the existence of significant barriers to vaccine uptake on the African continent. Given that HCWs play a crucial role in guiding the public's vaccination decisions, it is imperative to prioritize education and training efforts about the safety and effectiveness of COVID-19 vaccines.

Barriers and Facilitators to the Outpatient Management of Low-risk Pulmonary Embolism From the Emergency Department.

Although recommended by professional society guidelines, outpatient management of low-risk pulmonary embolism (PE) from emergency departments (EDs) in the US remains uncommon. The objective of this study was to identify barriers and facilitators to the outpatient management of PE from the ED using implementation science methodology. We conducted semistructured interviews with a purposeful sample of emergency physicians using maximum variation sampling, aiming to recruit physicians with diverse practice patterns regarding the management of low-risk PE. We developed an interview guide using the implementation science frameworks-the Consolidated Framework for Implementation Research and the Theoretical Domains Framework. Interviews were recorded, transcribed, and analyzed in an iterative process. We interviewed 26 emergency physicians from 11 hospital systems, and the participants were diverse with regard to years in practice, practice setting, and engagement with outpatient management of PE. Although outer setting determinants, such as medicolegal climate, follow-up, and insurance status were universal, our participants revealed that the importance of these determinants were moderated by individual-level and inner setting determinants. Prominent themes included belief in consequences, belief in capabilities, and institutional support and culture. Inertia of clinical practice and complexity of the process were important subthemes. In this qualitative study, clinicians reported common barriers and facilitators that initially focused on outer setting and external barriers but centered on clinician beliefs, fear, and local culture. Efforts to increase outpatient treatment of select patients with acute PE should be informed by these barriers and facilitators, which are aligned with the deimplementation theory.

A multi-country survey of the socio-demographic factors associated with adherence to COVID-19 preventive measures during the first wave of the COVID-19 pandemic

BackgroundHealth behaviours are influenced by individual characteristics including age, gender, education and economic level. This study aimed to assess the associations between individual-level determinants and adherence to COVID-19 preventive measures.MethodsWe performed secondary analyses of international data collected using an online survey during the first wave of the COVID-19 pandemic between June and December 2020. The dependent variables were self-reported adherence to COVID-19 preventive measures (wearing of face masks, frequent washing/sanitizing of hands, physical distancing, working remotely). The independent variables were age, sex at birth (female vs male), having a chronic disease related elevated risk for severe COVID-19 (none/little, might be at increased risk, at increased risk), educational level completed (no formal education, primary, secondary vs college/university) and employment status (retiree, students, not employed vs employed). Four multivariate logistic regression analyses were conducted to determine the associations between the dependent variables and independent variables. Interaction terms with country-income level were tested in regressions to explore its moderating effect.ResultsOut of 16,866 respondents, 12,634 (74.9%) wore masks or face coverings, 12,336 (73.1%) washed or sanitized their hands frequently, 11,464 (68.0%) reported adherence to physical distancing and 5,646 (33.5%) worked remotely. In adjusted analyses, increased age, college/university education, employment, and having risks for severe COVID-19 were associated with significantly higher odds of adhering to COVID-19 preventive measures. Retirees and students had lower odds of adhering to COVID-19 prevention measures than employed individuals. Males had significantly lower odds of wearing face masks (AOR: 0.901), frequent washing/sanitizing hands (AOR: 0.774) and working remotely (AOR: 0.875) compared to females. Country-income level generally moderated the above relationships such that the associations disappeared in lower income countries.ConclusionThe study findings suggest that the individual socio-demographic factors—age, sex, employment status, education status and having a chronic disease – influence adherence to COVID-19 preventive measures. Findings further reiterate the need for health education and health promotion campaigns on preventive health measures to focus on subpopulations, such as younger males, students and retirees, that require targeted or unique messaging.

Who Wants to Leave? Global Survey Evidence on How Individual Emigration Aspirations Differ Between Peaceful and Conflict-Affected Contexts

Does conflict change who desires to emigrate? Surprisingly, we still lack globally comparable empirical evidence on whether the types of individuals who want to leave their country differ between peaceful and conflict-affected locations. In this paper, we address this gap. We analyze unique survey data with global coverage to assess whether individual-level determinants of international permanent emigration aspirations differ during intrastate armed conflict compared to peaceful times and regions. We argue that armed conflict acts as an equalizer that attenuates the effect which individual economic and demographic variables have on international permanent emigration aspirations in peaceful contexts. As a result, aspirations to relocate permanently to another country increase among those demographic groups which are less inclined to move in peaceful situations. Our results indicate that variables related to a longer-term economic cost-benefit analysis, such as income or age, significantly lose importance for international permanent emigration aspirations in conflict situations. This demographic-specific effect explains an overall increase in emigration aspirations during conflicts. On average, we find no evidence that conflict increases the aspirations of all respondents to permanently move to another country. In contrast to income and age, the effects of demographic variables such as gender, household composition, or marital status are not significantly different across contexts.

Examining Determinants of Corruption at the Individual Level in South Asia

Although the topic of corruption in South Asia has attracted a great deal of attention, extant research on individual-level factors is sparse. With this background, this paper examines the effect of selected individual-level determinants on South Asian people’s justifiability of corruption. For analysis, the paper uses the World Value Survey (WVS) dataset and carries out its own survey as well. Using multinomial logistic regression (MLR) and binomial logistic regression (BLR) as a robustness check, this paper identifies that variables of age, education, religiosity, and individualism/collectivism have significant effects on respondents’ corruption justifiability in South Asia. In addition, the paper performs additional analyses independently using two surveys utilized in the main analysis as a single dataset to report the main differences between them. In conclusion, this paper proposes a region-specific suggestion for South Asian governments and policy makers.

Socio-economic inequalities in body mass index among preschool children: do sports programs in early childhood education and care centers make a difference?

Overweight in childhood is considered to be one of the most serious public health challenges. Many studies have investigated individual-level determinants of children's body mass index (BMI), yet studies exploring determinants at the meso-level are sparse. The aim of our study was to examine how a sports focus at early childhood education and care (ECEC) centers moderates the effect of parental socio-economic position (SEP) on children's BMI. We used data from the German National Educational Panel Study and included 1,891 children (955 boys and 936 girls) from 224 ECEC centers in our analysis. Linear multilevel regressions were used to estimate the main effects of family SEP and the ECEC center sports focus, as well as their interaction, on children's BMI. All analyses were stratified by sex and adjusted for age, migration background, number of siblings, and employment status of parents. Our analysis confirmed the wellknown health inequalities in childhood overweight with a social gradient toward a higher BMI for children from lower SEP families. An interactive effect between family SEP and ECEC center sports focus was found. Boys with low family SEP not attending a sports-focused ECEC center had the highest BMI among all boys. In contrast, boys with low family SEP attending a sports-focused ECEC center had the lowest BMI. For girls, no association regarding ECEC center focus or interactive effects emerged. Girls with a high SEP had the lowest BMI, independent of the ECEC center focus. We provided evidence for the gender-specific relevance of sports-focused ECEC centers for the prevention of overweight. Especially boys from low SEP families benefited from a sports focus, whereas for girls the family's SEP was more relevant. As a consequence, gender differences in determinants for BMI at different levels and their interaction should be considered in further research and preventive measures. Our research indicates that ECEC centers may decrease health inequalities by providing opportunities for physical activity.

A Scoping Review of Cancer Interventions with Arab Americans.

This scoping review provides an overview of cancer interventions implemented with Arab Americans across the cancer control continuum, including an examination of outcomes and implementation processes. The search strategy included database searchingand reviewing reference lists and forward citations to identify articles describing interventions with Arab adults living in the US, with no restrictions on date of publication or research methodology. The review included 23 papers describing 12 unique cancer interventions. Most interventions focused on individual-level determinants of breast and cervical cancer screening; used non-quasi-experimental research designs to evaluate intervention effectiveness; and demonstrated improvements in short-term cancer screening knowledge. Implementation processeswere less commonly described. Most interventions were culturally and linguistically tailored to communities of focus; were delivered in educational sessions in community settings; engaged with the community mostly for recruitment and implementation; and were funded by foundation grants. Suggestions for research and intervention development are discussed.

Demographic, structural, and psychological predictors of risk-increasing and mask wearing behaviors among US adults between December 2020–March 2021

ObjectivesTo assess demographic, structural, and psychological predictors of risk-increasing and risk-decreasing behaviors MethodsThis study used data from an online longitudinal, three-wave COVID-19 survey (12/20–03/21) regarding the behaviors, attitudes, and experiences of US Veteran (n = 584) and non-Veteran (n = 346) adults. ResultsInability to get groceries delivered emerged as the strongest predictor of more frequent risk-increasing behavior across all timepoints. Other consistent predictors of more frequent risk-increasing behavior and less frequent mask wearing included less worry about getting COVID-19, disbelief in science, belief in COVID-19 conspiracies, and negative perceptions of the state response. No demographic factor consistently predicted risk-increasing behavior or mask wearing, though different demographic predictors emerged for more frequent risk-increasing behaviors (e.g., lower health literacy) and mask-wearing (e.g., older age and urban residence) at certain timepoints. The most frequently endorsed reasons for having contact with others concerned health-related (food, medical care, and exercise) and social needs (seeing friends/family and boredom). ConclusionsThese findings highlight key individual-level determinants of risk-increasing behaviors and mask wearing which encompass demographic, structural, and psychological factors. Practice ImplicationsFindings can support public health experts and health communicators promote engagement with risk-reducing behaviors and address key barriers to engaging in these behaviors.

Ability of detecting and willingness to share fake news

By conducting large-scale surveys in Germany and the United Kingdom, we investigate the individual-level determinants of the ability to detect fake news and the inclination to share it. We distinguish between deliberate and accidental sharing of fake news. We document that accidental sharing is much more common than deliberate sharing. Furthermore, our results indicate that older, male, high-income, and politically left-leaning respondents better detect fake news. We also find that accidental sharing decreases with age and is more prevalent among right-leaning respondents. Deliberate sharing of fake news is more prevalent among younger respondents in the United Kingdom. Finally, our results imply that respondents have a good assessment of their ability to detect fake news: those we identified as accidental sharers were also more likely to have admitted to having shared fake news.

Increasing Prevention of Mother to Child Transmission (PMTCT) Uptake through Facility-Based Health Promotion: Intervention Development

In Sudan, the HIV testing rates during pregnancy remain low. Limitations in scaling and uptake of PMTCT services are linked to several factors within the healthcare system, including the motivation of healthcare providers. This article describes how a health facility-based health promotion intervention plan was developed, implemented, and evaluated to increase the uptake of PMTCT services using the Intervention Mapping approach. Individual-level and environmental determinants were previously identified and included in the intervention plan. Some factors that impacted the intention of women to test for HIV during pregnancy include level of knowledge on MTCT, who offers the HIV test, the fear and tension experienced when thinking about HIV/AIDS, the non-confidentiality of the HIV test results, and self-efficacy. This provides insights into how to develop, implement, and evaluate a facility-based health promotion intervention. The pre-assessment was critical in shaping the intervention and making it relevant and evidence based. The Intervention Mapping approach that was applied facilitated the systematic design of the intervention and supported guiding the implementation.

Trend analysis of multi-level determinants of maternal and newborn postnatal care utilization in Pakistan from 2006 to 2018: Evidence from Pakistan Demographic and Health Surveys

BackgroundPostnatal care (PNC) is crucial for maternal and newborn health. Healthcare-seeking practices within the postpartum period help healthcare providers in early detection of complications related to childbirth and post-delivery period. This study aims to investigate trends of PNC utilization from 2006 to 2018, and to explore the effects of multi-level determinants of both maternal and newborn PNC in Pakistan.MethodsSecondary data analysis of the last three waves of the nationally representative Pakistan Demographic and Health Surveys (PDHSs) was conducted Analysis was limited to all those women who had delivered a child during the last 5 years preceding each wave of PDHS Bivariate and multivariate logistic regression was applied to determine the association of maternal and newborn PNC utilization with multi-level determinants at individual, community, and institutional levels.ResultsIn Pakistan, an upward linear trend in maternal PNC utilization was found, with an increase from 43.5 to 63.6% from 2006 to 2018. However, a non-linear trend was observed in newborn PNC utilization, with an upsurge from 20.6 to 50.5% from 2006 to 2013, nonetheless a decrease of 30.7% in 2018. Furthermore, the results highlighted that the likelihood of maternal and newborn PNC utilization was higher amongst older age women, who completed some years of schooling, were employed, had decision-making and emotional autonomy, had caesarean sections, and delivered at health facilities by skilled birth attendants. Multivariate analysis also revealed higher odds for women of older age, who had decision-making and emotional autonomy, and had caesarean section deliveries over the period of 2006–2018 for both maternal and newborn PNC utilization. Further, higher odds for maternal PNC utilization were found with parity and size of newborn, while less for ANC attendance and available means of transportation. Furthermore, increased odds were recorded for newborn PNC utilization with the number of children, ANC attendance, gender of child and mass media exposure from 2006 to 18.ConclusionA difference in maternal and newborn PNC utilization was found in Pakistan, attributed to multiple individual (socio-demographic and obstetrics), community, and institutional level determinants. Overall, findings suggest the need to promote the benefits of PNC for early diagnosis of postpartum complications and to plan effective public health interventions to enhance women’s access to healthcare facilities and skilled birth assistance to save mothers’ and newborns’ lives.

PrEP and HIV prevention decision-making among social network members of women who have experienced incarceration: a qualitative study

ABSTRACT Incarceration and HIV are a syndemic for US women, yet very few women who have experienced incarceration use pre-exposure prophylaxis (PrEP) for HIV. We conducted semi-structured interviews with 32 participants recruited by women who have experienced incarceration from their social networks, informed by the modified social ecological model for PrEP. Emergent themes from the interviews included individual-level (low personal HIV risk assessment, personal responsibility for HIV prevention, and decisions in addiction versus recovery), network-level (influential sex partners and the importance of trust, supportive treatment peers, and high-risk but indifferent drug use networks), community-level (stigma, and mitigation of stigma in supportive substance use disorder treatment environments), and public policy-level (incarceration and PrEP cost and access) determinants. PrEP interventions for women who have experienced incarceration and their networks will need to incorporate contingency planning into HIV risk assessment, navigate complex network dynamics, and be situated in trusted contexts to address structural barriers.