Key Social Determinants Of Health Research Articles

Exploring racial/ethnic disparities in rehabilitation outcomes after TBI: A Veterans Affairs Model Systems study.

Almost one-third of the U.S. military population is comprised of service members and veterans (SMVs) of color. Research suggests poorer functional and psychosocial outcomes among Black and Hispanic/Latine vs. White civilians following traumatic brain injury (TBI). This study examined racial/ethnic differences in 5-year functional independence and life satisfaction trajectories among SMVs who had undergone acute rehabilitation at one of five Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). Differences in demographic and injury-related factors were assessed during acute rehabilitation among White (n = 663), Black (n = 89), and Hispanic/Latine (n = 124) groups. Functional Independence Measure (FIM) Motor, FIM Cognitive, and Satisfaction with Life Scale (SWLS) scores were collected at 1, 2, and 5 years after injury. Racial/ethnic comparisons in these outcome trajectories were made using hierarchical linear modeling. Black SMVs were less likely than White and Hispanic/Latine SMVs to have been deployed to a combat zone; there were no other racial/ethnic differences in any demographic or injury-related variable assessed. In terms of outcomes, no racial/ethnic differences emerged in FIM Motor, FIM cognitive, or SWLS trajectories. The absence of observable racial/ethnic differences in 5-year outcome trajectories after TBI among SMVs from VA TBIMS PRCs contrasts sharply with previous research identifying disparities in these same outcomes and throughout the larger VA health care system. Individuals enrolled in VA PRCs are likely homogenized on key social determinants of health that would otherwise contribute to racial/ethnic disparities in outcome trajectories.

Healthcare system action on employment as a social determinant of health in people living with HIV: A qualitative study.

Employment is a key social determinant of health. People living with HIV (PLWH) have higher unemployment rates than the general population. Vocational rehabilitation services have been shown to have significant and positive impact on employment status for PLWH. Understanding whether integrating vocational rehabilitation with health care services is acceptable, from the perspectives of PLWH and their health care providers, is an area that is understudied. We conducted a qualitative study and collected data from focus groups and interviews to understand the perspectives of stakeholders regarding the potential for vocational rehabilitation and health care integration. We completed five focus groups with 45 health care providers and one-to-one interviews with 23 PLWHs. Participants were sampled from infectious disease, primary care clinics, and AIDS Service Organizations in Toronto and Ottawa, Canada. Interviews were audio-recorded and transcribed. We conducted a reflexive thematic analysis of the transcripts. We found health care providers have little experience assisting patients with employment and PLWH had little experience receiving employment interventions from their health care team. This lack of integration between health care and vocational services was related to uncertainties around drug coverage, physician role and living with an episodic disability. Health care providers thought that there is potential for a larger role for health care clinics in providing employment interventions for PLWH however patients were divided. Some PLWH suggest that health care providers could provide advice on the disclosure of status, work limitations and act as advocates with employers. Health care providers and some PLWH recognize the importance of integrating health services with vocational services but both groups have little experience with implementing these types of interventions. Thus, there needs to be more study of such interventions, including the processes entailed and outcomes they aim to achieve.

Homeowner perspectives on the implementation of the Community Homes for Opportunity (CHO) program: an ethnographic group homes study in Southwestern Ontario Canada

BackgroundThe global extant literature acknowledge that housing serves as a key social determinant of health. Housing interventions that involve group homes have been found to support the recovery of persons with mental illness and those with addiction issues. The current study explored the views of homeowners in relation to a supportive housing program called Community Homes for Opportunity (CHO) that modernised a provincial group home program (Homes for Special Care [HSC]) and provided recommendations for improving the program implementation in other geographical areas of Ontario.MethodsWe applied ethnographic qualitative techniques to purposefully recruit 36 homeowner participants from 28 group homes in Southwest Ontario, Ontario Canada. Focus group discussions were conducted at two time points, during CHO program implementation (Fall 2018, and post implementation phases (Winter 2019) respectively.ResultsData analysis yielded 5 major themes. These include: (1) general impressions about the modernization process, (2) perceived social, economic and health outcomes, (3) enablers of the modernization program, (4) challenges to implementation of the modernization program, and (5) suggestions for implementation of the CHO in future.ConclusionsA more effective and expanded CHO program will need the effective collaboration of all stakeholders including homeowners for successful implementation.

Religion as a social determinant of women's cancer screening: Evidence from state level data for policy and resource allocation

AbstractReligion as a Social Determinant of Health (SDOH) is established in relevant literature. The challenge is to translate the theoretical and empirical relationship between religion and health to practical applications and policymaking to build partnerships between state government entities and faith‐based organizations. Our manuscript focuses on the connection between adherence to religion and the pernicious public health problem of cancer in women. Using publicly available state level data and Ordinary Least Square regression analysis, we identify the SDOH, including adherence to religion, that are associated with state level rates of cancer screening for women. We confirm that states with higher levels of adherence to religion have higher rates of cancer screening for women including Pap smear and mammogram. Our results show that the magnitude of the effect of adherence to religion and state level rates of cancer screening for women is similar to that of other key SDOH. Our results provide state‐level targets for population health improvements that should be addressed with policy that recognizes and encourages partnerships with faith‐based organizations to improve health for women.

Addressing Racism in Ethics Consultation: An Expansion of the Four-Box Method.

AbstractRacism is a pervasive issue in patient care and a key social determinant of health. Clinical ethicists, like others involved in patient care, have a duty to recognize and respond to racism on both individual and systems-wide levels to improve patient care. Doing so can be challenging and, like other skills in ethics consultation, may benefit from specialized training, standardized tools and approaches, and practice. Learning from existing frameworks and tools, as well as building new ones, can help guide clinical ethicists to systematically approach racism as it affects clinical cases. Here, we propose an expansion of the commonly used four-box method to clinical ethics consultation, where racism is considered as a potential factor in each of the four boxes. We apply this method to two clinical cases to highlight ethically salient information that might be missed using the standard formulation of the four boxes but captured with the expanded version. We argue that this expansion of an existing clinical ethics consultation tool is ethically justified insofar as it (a) creates a more just approach, (b) supports individual consultants and services, and (c) facilitates communication in contexts where racism impinges on effecting good patient care.

Health literacy and uptake of annual physical checkups among emerging adults in the United States: Findings from the Behavioral Risk Factor Surveillance System

AbstractPublic health literature is replete with evidence on the determinants of preventive healthcare utilization. However, gap exists in the relationship between health literacy, a key social determinant of health, and annual physical checkups, especially among younger adults in the United States. This age group is one of the least likely to utilize such services for screening and prevention of diseases, which can have a significant impact on their long‐term health as they progress through the life course. Using the Andersen Healthcare Utilization framework, this study investigated the association between health literacy, an enabling factor, and uptake of annual physical checkups among emerging adults aged 18–29. A binary logistic regression model was employed to achieve the study objective using data from the 2016 Behavioral Risk Factor Surveillance System data (N = 9515). Findings showed that 61% of young adults had physical checkups in the past year. After adjusting for predisposing, need, and other enabling factors, experiencing difficulties with oral and written health literacy and having difficulties obtaining medical information and advice were significantly associated with lower odds of physical checkups in the past year. These findings provide evidence for strategies like Healthy People 2030 that aim to increase preventive healthcare service utilization among emerging adults.

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.

Racial and Ethnic Disparities in Hypertension: Barriers and Opportunities to Improve Blood Pressure Control.

To characterize the barriers and opportunities associated with racial and ethnic disparities in blood pressure (BP) control. Blood pressure (BP) control rates in the USA have worsened over the last decade, with significantly lower rates of control among people from racial and ethnic minority groups, with non-Hispanic (NH) Black persons having 10% lower control rates compared to NH White counterparts. Many factors contribute to BP control including key social determinants of health (SDoH) such as health literacy, socioeconomic status, and access to healthcare as well as low awareness rates and dietary habits. Numerous pharmacologic and non-pharmacologic interventions have been developed to reduce racial and ethnic disparities in BP control. Among these, dietary programs designed to help reduce salt intake, faith-based interventions, and community-based programs have found success in achieving better BP control among people from racial and ethnic minority groups. Disparities in the prevalence and management of hypertension persist and remain high, particularly among racial and ethnic minority populations. Ongoing efforts are needed to address SDoH along with the unique genetic, social, economic, and cultural diversity within these groups that contribute to ongoing BP management inequalities.

SOCIAL DETERMINANTS OF HEALTH UNDERLIE RACIAL/ETHNIC DISPARITIES IN PSYCHOLOGICAL HEALTH AND WELL-BEING

Abstract This study sought to determine the impact of selected social determinants of health on psychological health and well-being (defined as depression, cognition, self-rated health) among Black and Hispanic/Latinx adults relative to White adults aged 51 to 89. We measured disparities in depression, cognition, and self-rated health among 2,306 Non-Hispanic/Latinx Black, 1,593 Hispanic/Latinx, and 7,244 Non-Hispanic/Latinx White adults from the Health and Retirement Study (n=11,143). Blinder-Oaxaca decomposition was used to examine whether differences in selected social determinants of health explained a larger share of the disparities than age, sex, measures of health, health behaviors, and healthcare utilization. Selected social determinants included education, parents’ education, number of years worked, marital status, veteran status, geographic residence, nativity status, income, and insurance coverage. Black and Hispanic/Latinx adults reported worse depression, cognition, and self-rated health compared to White adults. Selected social determinants of health explained a larger proportion of the Black-White disparities in depression (51%), cognition (39%), and self-rated health (37%) than did age, sex, measures of health, health behaviors, and healthcare utilization. Social determinants of health explained a larger proportion of the Hispanic/Latinx-White disparity in cognition (76%) and self-rated health (75%), but age and functional status primarily drove the disparity in depression (28%). Education, parents’ education, years worked, income, and insurance parity were social determinants associated with the disparities.In conclusion, differences in social determinants of health underlie racial/ethnic disparities in depression, cognition, and self-rated health among older adults. Education, income, number of years worked, and insurance parity are key social determinants of health.

I'm just trying to stay: Experiences of temporal uncertainty in modular and supportive housing among young people who use drugs in Vancouver.

Over the past decades the city of Vancouver has attempted to address a lack of affordable housing for it most marginalized citizens, including young people who use drugs (YPWUD), by expanding access to temporary modular and supportive housing. These projects are guided by a Housing First philosophy that recognizes housing as a key social determinant of health. In this commentary, we draw attention to how, rather than providing a clear pathway to greater stability, modular and supportive housing have become part of broader "institutional circuits" that reinforce residential transience and what we call "temporal uncertainty." We use this term to describe a painful and frustrating inability to move though time in desired ways despite the promise of greater stability that housing is supposed to engender. Rather than allowing young people to establish more predictable day-to-day rhythms and routines and enact the futures they imagine for themselves, residing in modular and supportive housing environments often generates significant instability and uncertainty. We believe that Housing First interventions have significant potential to reduce harms and improve outcomes for YPWUD. However, chronic temporal uncertainty must be addressed, including through the creation of more permanent, desirable social housing, extending supports to young people beyond tenancies, and working with them to develop timelines and plans for what happens next.

Association of US County-Level Eviction Rates and All-Cause Mortality.

Housing instability is a key social determinant of health and has been linked to adverse short- and long-term health. Eviction reflects a severe form of housing instability and disproportionately affects minority and women residents in the USA; however, its relationship with mortality has not previously been described. To evaluate the independent association of county-level eviction rates with all-cause mortality in the USA after adjustment for county demographic, socioeconomic, and health-related characteristics. Cross-sectional. Six hundred eighty-six US counties with available 2016 county-level eviction and mortality data. 2016 US county-level eviction rate. 2016 US county-level age-adjusted all-cause mortality. Among 686 counties (66.1 million residents, 50.5% [49.7-51.2] women, 2% [0.5-11.1] Black race) with available eviction and mortality data in 2016, we observed a significant and graded relationship between county-level eviction rate and all-cause mortality. Counties in the highest eviction tertile demonstrated a greater proportion of residents of Black race and women and a higher prevalence of poverty and comorbid health conditions. After adjustment for county-level sociodemographic traits and prevalent comorbid health conditions, age-adjusted all-cause mortality was highest among counties in the highest eviction tertile (Tertile 3 vs 1 (per 100,000 people) 33.57: 95% CI: 10.5-56.6 p=.004). Consistent results were observed in continuous analysis of eviction, with all-cause mortality increasing by 9.32 deaths per 100,000 people (4.77, 13.89, p<.0001) for every 1% increase in eviction rates. Significant interaction in the relationship between eviction and all-cause mortality was observed by the proportion of Black and women residents. In this cross-sectional analysis, county-level eviction rates were significantly associated with all-cause mortality with the strongest effects observed among counties with the highest proportion of Black and women residents. State and federal protections from evictions may help to reduce the health consequences of housing instability and address disparities in health outcomes.

COVID-19 impact on the psychological health of Latinx transgender and non-binary individuals in mainland United States and Puerto Rico: a mixed-methods study

BackgroundThe COVID-19 pandemic continues to generate an unprecedented impact on all aspects of everyday life across the world. However, those with historically and currently marginalized identities (i.e., gender or ethnicity) who already experience a wide range of structural inequities have been disproportionally impacted. LTNB are a particularly at-risk population as they lie at the intersection of race/ethnicity, gender identity, language, migration status, geographical location, among others, which could further increase their COVID-19 and other health-related risks and disparities. The objective of this study was to examine the impact of key social determinants of health (i.e., gender identity, country, health insurance, employment) among a sample of LTNB individuals.MethodsThe team implemented a cross-sectional exploratory design with an online survey technique using the secure web platforms REDcap and SurveyMonkey. A total of 133 participants completed the online survey. Most of the sample self-identified as transwomen (38.8%), transmen (26.3%), and non-binary (21.8%) between the ages of 21 to 72. All participants were Latinx living in either Puerto Rico (47.7%) or mainland United States (52.3%). Descriptive statistics, reliability tests, Mann-Whitney and rapid thematic analysis test were conducted.ResultsFindings show that most participants were always (38.1%) or almost always (33.3%) worried about contracting COVID-19. Individuals living in Puerto Rico reported more difficulties than those residing in the mainland US regarding COVID-19 impact on psychosocial, emotional, and COVID-related thinking. Most participants’ answers for the COVID-19 open-ended questions focused on three main domains: income, access to trans-affirmative health care, and coping strategies.DiscussionFindings evidence that although most of LTNB participants were negatively impacted by the COVID-19 pandemic in multiple aspects of their lives, those living in Puerto Rico experienced these differently when compared to those in mainland US. More research is needed to understand better the mechanisms and pathways through which this context specifically impacts LTNB health and wellbeing, particularly in Puerto Rico. This study could help shape the public health response taking into account the geographical location and other intersectional identities that play critical roles in the production and reproduction of inequities.

The Language of Incarceration and of Persons Subject to Incarceration

Abstract Reflecting on Smith (2021) in this issue, this commentary extends our consideration of issues in carceral health and questions the dehumanizing language we sometimes use—including in public health and public health ethics—to talk about persons held in incarceration. Even the language we use for the carceral system itself (such as ‘criminal justice system’) is fraught: it casts a laudatory light on the system and papers over its role in compounding racial health inequities and in sustaining colonialism. A host of issues call out for ethical analysis, using lenses that can encompass the tensions and contradictions experienced by people within the system who deliver healthcare and those within the system trying to access that care. Beyond access to health care (promotion, prevention, treatment and palliation), the societal commitment to dealing with social issues by depriving people of many key social determinants of health is at the heart of many of these tensions and contradictions.

Self-determination by First Nations Australians in alcohol policy: Lessons from Mbantua/Alice Springs (Northern Territory, Australia).

First Nations Australians have an internationally-recognised right to self-determination - a key social determinant of health. The recognition and application of this right varies within different regions and policy contexts but is currently unknown for First Nations Australians' engagement in alcohol policy development. This study seeks to: explore First Nations Australians' experiences of alcohol policy in Central Australia (Northern Territory); and identify how First Nations Australians' right to self-determination can be recognised and applied in the development of alcohol policy in Mbantua/Alice Springs. Using a blended yarning and appreciative inquiry approach, 24 interviews were conducted. Interviews were thematically coded in multiple stages, using diagrammatic methods. Four key themes emerged: (i) experiences of purchasing alcohol; (ii)communication of the current alcohol policy; (iii) experiences of policy described by participants (and their community); and (iv) self-determination in alcohol policy. Current pathways for contributing to alcohol policy have been ineffective in achieving meaningful engagement with Australia's First Nations community members. This study provides some guidance as to how self-determination can more effectively be incorporated in the development of alcohol policy in the NT.

Understanding the Associations among Social Vulnerabilities, Indigenous Peoples, and COVID-19 Cases within Canadian Health Regions.

Indigenous Peoples are at an increased risk for infectious disease, including COVID-19, due to the historically embedded deleterious social determinants of health. Furthermore, structural limitations in Canadian federal government data contribute to the lack of comparative rates of COVID-19 between Indigenous and non-Indigenous people. To make visible Indigenous Peoples’ experiences in the public health discourse in the midst of COVID-19, this paper aims to answer the following interrelated research questions: (1) What are the associations of key social determinants of health and COVID-19 cases among Canadian health regions? and (2) How do these relationships relate to Indigenous communities? As both proximal and distal social determinants of health conjointly contribute to COVID-19 impacts on Indigenous health, this study used a unique dataset assembled from multiple sources to examine the associations among key social determinants of health characteristics and health with a focus on Indigenous Peoples. We highlight key social vulnerabilities that stem from systemic racism and that place Indigenous populations at increased risk for COVID-19. Many Indigenous health issues are rooted in the historical impacts of colonization, and partially invisible due to systemic federal underfunding in Indigenous communities. The Canadian government must invest in collecting accurate, reliable, and disaggregated data on COVID-19 case counts for Indigenous Peoples, as well as in improving Indigenous community infrastructure and services.

Robust evidence of Bolsa Família Programme's benefits

Cash transfer is a social assistance intervention that directly addresses income, a key social determinant of health. Generally, cash transfers are cash payments provided by formal institutions (national governments, international organisations, or donors) to select recipients that might be conditional on prescribed behaviours. The Bolsa Família Programme (BFP), one of the largest conditional cash transfer programmes in the world, is intended to diminish poverty and hunger by purposely providing regular cash transfers for an extended period.

Housing Insecurity Among Patients With Cancer.

Social determinants of health are the economic and environmental conditions under which people are born, live, work, and age that affect health. These structural factors underlie many of the long-standing inequities in cancer care and outcomes that vary by geography, socioeconomic status, and race and ethnicity in the United States. Housing insecurity, including lack of safe, affordable, and stable housing, is a key social determinant of health that can influence-and be influenced by-cancer care across the continuum, from prevention to screening, diagnosis, treatment, and survivorship. During 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing social determinants of health, including food, housing, and transportation insecurity, and their associations with cancer care and patient outcomes. This dissemination commentary summarizes the formal presentations and panel discussions from the webinar devoted to housing insecurity. It provides an overview of housing insecurity and health care across the cancer control continuum, describes health system interventions to minimize the impact of housing insecurity on patients with cancer, and identifies challenges and opportunities for addressing housing insecurity and improving health equity. Systematically identifying and addressing housing insecurity to ensure equitable access to cancer care and reduce health disparities will require ongoing investment at the practice, systems, and broader policy levels.

Addressing Transportation Insecurity Among Patients With Cancer.

Health-care-related transportation insecurity is common in the United States. Patients with cancer are especially vulnerable because cancer care is episodic in nature, occurs over a prolonged period, is marked by frequent clinical encounters, requires intense treatments, and results in substantial financial hardship. As a result of transportation insecurity, patients with cancer may forego, miss, delay, alter, and/or prematurely terminate necessary care. Limited data suggest that these alterations in care have the potential to increase the rates of cancer recurrence and mortality and exacerbate disparities in cancer incidence, severity, and outcomes. Transportation insecurity also negatively impacts at the informal caregiver, provider, health system, and societal levels. Recognizing that transportation is a critical determinant of outcomes for patients with cancer, there are ongoing efforts to develop evidence-based protocols to identify at-risk patients and address transportation insecurity at federal policy, health system, not-for-profit, and industry levels. In 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing key social determinants of health including food, housing, and transportation among patients with cancer. This commentary summarizes the formal presentations and discussions related to transportation insecurity and will 1) discuss the heterogeneous nature of transportation insecurity among patients with cancer; 2) characterize its prevalence along the cancer continuum; 3) examine its multilevel consequences; 4) discuss measurement and screening tools; 5) highlight ongoing efforts to address transportation insecurity; 6) suggest policy levers; and 7) outline a research agenda to address critical knowledge gaps.

Early pandemic impacts on family environments that shape childhood development and health: A Canadian study.

ObjectivesChanges to income and employment are key social determinants of health that have impacted many families during the COVID‐19 pandemic. This research aimed to understand how changes to employment and income influenced family environments that contribute to early childhood development and health.MethodsA concurrent triangulation mixed method design was used through a cross‐sectional survey on early impacts of the COVID‐19 pandemic involving families with young children in the Canadian Maritime provinces (n = 2158). Analyses included multivariate regression models to examine whether changes to employment and income predicted changes to Family access to resources and social support, parenting Abilities and self‐care at home, and home Routines and Environments (FARE Change Scale). Content analysis was used to identify themes from the open‐ended questions.ResultsChanges to employment and income early in the pandemic like no longer working but continued to receive salary, working fewer hours for the same salary earned before the pandemic, no longer working nor receiving salary, working fewer hours resulting in salary reduction, essential worker status and household income were significant predictors of FARE Change Scale when ethnicity/cultural background and province of residence are controlled (P < .05). Themes provided a description of family impacts, including shifting employment and income, finding time and capacity, feelings of guilt and the creation of new routines.ConclusionOur study provides insight on the implications of public health restrictions, such as the importance of increased time for parents (through reduced work hours) and access to resources and social support to support child development and health.

The Importance of Communication in Collaborative Community Development: Lessons Learned from Three Cases

Collaborative community development projects aimed at promoting economic vitality, with attendant consequences as a key social determinant of health, necessarily pose questions about how to best communicate between developers, project partners, and community members. Many such projects are taking place across the United States, including in Ohio. This commentary draws on examples from 3 communities (2 outside of our state of Ohio, and another in the Linden neighborhood of Columbus, Ohio) to distill 3 key lessons in the area of communication. First, we argue that communication should be proactive, not reactive. Second, we explain why planners should be consistent in the provision of updates related to progress or lack thereof in real time on websites and apps, all while ensuring that information remains current. Third, though communication remains an under-appreciated aspect of partnership-based community development work, including explicitly health-oriented work, we argue that communicating progress to community members is not only logistically important, but part of a broader effort to build trust within communities in order to create long-lasting and sustainable change. This trust, after all, is a necessary foundation for community-focused workconcerned with addressing the social determinants of health.