Several Social Determinants Of Health Research Articles

Individual- and community-level social determinants of health are associated with cognition in older adults with focal epilepsy

ObjectiveEpilepsy is associated with significant health disparities, including access to specialized care and adverse outcomes that have been associated with several social determinants of health (SDOH). We sought to examine the relationship between individual- and community-level SDOH and cognitive outcomes in older adults with epilepsy. Materials and methodsWe collected clinical, SDOH, and neuropsychological data in 57 older adults with epilepsy. Individual-level SDOH included patient factors (quality of education, income, insurance, marital status) and early-life environmental factors (parental education and occupation, childhood employment). Neighborhood deprivation was measured with the Area Deprivation Index (ADI). Stepwise regressions were conducted to examine the independent contribution of individual-level SDOH to cognitive performance, and Spearman rho correlations were conducted to examine the relationship between ADI and cognitive performance. The SDOH profiles of patients who met the criteria for cognitive impairment were examined. ResultsAfter controlling for clinical variables, patient factors (public health insurance, poorer quality of education) and early-life environmental factors (lower mother’s education, lower father’s and mother’s occupational complexity, history of childhood employment) were significant predictors of lower performance on measures of global cognition, verbal learning and memory, processing speed, and executive function. Higher ADI values (greater disadvantage) were associated with lower scores on global cognitive measures, verbal learning and memory, and executive function. Patients who met criteria for cognitive impairment had, on average, a greater number of adverse SDOH, including lower household incomes and father’s education, and higher ADI values compared to those who were cognitively intact. ConclusionWe provide new evidence of the role of individual- and community-level SDOH on cognitive outcomes in older adults with epilepsy. This emerging literature highlights the need to examine SDOH beyond epilepsy-related clinical factors. These data could inform the development of interventions focused on increasing access to epilepsy care, education, and resources and promoting brain and cognitive health within the most at-risk communities.

Predictors of stool deoxyribonucleic acid test use in the United States: Implications for outreach to under-resourced populations

ObjectiveAlthough colorectal cancer screening (CRCS) is a public health priority, uptake is suboptimal in under-resourced groups. Noninvasive modalities, including stool deoxyribonucleic acid (sDNA) testing, may mitigate economic, geographic, cultural, or impairment-related barriers to CRCS. We assessed use of sDNA testing and other CRCS modalities in U.S. residents, comparing subgroups defined by several social determinants of health (SDOH). MethodsA nationally representative sample of community-dwelling respondents aged 50–75 years self-reported use of CRCS modalities in the 2020 Behavioral Risk Factor Surveillance System Survey. Statistical analyses assessed up-to-date screening status and choice of modality in the recommended screening interval. ResultsOf 179,833 sampled respondents, 60.8% reported colonoscopy, 5.7% sDNA testing, 5.5% another modality. The rate of up-to-date screening was 72.0% overall and negatively associated with Hispanic ethnicity (63.6%), lower educational and annual income levels (e.g., <high school, 63.7%, <$20,000, 67.2%), and cost-related difficulty accessing physician care (57.4%; all p < 0.001) but not with Black non-Hispanic race/ethnicity (74.6%) or sensory, cognitive, or physical impairments (73.1%–73.9%). Choice of sDNA instead of colonoscopy was made by 8.5% overall and was more common in the same SDOH groups (Hispanic ethnicity, 17.7%; <high school, 17.4%; <$20,000, 16.8%; cost-related difficulty accessing care, 12.0%); Black non-Hispanic race/ethnicity (11.6%); and impairments (sensory, 12.0%; other cognitive or physical, 12.9%). ConclusionsUnder-resourced persons were more likely than better-resourced persons to access sDNA testing, possibly offsetting screening barriers in some groups. Findings suggest opportunities to increase CRCS with heightened communication about sDNA testing to those who may experience difficulty accessing other modalities.

Determinants of intention to conceal tuberculosis status among family members: an analysis of seven Sub-Saharan African countries

BackgroundTuberculosis (TB) remains a significant public health burden in Sub-Saharan Africa (SSA), accounting for about 25% of global TB cases. In several communities, TB diagnosis, treatment, and control have become a critical challenge, largely due to the intention to conceal TB status among family members. It is therefore crucial to understand the factors associated with the intentions to conceal TB status among family members in SSA.MethodsThis quantitative study utilised data from the most recent Demographic and Health Surveys (DHS). The objective was to examine the factors associated with the intention to conceal the TB status of family members. The sample consisted of 58,849 individuals aged 10 years or older from seven SSA countries. Binary logistic regression was employed to assess the associations between TB status concealment and various socio-demographic and economic variables.ResultsThe overall prevalence of TB status concealment intentions for the seven countries was 28.0% (95% CI: 27.6–28.4). Malawi and Eswatini accounted for the highest (47.3%) and lowest (3.0%) prevalence of TB concealment intentions respectively. TB status concealment intentions decreased with increasing age (p < 0.001). Living in rural areas was associated with lower odds of intending to conceal the TB of family members compared to living in urban areas (aOR = 0.92; p = 0.008). Higher education levels were associated with lower odds of TB status concealment intentions (aOR = 0.50; p < 0.001) compared to lower education levels. As participants wealth index increased, the odds of TB status concealment intentions decreased (aOR = 0.83; p < 0.001). Country of residence also showed significant associations with individuals in Ghana (aOR = 4.51; p < 0.001), Lesotho (aOR = 2.08; p < 0.001), Malawi (aOR = 4.10; p < 0.001), Namibia (aOR = 4.40; p < 0.001), and Sao-Tome and Principe (aOR = 5.56; p < 0.001) showing higher odds of TB status concealment intentions compared to Eswatini.ConclusionsThe findings conclude that several social determinants of health, including age, urbanicity, education, and wealth contribute to TB status concealment intentions for family members. Considering these factors is important for designing targeted interventions to improve TB control in the sample. In light of the unavailability of cultural variables in the dataset, future research can leverage qualitative approaches to conduct a more comprehensive exploration of the cultural factors linked to TB status concealment intentions in the population.

Abstract HUP3: Neighborhood Deprivation and Functional Outcomes Following Ischemic Stroke

Introduction: The association between neighborhood deprivation and risk of disease is well-documented. However, the role of neighborhood deprivation in long-term outcomes following acute brain injury remains understudied. We tested the hypothesis that neighborhood deprivation leads to unfavorable long-term functional outcomes following acute ischemic stroke (AIS). Methods: We conducted a nested study within the Yale Longitudinal Study of Acute Brain Injury, a prospective study which follows patients with acute brain injury admitted to the Yale Health System. The present study focused on AIS survivors and assessed neighborhood deprivation using the Area Deprivation Index (ADI), a metric that uses 9-digit zip codes to rank neighborhoods based on income, employment, education, and housing quality. Patients were stratified into tertiles based on their ADI, designated as low, intermediate, or high deprivation. Functional outcomes were evaluated using the modified Rankin Scale at one-year post-stroke, dichotomized into favorable (scores 0-2) and unfavorable (scores 3-6). Our analysis employed multivariable logistic regression for adjusted analyses. Results: Among 2,540 AIS patients enrolled between 2018 and 2021, 2,164 patients had zip code and outcomes data (mean age 69 years, 48% female, 7.5% Black, 7.7% Hispanic). The one-year unadjusted risk of poor outcomes was 35%, 40% and 46% for patients residing in neighborhoods with low, intermediate, and high deprivation, respectively (unadjusted p=0.001). These findings remained significant in multivariate analyses that controlled for confounding factors: compared to patients living in neighborhoods with low deprivation, those living in areas with intermediate and high deprivation had 44% (OR 1.44, 95% CI 1.11-1.86) and 107% (OR 2.07, 95% CI 1.58-2.72) greater risk of unfavorable outcomes (test-for-trend p&lt;0.001). Conclusion: Our study, focusing on survivors of AIS participating in a prospective acute brain injury study, underscores the connection between neighborhood deprivation and an elevated risk of unfavorable outcomes. We validate the utility of the ADI as a valuable analytical tool for evaluating neighborhood deprivation as a composite for several social determinants of health.

Abstract WMP53: Neighborhood Deprivation and Functional Outcomes Following Ischemic Stroke

Introduction: The association between neighborhood deprivation and risk of disease is well-documented. However, the role of neighborhood deprivation in long-term outcomes following acute brain injury remains understudied. We tested the hypothesis that neighborhood deprivation leads to unfavorable long-term functional outcomes following acute ischemic stroke (AIS). Methods: We conducted a nested study within the Yale Longitudinal Study of Acute Brain Injury, a prospective study which follows patients with acute brain injury admitted to the Yale Health System. The present study focused on AIS survivors and assessed neighborhood deprivation using the Area Deprivation Index (ADI), a metric that uses 9-digit zip codes to rank neighborhoods based on income, employment, education, and housing quality. Patients were stratified into tertiles based on their ADI, designated as low, intermediate, or high deprivation. Functional outcomes were evaluated using the modified Rankin Scale at one-year post-stroke, dichotomized into favorable (scores 0-2) and unfavorable (scores 3-6). Our analysis employed multivariable logistic regression for adjusted analyses. Results: Among 2,540 AIS patients enrolled between 2018 and 2021, 2,164 patients had zip code and outcomes data (mean age 69 years, 48% female, 7.5% Black, 7.7% Hispanic). The one-year unadjusted risk of poor outcomes was 35%, 40% and 46% for patients residing in neighborhoods with low, intermediate, and high deprivation, respectively (unadjusted p=0.001). These findings remained significant in multivariate analyses that controlled for confounding factors: compared to patients living in neighborhoods with low deprivation, those living in areas with intermediate and high deprivation had 44% (OR 1.44, 95% CI 1.11-1.86) and 107% (OR 2.07, 95% CI 1.58-2.72) greater risk of unfavorable outcomes (test-for-trend p&lt;0.001). Conclusion: Our study, focusing on survivors of AIS participating in a prospective acute brain injury study, underscores the connection between neighborhood deprivation and an elevated risk of unfavorable outcomes. We validate the utility of the ADI as a valuable analytical tool for evaluating neighborhood deprivation as a composite for several social determinants of health.

Health equity in COVID-19 testing among patients of a large national pharmacy chain.

Several social determinants of health and other structural factors drive racial and ethnic disparities in COVID-19 risk, morbidity, and mortality. Public-private collaborations with community pharmacies have been successful in expanding access to COVID-19 testing and reaching historically underserved communities. The objectives of this study were to describe individuals who sought testing for COVID-19 at a national community pharmacy chain and to understand potential racial and ethnic inequities in testing access, positivity, and infection with emerging variants of concern. We conducted a cross-sectional study of individuals aged ≥18 who were tested for COVID-19 (SARS-CoV-2) at a Walgreens pharmacy or Walgreen-affiliated mass testing site between May 1, 2021 and February 28, 2022. Positivity was defined as the proportion of positive tests among all administered tests. A geographically balanced random subset of positive tests underwent whole genome sequencing to identify specific viral variants (alpha, delta, and omicron). Logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) to compare the likelihood of testing positive and testing positive with an emerging variant of concern across race and ethnicity groups. A total of 18,576,360 tests were analyzed (16.0% tests were positive for COVID-19; 59.5% of tests were from White individuals and 13.1% were from Black individuals). American Indian or Alaska Native (OR = 1.12; 95%CI = 1.10-1.13), Hispanic or Latino (1.20; 95%CI = 1.120, 1.21), and Black (1.12; 95%CI = 1.12, 1.13) individuals were more likely to test positive for COVID-19 compared to White individuals. Non-White individuals were also more likely to test positive for emerging variants of concern (e.g., Black individuals were 3.34 (95%CI = 3.14-3.56) times more likely to test positive for omicron compared to White individuals during the transition period from delta to omicron). Using a national database of testing data, we found racial and ethnic differences in the likelihood of testing positive for COVID-19 and testing positive for emerging viral strains. These results demonstrate the feasibility of public-private collaborations with local pharmacies and pharmacy chains to support pandemic response and reach harder to reach populations with important health services.

Attributable Costs of Stroke in Ontario, Canada and Their Variation by Stroke Type and Social Determinants of Health.

Estimates of attributable costs of stroke are scarce, as most prior studies do not account for the baseline health care costs in people at risk of stroke. We estimated the attributable costs of stroke in a universal health care setting and their variation across stroke types and several social determinants of health. We undertook a population-based administrative database-derived matched retrospective cohort study in Ontario, Canada. Community-dwelling adults aged ≥40 years with a stroke between 2003 and 2018 were matched (1:1) on demographics and comorbidities with controls without stroke. Using a difference-in-differences approach, we estimated the mean 1-year direct health care costs attributable to stroke from a public health care payer perspective, accounting for censoring with a weighted available sample estimator. We described health sector-specific costs and reported variation across stroke type and social determinants of health. The mean 1-year attributable costs of stroke were Canadian dollars 33 522 (95% CI, $33 231-$33 813), with higher costs for intracerebral hemorrhage ($40 244; $39 193-$41 294) than ischemic stroke ($32 547; $32 252-$32 843). Most of these costs were incurred in acute care hospitals ($15 693) and rehabilitation facilities ($7215). Compared with all patients with stroke, the mean attributable costs were higher among immigrants ($40 554; $39 316-$41 793), those aged <65 years ($35 175; $34 533-$35 818), and those residing in low-income neighborhoods ($34 687; $34 054-$35 320) and lower among rural residents ($29 047; $28 362-$29 731). Our findings of high attributable costs of stroke, especially in immigrants, younger patients, and residents of low-income neighborhoods, can be used to evaluate potential health care cost savings associated with different primary stroke prevention strategies.

Treating Common Variable Immunodeficiency With Subcutaneous Immunoglobulin: A Challenge With Several Social Determinants of Health.

Treating Common Variable Immunodeficiency With Subcutaneous Immunoglobulin: A Challenge With Several Social Determinants of Health.

Neighborhood Deprivation and Polygenic Contribution to Acute Ischemic Stroke: Results from the All of Us Research Program (S49.007)

<h3>Objective:</h3> We hypothesize that neighborhood deprivation, a geographic metric that captures several social determinants of health, modifies the effect of genetic variation on risk of acute ischemic stroke (AIS). <h3>Background:</h3> The interaction between social determinants of health and genetic risk factors in their association with AIS is poorly understood. <h3>Design/Methods:</h3> We ran a cross-sectional study in <i>All of Us</i>, a large population study that aims to enroll one million Americans. We ascertained AIS cases using Observational Medical Outcomes Partnership codes. We evaluated neighborhood deprivation using the deprivation index, an aggregate variable derived from six American Community Survey metrics divided into tertiles. We modeled the polygenic contribution to AIS through a polygenic risk score that included 530 known genetic risk variants for cardiometabolic risk factors. We used multivariable logistic regression to model AIS likelihood as a function of neighborhood deprivation and polygenic risk, using product terms to test for interaction, and adjusting for age, sex, and ethnicity. <h3>Results:</h3> Of the 372,397 participants currently enrolled in <i>All of Us</i>, 147,492 had available genetic and deprivation index data; of these, 3,201 (2.2%) had strokes. Both neighborhood deprivation and the polygenic risk score were independently associated with AIS (both p&lt;0.05). We found a significant interaction between neighborhood deprivation and polygenic risk (interaction p=0.02): the polygenic risk score was significantly associated with the likelihood of AIS in the least deprived areas (OR 1.08, 95%CI 1.02–1.15; p=0.01) but was not associated with AIS in moderately and highly deprived areas (both p&gt;0.05). <h3>Conclusions:</h3> Among study participants enrolled in All of Us, those living in areas of low neighborhood deprivation were more susceptible to the effects of polygenic variation. It is possible that social determinants of health associated with a higher likelihood of AIS dilute the contribution of genetic risk factors. <b>Disclosure:</b> Dr. Rivier has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Pyxis Partners. Dr. Acosta has nothing to disclose. Dr. Renedo has nothing to disclose. Thomas Gill has nothing to disclose. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ceribell. Dr. Sheth has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Zoll. Dr. Sheth has received personal compensation in the range of $10,000-$49,999 for serving on a Scientific Advisory or Data Safety Monitoring board for NControl. Dr. Sheth has received stock or an ownership interest from Astrocyte. Dr. Sheth has received stock or an ownership interest from Alva. The institution of Dr. Sheth has received research support from Biogen. The institution of Dr. Sheth has received research support from Novartis. The institution of Dr. Sheth has received research support from Bard. The institution of Dr. Sheth has received research support from Hyperfine. Dr. Sheth has received intellectual property interests from a discovery or technology relating to health care. The institution of Dr. Falcone has received research support from NIH. The institution of Dr. Falcone has received research support from AHA.

MP18-07 IMPACT OF SOCIAL DETERMINANTS OF HEALTH ON DELAYS TO SEEK CARE FOR CHILDREN WITH TESTICULAR TORSION

You have accessJournal of UrologyCME1 Apr 2023MP18-07 IMPACT OF SOCIAL DETERMINANTS OF HEALTH ON DELAYS TO SEEK CARE FOR CHILDREN WITH TESTICULAR TORSION Ashley Pittman, Monica Morales, Sri Chinta, Amy Pan, Liyun Zhang, and Jonathan S. Ellison Ashley PittmanAshley Pittman More articles by this author , Monica MoralesMonica Morales More articles by this author , Sri ChintaSri Chinta More articles by this author , Amy PanAmy Pan More articles by this author , Liyun ZhangLiyun Zhang More articles by this author , and Jonathan S. EllisonJonathan S. Ellison More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003238.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Testicular torsion is a well-documented pediatric urological emergency that poses a time-sensitive risk to the testicle. Although management and treatment for suspected testicular torsion is standardized across most hospitals, delays may occur in time to presentation. Several social determinants of health (SDH) have been associated with higher orchiectomy rates for testicular torsion. However, factors associated with time to presentation are not well characterized. We investigated time from symptom onset to presentation patterns, hypothesizing an association between SDHs and prolonged time to presentation. METHODS: A retrospective chart review of children ≤17 years of age presenting with testicular torsionat a single tertiary pediatric center from 2013-2022 was performed. Children who were <1 month of age, no documented time of symptom onset, or did not receive surgery were excluded. Demographics, symptom onset, time course of care, and surgical outcomes were extracted from the electronic medical records. The primary outcome measure of the study was time from symptom onset to ED presentation. SDHs such as interpreter utilization, race, zip code, area deprivation index, and insurance status were compared and analyzed using univariate analyses. RESULTS: In total 253 children met inclusion criteria. The essential demographic variables include utilization of interpreter 22 (8.7%), public insurance 168 (66.4%), and Hispanic or Latino ethnicity 43 (17.0%). Racial make-up of the cohort was White 144 (56.9%), Black 79 (31.2%), Other 12 (4.7%), and Unknown 18 (7.1%). No difference was noted on univariate analysis of time to presentation between ethnicity, race, or interpreter usage. However, public insurance had a statistically significant greater time to presentation (Median 11.5 IQR 3.9-49.3 hrs vs 4.9, 2.7-26.2 hrs) (p=0.004) shown in Figure 1. A logistic regression analysis found ethnicity to have a higher association with adverse orchiectomy outcomes. CONCLUSIONS: Children with public insurance had significantly longer time intervals from reported symptom onset to presentation. Additionally, ethnicity was associated with higher orchiectomy rates. Further exploring barriers to seek care for testicular torsion serves as a foundation to reduce health disparities. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e225 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ashley Pittman More articles by this author Monica Morales More articles by this author Sri Chinta More articles by this author Amy Pan More articles by this author Liyun Zhang More articles by this author Jonathan S. Ellison More articles by this author Expand All Advertisement PDF downloadLoading ...

Abstract HUP1: Neighborhood Deprivation And Polygenic Contribution To Acute Ischemic Stroke: Results From The All Of Us Research Program

Background: The interaction between social determinants of health and genetic risk factors in causing acute ischemic stroke (AIS) is poorly understood. We hypothesize that community deprivation, a geographic metric that captures several social determinants of health, modifies the effect of genetic variation on risk of AIS. Methods: We analyzed data from All of Us , a large population study that aims to enroll one million Americans. We ascertained AIS cases using Observational Medical Outcomes Partnership codes. We evaluated community deprivation using the deprivation index, an aggregate variable derived from six metrics of the American Community Survey that was divided into tertiles. We modeled the polygenic contribution to AIS through a polygenic risk score that included 530 known genetic risk variants for cardiometabolic risk factors. We used multivariable logistic regression to model AIS risk as a function of community deprivation and polygenic risk, using product terms to test for interaction. Results: Out of 372,397 participants currently enrolled in All of Us , 147,492 had available genetic and deprivation index data, including 3,201 (2.2%) strokes. Both community deprivation and the polygenic risk score were independently associated with AIS risk (both p&lt;0.05). We found a significant interaction between community deprivation and polygenic risk (interaction p=0.02, Figure): the polygenic risk score was significantly associated with AIS risk in areas with low community deprivation (OR 1.08, 95%CI 1.02-1.15; p=0.01) but was not associated with this risk in areas of intermediate and high deprivation (both p&gt;0.05). Conclusion: Among study participants enrolled in All of Us, those living in areas of low community deprivation were more susceptible to the effects of polygenic variation. We speculate that in areas with high deprivation, several social determinants of health known to lead to higher risk of AIS dilute the contribution of genetic risk factors.

Abstract 32: Neighborhood Deprivation And Polygenic Contribution To Acute Ischemic Stroke: Results From The All Of Us Research Program

Background: The interaction between social determinants of health and genetic risk factors in causing acute ischemic stroke (AIS) is poorly understood. We hypothesize that community deprivation, a geographic metric that captures several social determinants of health, modifies the effect of genetic variation on risk of AIS. Methods: We analyzed data from All of Us , a large population study that aims to enroll one million Americans. We ascertained AIS cases using Observational Medical Outcomes Partnership codes. We evaluated community deprivation using the deprivation index, an aggregate variable derived from six metrics of the American Community Survey that was divided into tertiles. We modeled the polygenic contribution to AIS through a polygenic risk score that included 530 known genetic risk variants for cardiometabolic risk factors. We used multivariable logistic regression to model AIS risk as a function of community deprivation and polygenic risk, using product terms to test for interaction. Results: Out of 372,397 participants currently enrolled in All of Us , 147,492 had available genetic and deprivation index data, including 3,201 (2.2%) strokes. Both community deprivation and the polygenic risk score were independently associated with AIS risk (both p&lt;0.05). We found a significant interaction between community deprivation and polygenic risk (interaction p=0.02, Figure): the polygenic risk score was significantly associated with AIS risk in areas with low community deprivation (OR 1.08, 95%CI 1.02-1.15; p=0.01) but was not associated with this risk in areas of intermediate and high deprivation (both p&gt;0.05). Conclusion: Among study participants enrolled in All of Us, those living in areas of low community deprivation were more susceptible to the effects of polygenic variation. We speculate that in areas with high deprivation, several social determinants of health known to lead to higher risk of AIS dilute the contribution of genetic risk factors.

Unmet health care needs during the COVID-19 pandemic among adults: a prospective cohort study in the Canadian Longitudinal Study on Aging.

The COVID-19 pandemic affected access to health care services in Canada; however, limited research examines the influence of the social determinants of health on unmet health care needs during the first year of the pandemic. The objectives of this study were to describe unmet health care needs during the first year of the pandemic and to investigate the association of unmet needs with the social determinants of health. We conducted a prospective cohort study of 23 972 adults participating in the Canadian Longitudinal Study on Aging (CLSA) COVID-19 Study (April-December 2020) to identify the social determinants of health associated with unmet health care needs during the pandemic. Using logistic regression, we assessed the association between several social determinants of health on the following 3 outcomes (separately): experiencing any challenges in accessing health care services, not going to a hospital or seeing a doctor when needed, and experiencing barriers to accessing testing for SARS-CoV-2 infection. From September to December 2020, 25% of participants experienced challenges accessing health care services, 8% did not go to a hospital or see a doctor when needed and 4% faced barriers accessing testing for SARS-CoV-2 infection. The prevalence of all 3 unmet need outcomes was lower among older age groups. Differences were observed by sex, region, education, income and racial background. Immigrants (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.09-1.27) or people with chronic conditions (OR 1.35, 95% CI 1.27-1.43) had higher odds of experiencing challenges accessing health care services and had higher odds of not going to a hospital or seeing a doctor (immigrants OR 1.26, 95% CI 1.11-1.43; chronic conditions OR 1.45, 95% CI 1.31-1.61). Prepandemic unmet health care needs were strongly associated with all 3 outcomes. Substantial unmet health care needs were reported by Canadian adults during the first year of the pandemic. The results of this study have important implications for health equity.

Multimorbidity resilience and health behaviors among older adults: A longitudinal study using the Canadian Longitudinal Study on Aging.

ObjectiveThere has been a growing interest in examining why some individuals adapt and bounce back from multimorbidity (resilience) better than others. This paper investigates the positive role of protective health behaviors on multimorbidity resilience (MR) among older adults focusing on older persons with two or more concurrent chronic conditions, and separately for three multimorbidity chronic illness clusters.MethodsUsing Baseline and Follow-up One data from the Comprehensive Cohort of the Canadian Longitudinal Study on Aging, we studied 10,628 participants aged 65 years and older who reported two or more of 27 chronic conditions, and three multimorbidity clusters: Cardiovascular/metabolic, Musculoskeletal, and Mental health. Associations between health behaviors and MR were evaluated using Linear Mixed Models, adjusting for socio-demographic, social/environmental, and illness context social determinants of health.ResultsAmong older adults with two or more illnesses, smoking, satisfaction with sleep, appetite, and skipping meals were associated with MR in the expected direction. Also, obesity (compared to normal weight) and skipping meals showed longitudinal interaction effects with survey wave. Most of the results were replicated for the physical multimorbidity clusters (Cardiovascular/metabolic and Musculoskeletal) compared to the full 2+ multimorbidity analyses; however, for the Mental health cluster, only satisfaction with sleep was supported as a lifestyle predictor of MR.DiscussionSeveral modifiable health behaviors identified in the broader health and aging literature are important in affecting levels of multimorbidity resilience in older age. These factors are important strength-based areas to target. Additionally, several social determinants of health are also supported and parallel research on multimorbidity risk. The effects of lifestyle factors for resilience among older adults is dependent on the type of multimorbidity measured. We conclude that the results have significant public health, program intervention, and clinical implications for healthy aging among persons coping with multimorbidity.

High coverage but low quality of maternal and newborn health services in the coverage cascade: who is benefitted and left behind in accessing better quality health services in Nepal?

BackgroundAntenatal care (ANC) visits, institutional delivery, and postnatal care (PNC) visits are vital to improve the health of mothers and newborns. Despite improved access to these routine maternal and newborn health (MNH) services in Nepal, little is known about the cascade of health service coverage, particularly contact coverage, intervention-specific coverage, and quality-adjusted coverage of MNH services. This study examined the cascade of MNH services coverage, as well as social determinants associated with uptake of quality MNH services in Nepal.MethodsWe conducted a secondary analysis of data derived from the Nepal Demographic and Health Survey (NDHS) 2016, taking 1978 women aged 15–49 years who had a live birth in the 2 years preceding the survey. Three outcome variables were (i) four or more (4+) ANC visits, (ii) institutional delivery, and (iii) first PNC visit for mothers and newborns within 48 h of childbirth. We applied a cascade of health services coverage, including contact coverage, intervention-specific and quality-adjusted coverage, using a list of specific intervention components for each outcome variable. Several social determinants of health were included as independent variables to identify determinants of uptake of quality MNH services. We generated a quality score for each outcome variable and dichotomised the scores into two categories of “poor” and “optimal” quality, considering > 0.8 as a cut-off point. Binomial logistic regression was conducted and odds ratios (OR) were reported with 95% confidence intervals (CIs) at the significance level of p < 0.05 (two-tailed).ResultsContact coverage was higher than intervention-specific coverage and quality-adjusted coverage across all MNH services. Women with advantaged ethnicities or who had access to bank accounts had higher odds of receiving optimal quality MNH services, while women who speak the Maithili language and who had high birth order (≥ 4) had lower odds of receiving optimal quality ANC services. Women who received better quality ANC services had higher odds of receiving optimal quality institutional delivery. Women received poor quality PNC services if they were from remote provinces, had higher birth order and perceived problems when not having access to female providers.ConclusionsWomen experiencing ethnic and social disadvantages, and from remote provinces received poor quality MNH services. The quality-adjusted coverage can be estimated using household survey data, such as demographic and health surveys, especially in countries with limited routine data. Policies and programs should focus on increasing quality of MNH services and targeting disadvantaged populations and those living in remote areas. Ensuring access to female health providers and improving the quality of earlier maternity visits could improve the quality of health care during the pregnancy-delivery-postnatal period.

Americans’ Health Priorities During the COVID-19 Pandemic

ObjectivesThis study aimed to examine how Americans’ opinions of the seriousness of various health-related problems have changed over time and to quantify the public’s preferences for research prioritization. MethodsWe conducted a survey that asked respondents to rate the seriousness of 80 health-related problems on a 4-point Likert scale (“very serious problem,” “somewhat serious problem,” “not too serious of a problem,” or “not a problem at all”). Results were compared with past surveys from 2001 and 2013 that examined the same set of health-related problems (with the exception of COVID-19). The survey also included best-worst scaling questions that asked respondents to select, from 20 health problems, those they considered most and least important for research funding. Respondents were recruited from the KnowledgePanel, a nationally representative sample of American households. ResultsA total of 768 adults completed the survey between September 3, 2020, and September 14, 2020. The health-related problems that Americans consider to be “very serious” generally align with the leading causes of death and noncommunicable diseases such as heart disease, diabetes, and mental health; nevertheless, several social determinants of health are also identified. COVID-19 was an unsurprising top priority, whereas cancer remains the highest and a persistent priority for research funding. ConclusionsAmericans consider a diverse set of health-related problems to be “very serious,” with recognition of social determinants of health rising. Our findings offer guidance as to the disease areas for which the public would value further public and private investment in treatment innovations.

Prevalence of US Adults With Cardiovascular Disease Reporting Barriers to Clinician Office Visits: IMPLICATIONS FOR ACCESSIBLE MODELS FOR CARDIAC REHABILITATION.

Despite known health benefits of cardiac rehabilitation (CR) for patients with cardiovascular disease (CVD), only a quarter of eligible patients attend. Among CR barriers are physical (eg, walking) and in-person attendance limitations. The purpose of this study was to determine the prevalence of difficulty walking and dependence on another person to attend medical appointments among people with and without CVD using national survey data. We compared the prevalence of difficulty walking and difficulty attending medical appointments alone among adults with and without CVD using national survey data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2015-2019. We used logistic regression and Rao-Scott χ2 analysis while controlling for several social determinants of health as covariates. Of 2 212 973 respondents, 200 087 (9.04%) had CVD. The odds of individuals with CVD experiencing either difficulty walking or difficulty attending medical appointments alone were >3 times greater than the odds for individuals without CVD. In all adults with CVD, 42% reported difficulty walking and 20% reported dependence on another person to attend medical appointments. In all adults with CVD, 46% reported difficulty with one or both difficulties compared with 14% of adults without CVD. We estimate that 11.9 million Americans with self-reported CVD have difficulty walking, or are dependent on another person to attend medical appointments, or both. Alternative models of CR that adapt to these limitations are needed to increase attendance of CR so that all adults with CVD can improve their health outcomes.

Universal coverage of the first antenatal care visit but poor continuity of care across the maternal and newborn health continuum among Nepalese women: analysis of levels and correlates

BackgroundRoutine maternity care visits (MCVs) such as antenatal care (ANC), institutional delivery, and postnatal care (PNC) visits are crucial to utilisation of maternal and newborn health (MNH) interventions during pregnancy-postnatal period. In Nepal, however, not all women complete these routine MCVs. Therefore, this study examined the levels and correlates of (dis)continuity of MCVs across the antenatal-postnatal period.MethodsWe conducted further analysis of the 2016 Nepal Demographic and Health Survey. A total of 1,978 women aged 15–49 years, who had live birth two years preceding the survey, were included in the analysis. The outcome variable was (dis)continuity of routine MCVs (at least four ANC visits, institutional delivery, and PNC visit) across the pathway of antennal through to postnatal period. Independent variables included several social determinants of health under structural, intermediary, and health system domains. Multinomial logistic regression was conducted to identify the correlates of routine MCVs. Relative risk ratios (RR) were reported with 95% confidence intervals at a significance level of p<0.05.ResultsApproximately 41% of women completed all routine MCVs with a high proportion of discontinuation around childbirth. Women of disadvantaged ethnicities, from low wealth status, who were illiterate had higher RR of discontinuation of MCVs (compared to completion of all MCVs). Similarly, women who speak Bhojpuri, from remote provinces (Karnali and Sudurpaschim), who had a high birth order (≥4), who were involved in the agricultural sector, and who had unwanted last birth had a higher RR of discontinuation of MCVs. Women discontinued routine MCVs if they had poor awareness of health mother-groups and perceived the problem of not having female providers.ConclusionsRoutine monitoring using composite coverage indicators is required to track the levels of (dis)continuity of routine MCVs at the maternity care continuum. Strategies such as raising awareness on the importance of maternity care, care provision from female health workers could potentially improve the completion of MCVs. In addition, policy and programmes for continuity of maternity care are needed to focus on women with socioeconomic and ethnic disadvantages and from remote provinces.

The importance of social activity to risk of major depression in older adults.

Several social determinants of health (SDoH) have been associated with the onset of major depressive disorder (MDD). However, prior studies largely focused on individual SDoH and thus less is known about the relative importance (RI) of SDoH variables, especially in older adults. Given that risk factors for MDD may differ across the lifespan, we aimed to identify the SDoH that was most strongly related to newly diagnosed MDD in a cohort of older adults. We used self-reported health-related survey data from 41 174 older adults (50-89 years, median age = 67 years) who participated in the Mayo Clinic Biobank, and linked ICD codes for MDD in the participants' electronic health records. Participants with a history of clinically documented or self-reported MDD prior to survey completion were excluded from analysis (N = 10 938, 27%). We used Cox proportional hazards models with a gradient boosting machine approach to quantify the RI of 30 pre-selected SDoH variables on the risk of future MDD diagnosis. Following biobank enrollment, 2073 older participants were diagnosed with MDD during the follow-up period (median duration = 6.7 years). The most influential SDoH was perceived level of social activity (RI = 0.17). Lower level of social activity was associated with a higher risk of MDD [hazard ratio = 2.27 (95% CI 2.00-2.50) for highest v. lowest level]. Across a range of SDoH variables, perceived level of social activity is most strongly related to MDD in older adults. Monitoring changes in the level of social activity may help identify older adults at an increased risk of MDD.

Visit Trends and Factors Associated With Telemedicine Uptake Among Persons With HIV During the COVID-19 Pandemic.

BackgroundIn response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, clinicians in outpatient HIV practices began to routinely offer telemedicine (video and/or phone visits) to replace in-person appointments. Video visits are preferred over phone visits, but determinants of video visit uptake in HIV care settings have not been well described.MethodsTrends in type of encounter (face-to-face, video, and phone) before and during the pandemic were reviewed for persons with HIV (PWH) at an urban, academic, outpatient HIV clinic in Seattle, Washington. Logistic regression was used to assess factors associated with video visit use including sociodemographic characteristics (age, race, ethnicity, language, insurance status, housing status) and electronic patient portal login.ResultsAfter an initial increase in video visits to 30% of all completed encounters, the proportion declined and plateaued at ~10%. A substantial proportion of face-to-face visits were replaced by phone visits (~50% of all visits were by phone early in the pandemic, now stable at 10%–20%). Logistic regression demonstrated that older age (>50 or >65 years old compared with 18–35 years old), Black, Asian, or Pacific Islander race (compared with White race), and Medicaid insurance (compared with private insurance) were significantly associated with never completing a video visit, whereas history of patient portal login was significantly associated with completing a video visit.ConclusionsSince the pandemic began, an unexpectedly high proportion of telemedicine visits have been by phone instead of video. Several social determinants of health and patient portal usage are associated with video visit uptake.