Social Determinants Research Articles

Greening the mind: exploring the link between vertical gardens, urban forests, and mental health

Abstract Background Mental disorders impose a significant global burden, affecting millions of individuals, contributing to disability, reduced quality of life, and economic costs worldwide. Between 1990 and 2019, the global number of disability-adjusted life-years due to mental disorders increased from 80.8 million to 125.3 million. The economic costs are projected to rise to 6,000 billion euros by 2030. Urbanization has been associated with a worsening of mental disorders over the years due to various factors, such as increased stress, social isolation, reduced access to green spaces, and higher levels of pollution. Decades of research have instead shown that exposure to green space may promote psychological well-being, regulate stress, and endorse social health across the lifespan. In this systematic review, we aim to investigate how proximity to vertical gardens or urban forests, specifically, may affect mental health. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were followed. The study protocol was registered in PROSPERO (CRD42024517969) with the following PECOS question: Is there an association between vertical gardens or urban forests and mental health? Results After performing searches on PubMed, Scopus, and Web of Science, and duplicate removal, we retrieved 556 articles. The main reasons for exclusion after title/abstract screening were mainly wrong outcome (not mental health) and wrong study type (not observational/intervention/cross-sectional studies). The selection of full texts is expected to end shortly and results will be available for November 2024. Preliminary findings support the role of green environmental assets in facilitating physical activity, social contact, and stress reduction. Conclusions In summary, mental disorders are exacerbated by urbanization’s stressors. Our review will further elucidate the potential benefits of urban green spaces like vertical gardens and urban forests on mental health. Key messages • Urbanization exacerbates the issue of mental disorders global burden. • Exposure to urban forests and vertical gardens may promote physiological well-being and mental health.

The primary healthcare workforce crisis: a comparative assessment of the European region

Abstract Background The healthcare workforce crisis strongly affects the primary healthcare sector, worsening the work conditions of healthcare workers and hampering service delivery and health system resilience. This study introduces a health system and governance approach to identify transformative capacities in health system contexts. Methods A qualitative comparative methodology was employed, and a rapid assessment of the primary healthcare workforce was conducted across nine countries: Denmark, Germany, Kazakhstan, Netherlands, Portugal, Romania, Serbia, Switzerland, and the United Kingdom/ England. Results Our findings reveal both convergence and pronounced diversity across the healthcare systems, with none fully aligning with the ideal attributes of primary healthcare suggested by WHO. However, across all categories, Denmark and the Netherlands, and to a lesser extent also Kazakhstan, depict closer alignment to this model than the other countries. Workforce composition and skill-mix vary strongly, while disparities persist in education and data availability, particularly within Social Health Insurance systems. Policy responses and interventions span governance, organisational, and professional realms, although with weaknesses in the implementation of policies and a systematic lack of data and evaluation. The WHO primary healthcare model only marginally informs policy decisions, but it may receive some more attention in Kazakhstan. Conclusions We conclude that aligning primary healthcare and workforce considerations within the broader health system context may help move the debate forward and build governance capacities to improve resilience in both areas. Speakers/Panelists Tiago Correia NOVA IHMT, Lisbon, Portugal Viola Burau Aarhus University, Aarhus C, Denmark Marius-Ionuț Ungureanu Babeș-Bolyai University, Cluj-Napoca, Romania Anna Sagan WHO European Centre for Primary Health Care, Almaty, Kazakhstan

Inequalities in access to early child services in Bulgaria

Abstract Background Children’s health has been a major focus of European health policy since 2000, with particular emphasis on early childhood and integrated services for children with chronic diseases. However, research on early child care in Bulgaria is sparse, mainly focusing on the role of nurseries, kindergartens and nursing care. Our aim is to investigate whether there are disparities in access to early childhood health services in Bulgaria. Methods A survey was conducted among mothers of children up to 7 years old between April and June 2022. The questionnaire, containing 49 questions, was based on the theoretical framework from the EU project ‘Models of child health appraise’, covering topics as: geographical and financial access to services, equity, quality, responsiveness to children and family needs, considered key features of outpatient child medical care. Statistical analysis utilized Chi-square, Fisher’s exact and ANOVA tests. Results A total of 413 Bulgarian women, with a mean age of 34.3 (±5.1), participated in the study. Almost all women (91.3%) reported that their children had a primary care provider. The mean time to reach the GP/pediatrician’s office was 16 minutes (95% CI 14.6 - 16.7), longest for residents of small towns and villages (21 minutes), p = 0.004. Parents from small towns (including villages) were six times more likely to experience financial difficulties related to their children’s healthcare services compared to those from the capital city (p = 0.047), as well as parents with low-income (p = 0.031). Emergency healthcare was the most demanded service by families with children under 7 years old, possibly due to its free availability. Parents with secondary education and from small towns lack access to non-medical health-promoting or preventive services such as breastfeeding consultations, speech therapy and others. Conclusions Significant financial and geographic disparities in access to early child health services exist in Bulgaria. Key messages • There are serious social health inequalities related to the access to outpatient child health services in Bulgaria. • There is an urgent need for specific child and family health strategy based on the principles of proportionate universalism.

4.A. Skills building seminar: Waves of community health engagement and governance: innovating through a design-as-policy approach

Abstract In this workshop we will engage our participants in a practice oriented exercise to experiment with a collaborative design-as-policy approach for a community health action plan. The exercise will be based on the lessons learned in two large evaluation projects: 1) an 8-year evaluation of the Dutch All about Health (AaH) platform of social health initiatives on the local, regional and national level; and 2) a comparative multiple case study, including Portugal, building a framework for sustainable citizen engagement, published in the WHO Handbook ‘Voice, Agency, Empowerment: The Handbook on Social Participation for UHC’. Both projects show striking similarities in findings, and developed guidance for devising collaborative action through (a) the use of community platforms, (b) concrete engagement mechanisms and (c) mediating civil society organizations. These will be brought together in a Guidance Tool that participants will work with in the exercise. The aim of the tool is to support initiatives to bring together both top-down participatory efforts and bottom-up grassroots movements in order to anchor community and minority voices into policy decision-making for a more level playing field for policy influence. The aim of the workshop is to let participants experiment with the Guidance Tool and develop collaborative design-as-policy skills. The outline of the skills building exercise: 1. Group introductions using Mentimeter and invitation to pick a particular complex health issue from participants’ own work or community setting (5 mins). 2. Three pitches on the projects, the Portugal case and the Guidance Tool (10 mins). 3. Exercise instructions (5 mins). 4. Exercise (35 mins) a. Upon room entrance participants receive a colored badge based on their professional background: public health professional/practitioner, community resident, researcher or policymaker; b. Form small sub groups of 6-8 participants with different backgrounds (2 mins); c. Introduce with key words on paper their respective complex community health issues and sub group jointly selects one issue for which most information and experience is present (6 mins); d. First round in duos within sub group: participants work through the guidance steps to an initial idea for the collaborative action approach consisting of a community platform, engagement mechanisms, and mediating civil society organizations, drawn out on paper (10 mins); e. Second round in duos within the sub group: duos review another duos initial design idea and conduct an intuitive SWOT analysis of feasibility, acceptability, and practicability (8 mins); f. Third round in sub group: compare the three proposals in SWOT perspective, select the most salient one, and improve with strong elements from other proposals (8 mins); g. Summarize in key words the final proposal and enter into Mentimeter. 5. Plenary wrap up using Mentimeter: select the winning proposal, and evaluate the exercise (5 mins). Key messages • Collaborative action is enhanced considerably through (a) the use of community platforms, (b) concrete engagement mechanisms and (c) mediating civil society organizations. • The Guidance Tool offers concrete steps for designing a reflexive and adaptive structure and process for community collaborative action and self-governance. Speakers/Panelists Marleen Bekker Wageningen University & Research, Wageningen, Netherlands Dheepa Rajan WHO, Brussels, Belgium Goncalo Figueiredo Augusto National Health Council, Lisbon, Portugal

7.M. Round table: A new lens on loneliness: leveraging the built environment for social health

Abstract Loneliness is a global issue impacting a third of all adults, with young adults (15-25 years) disproportionately affected. Prolonged loneliness has serious consequences for mental and physical health and should be addressed as a matter of urgency. The built environment, where we live, work, and socialise, is increasingly recognised as a significant factor influencing loneliness. However, existing interventions often focus on older adults and neglect the role of the built environments in promoting connectedness across the life course. To bridge this gap, we need interdisciplinary collaboration to understand how our environments and communities can mitigate loneliness. This workshop will explore the critical intersection of place and loneliness interventions. The three panellists bring unique interdisciplinary expertise on loneliness ranging from policy to intervention implementation. These three talks (10min each) will set the stage for a dynamic discussion (30min): 1. Nina Goldman, commissioned by the World Health Organization to undertake a global overview of national loneliness policies, will present findings on how national strategies integrate place-based strategies across sectors such as housing, transportation, and urban planning. 2. Mathias Lasgaard, leading researcher on loneliness interventions, will present the innovative ‘More Together’ (MoTo) project - a multifaceted intervention addressing loneliness in both young and older adults within the Silkeborg Municipality, Denmark. This presentation will contextualize MoTo within the broader landscape of targeted loneliness interventions. 3. Eric Schoenmakers, advisor of the national loneliness action program in the Netherlands, will introduce the “I BELONG” project, an international network dedicated to understanding the relationship between public spaces, loneliness, and effective interventions for young adults in the Netherlands. Key messages • We aim to stimulate a paradigm shift in the way we address loneliness by moving beyond individual-centred solutions to develop a more holistic and community-based approach. • We need more interdisciplinary collaboration to understand how our environments and communities can mitigate loneliness. Speakers/Panelists Nina Goldman University of Manchester, Manchester, UK Mathias Lasgaard Defactum, Central Denmark Region, Aarhus, Denmark Eric Schoenmakers Fontys University of Applied Sciences, Eindhoven, Netherlands

The role of class stigma in socioeconomic inequalities in type 2 diabetes: The Maastricht Study

Abstract Background Low socioeconomic position (SEP) is a risk factor for type 2 diabetes mellitus (T2DM). An underlying mechanism behind socioeconomic health inequalities can be stigma, particularly classism. Studying the influence of class stigma in the context of (pre)diabetes and socioeconomic inequalities may shed light on the societal factors influencing diabetes. Methods Data from 1947 participants aged 49-88 who participated in the second phase of The Maastricht Study starting between November 2020 and April 2023 were used. SEP (education, income, occupation) and 6-item classism scale were measured through self-reported questionnaires. (Pre)diabetes was measured through an oral glucose tolerance test. We conducted multinomial logistic regression analyses to investigate the associations between SEP, classism, and diabetes status. Results 20.9% (N = 406) of the study sample had T2DM (Mage=69.8(±6.8) years; 31.3% women). People with low SEP had more often T2DM (e.g., income OR = 2.13, 95%CI:1.54-2.82) and reported perceived classism (e.g., education OR = 2.07, 95%CI:1.33-3.21) than people with high SEP. Classism was not statistically significantly associated with T2DM (OR = 0.78, 95%CI:0.48-1.29). Conclusions Social health inequalities are apparent in T2DM; however, our results suggest that class stigma might not be a major factor in underlying processes. Further research can investigate the role of chronic stress and intersection of multiple stigmas. Key messages • The underlying factors behind socioeconomic health disparities are complex. Social and psychological environment in low SEP should be investigated carefully. • Although low SEP is strongly associated with T2DM and perceived classism, class stigma might not be a major target in explaining socioeconomic pathways in diabetes.

Design and Validation of a Health Inequalities Questionnaire for Occupational Health Nurses and Occupational Health Nursing Students in Spain.

This article aims to describe the methodology for the design, validation, reliability, and pilot testing of a questionnaire aimed at exploring the knowledge and training needs on health inequalities of occupational health nurses (OHNs) and occupational health nursing students in Spain. Working and employment conditions are social determinants that influence the health of workers. The unequal distribution of these factors leads to inequalities. The training and competencies of OHNs need to focus on the social determinants of health to reduce social inequalities. The questionnaire was structured in five sections and 24 closed questions, self-administered and online. It was validated by a panel of experts using Moriyama's criteria and achieved an average consensus of 93.85%. Internal reliability reached a Cronbach's alpha coefficient of 0.843 and a McDonald's omega of 0.953. Participation in the pilot test was 92.5% of the sample recruited. Achieving higher levels of health of the working population requires a consensus among different social actors to integrate social determinants, gender and equity perspectives into the overall health policy of the company.

"Organizing practice": The hidden work of homecare nurses in fighting health inequity and advancing social justice.

The nursing profession has a long history of advocating for social justice and health equity, and both values profoundly infuse nursing ethics, theory, and education. Homecare nursing occurs between the patient's daily life at home and the public health care system. Therefore, homecare nurses ideally possess insight into the living conditions and social determinants of health that their patients experience. This interpretive phenomenological study explores the strategies employed by homecare nurses to fight health inequity and advance social justice. Data were collected through participant observations, situational interviews, and small group interviews with 12 homecare nurses from two municipalities. Three analytical approaches were used: paradigm cases, exemplars, and thematic analysis. The data identified two primary strategies homecare nurses use to circumvent, solve, and mitigate the negative consequences of social determinants of health on patients' care and treatment: "Negotiating practice" and "Aligning practice." "Negotiating practice" ensures that care and treatment are delivered in a way acceptable to all involved. "Aligning practice" ensures cohesion, progression in the treatment and care trajectory, and support for patients and relatives in navigating the system. Both strategies are part of nurses' largely hidden work, reflecting the nursing profession's position as nested between the individual patient and the system.

Health Professions Students' Reflections About Principles of Interprofessional Collaboration after Shadowing Interprofessional Palliative Care Rounds.

Future healthcare professionals are educated on collaborative practice methods through interventions that may include shadowing. While shadowing allows students to learn from and about other health professions, it often fails to offer an opportunity for the student to work and collaborate with other health professionals. This study sought to investigate themes regarding interprofessional students' experiences during a palliative care shadowing activity and their understanding of collaborative patient-centered care, social determinants of health, and health disparities. Twenty-eight students representing 13 health professions from the Interprofessional Palliative Care program at Jefferson Center for Interprofessional Practice and Education at Thomas Jefferson University submitted reflection essays at the conclusion of their shadowing experience. Four hundred ninety-eight sentences from 28 essays were analyzed via qualitative directed content analysis. Coding categories were determined a priori using definitions of collaborative practice from the 2023 Interprofessional Education Collaborative (IPEC) competencies and definitions of social determinants of health from Healthy People 2030. Thirty-two percent of sentences described IPEC competencies, 18% described social determinants of health/ health disparities, 4% included student emotional reactions, and 2% included student descriptions of the development of their professional role. These results suggest that shadowing offers an opportunity to identify and learn interprofessional competencies in interprofessional palliative care curricula, as made evident through student reflection assignments.

Knowledge of Palliative Care in Men and Women Diagnosed With Metastatic Breast Cancer.

The purpose of this study was to evaluate knowledge of Palliative Care (PC) and the impact of systemic and patient-related factors on the use of PC in a diverse population of men and women diagnosed with metastatic breast cancer. A telephone administered survey was used with patients receiving treatment at a Cancer Center in an urban area of the Northeast US. Descriptive statistics and chi square analysis were used. Of the 101 participants, 44% had no knowledge of PC and only 21.78% indicated that they were receiving palliative care. Participants who reported being followed by palliative care were less likely to have been treated in the emergency department in the past year (P = 0.003) or to have been hospitalized (P = 0.042). However, when asked about symptom burden, using the Edmonton Symptom Assessment Scale, patients who reported being followed by PC were more likely to report severe pain as compared to patients not receiving PC (P < 0.001). There were no associations found between race/ethnicity or social determinants of health and knowledge of PC or receipt of services. This sample of men and women diagnosed with metastatic breast cancer and being treated in a Cancer Center had limited knowledge and exposure to Palliative Care services across race and ethnicity. While no specific disparity was noted, the utilization of PC was low. Whether a function of a lack of referrals or patient preference, an effort should be made to increase PC referrals for all patients diagnosed with cancer.

Applications of ChatGPT in Heart Failure Prevention, Diagnosis, Management, and Research: A Narrative Review

Heart failure (HF) is a leading cause of mortality, morbidity, and financial burden worldwide. The emergence of advanced artificial intelligence (AI) technologies, particularly Generative Pre-trained Transformer (GPT) systems, presents new opportunities to enhance HF management. In this review, we identified and examined existing studies on the use of ChatGPT in HF care by searching multiple medical databases (PubMed, Google Scholar, Medline, and Scopus). We assessed the role of ChatGPT in HF prevention, diagnosis, and management, focusing on its influence on clinical decision-making and patient education. However, ChatGPT faces limited training data, inherent biases, and ethical issues that hinder its widespread clinical adoption. We review these limitations and highlight the need for improved training approaches, greater model transparency, and robust regulatory compliance. Additionally, we explore the effectiveness of ChatGPT in managing HF, particularly in reducing hospital readmissions and improving patient outcomes with customized treatment plans while addressing social determinants of health (SDoH). In this review, we aim to provide healthcare professionals and policymakers with an in-depth understanding of ChatGPT’s potential and constraints within the realm of HF care.

Social Determinants of Health and How They Affect a Small Rural Community (Case Study) Eastern Shore of Maryland

Social Determinants of Health and How They Affect a Small Rural Community (Case Study) Eastern Shore of Maryland

The heart of the matter: a re-iteration of the role of the social determinants of health in addressing health inequity in Central Australia.

The persisting life-expectancy 'gap' between First Nations and non-First Nations Australians is fundamentally driven by the social determinants of health. These include income and social protection, access to adequate housing and food security, among others. These factors are particularly prominent in Central Australia. Inadequate housing has led to some of the highest rates of Streptococcus pyogenes infection in the world, which in turn drives an extremely high prevalence of rheumatic heart disease. Food insecurity and inadequate social protection manifesting as energy insecurity result in inadequate nutrition and have resulted in a huge burden of diabetes in Central Australia. These factors, combined with social exclusion, racism and the pervasive effect of colonisation, also drive a high rate of alcohol misuse. Only by prioritising equity in these 'social determinants' and emphasising the importance of First Nations leadership in formulating and implementing solutions will health inequity be addressed.

Essential public health competencies in nursing during the COVID-19 pandemic: A Delphi study

Background &amp; Aim: Nursing practice, characterized by its multifaceted nature, encompasses diverse settings and situations in public health, making it difficult to clearly define the role of nurses in this setting. The study aimed to determine the applicability and relevance of the Regional Core Competency Framework for Public Health in nursing practice during the COVID-19 pandemic. Methods &amp; Materials: Study based on the Delphi methodology, a structured approach to the systematic collectión of expert opinions, to obtain group agreements. Twenty-one nurses working in public health areas during the pandemic participated. Results: The competencies most applied by the nurses were in the domain of health situation analysis and surveillance and risk and damage control. 95% of the nurses were involved in care actions to prevent contagion; 71% analyzed social determinants of health, 100% were involved in the domain of policies, planning, regulation, and control, and 86% in the domain of health promotion. 89% made decisions to favor access to preventive and health care services. 78% valued social participation actions and 76% implemented immediate responses to COVID-19. Conclusion: The main public health competencies used by nursing for dealing with the COVID-19 pandemic are the management of educational processes, health promotion, primary health care, analysis of social determinants, management of health policies, information analysis, and management of immediate responses to challenges generated by COVID-19.

Social Determinants of Health, Diet, and Health Outcome

This Special Issue delves into the intricate relationship between social determinants of health (SDOHs), diet, and health outcomes through 13 articles authored by scholars from 10 countries across five continents [...]

Precision health: Determining the capacity of practicing nurses across the United States.

Precision Health (PH) holds the promise of revolutionizing healthcare by enabling personalized disease prevention and management through the integration of genomic data, lifestyle factors, environmental influences, and other social determinants of health (SDoH). However, the absence of a baseline assessment of knowledge, skills, and attitudes (KSAs) of practicing nurses' capacity for PH hinders its integration. The purpose of this study is to determine the capacity of practicing Registered Nurses (RNs) for PH across the United States and to assess the validity and reliability of a tool designed for this use-the Precision Health Nurse Capacity Scale (PHNCS). A descriptive exploratory study was conducted to evaluate the capacity of practicing RNs for this evolving phenomenon, PH, using a convenience sample. The survey was sent via email and made available to all members of the American Nurses Association (ANA) who work in a variety of practice environments. The ANA represents the over 4 million nurses practicing in the United States. The majority of nurse respondents felt it is important for nurses to become more educated about all aspects of PH including SDoH but they lack confidence in the integration of PH. The PHNCS was found to be a valid and reliable tool in measuring the capacity of nurses to practice PH. The incorporation of PH into nursing practice suffers an immediate impediment: the lack of know-how of the US nursing workforce. This inaugural data on KSAs for PH establishes a logical baseline from which the requisite education and training should commence. Precision Health is an emerging healthcare approach in the United States and globally. Enabling it will require a nursing workforce prepared with the requisite KSAs. Determining the capacity of the nursing workforce is a foundational step to begin this process.

Social Media and Digital Inequity: Reducing Health Inequities by Closing the Digital Divide

As its usage has grown, social media has positively and negatively impacted public health. Although social media presents known harms to mental health and spreads misinformation, it also offers rapid dissemination of public health information, expanded access to health resources, and a robust source of health information. However, these benefits are not equitably shared due in part to the “digital divide” of unequal access and use of information and communication technologies. Measurable inequalities in digital access exist among regions, with an eight-fold difference between Central Africa (9.8% social media penetration) and Northern Europe (80.2% social media penetration). Digital inequalities also differ by gender, age, and socioeconomic classes within countries. Increased digital access has been positively associated with improved health information and outcomes related to chronic diseases, infectious disease outbreaks, and reproductive health. Given the expanding role of social media in public health and the emerging evidence on the health benefits of digital access, we argue for reducing digital inequities by (1) creating an enabling government policy and regulatory environment that views digital health access as a social determinant of health; (2) targeting public and private investments to expand digital access for underserved regions and populations; (3) making digital access and use affordable to low-resource populations; and (4) improving digital competency among these groups through digital literacy programs.

Launching Financial Incentives for Physician Groups to Improve Equity of Care by Patient Race and Ethnicity.

Blue Cross Blue Shield of Massachusetts (BCBSMA), a large commercial health insurer, is using financial incentives to advance equity of care by patient race and ethnicity. Understanding experiences of this payer and its contracted physician groups can inform efforts elsewhere. We qualitatively assess physician groups' barriers and facilitators of planning and implementing BCBSMA's financial incentives to improve equity of ambulatory care quality by patient race and ethnicity. Key informant interviews (n = 44) of the physician group, BCBSMA, and external stakeholders were conducted, equity initiative meetings were observed, and documents were analyzed to identify barriers and facilitators of designing and preparing for financial incentives to advance racial equity. Physician group experiences of preparing for and responding to financial incentives for equity improvement were assessed. Analyses revealed 1) the central importance of valid and reliable equity performance measurement and carefully designed equity improvement incentives for physician group buy-in, 2) that prior to implementing financial incentives for equity improvement, physician groups needed to improve their quality management systems and the accuracy and completeness of patient race and ethnicity data, and 3) physician groups' populations served, baseline maturity of quality management systems, and efforts to assess and address patients' social risk factors were central to consider to plan for physician group financial incentives to improve racial equity. Given the major infrastructure investments and organizational change management resources required of physician groups to participate in a financial incentive program designed to reward equity improvement, alignment of equity measurement and performance requirements across payers would facilitate physician groups' engagement in efforts to improve quality of care for racial and ethnic minority patients.

"Who You Are and Where You Live Matters": Hospice Care in New York City During COVID-19 Perspectives on Hospice and Social Determinants: A Rapid Qualitative Analysis.

Context: Social determinants of health (SDOH) impacted the quality of home hospice care provided during the COVID-19 pandemic. Perspectives from professionals who provided care identify challenges and lessons learned from their experience. Objective: To examine hospice professionals' perspectives of how SDOH affected the delivery of high-quality home hospice care in New York City (NYC) during the COVID-19 pandemic. Methods: We conducted semistructured interviews with 30 hospice professionals who delivered care to home hospice patients during the COVID-19 pandemic in NYC using a qualitative descriptive design. Purposive sampling was used to recruit professionals from a range of disciplines including physicians, advanced practice providers, nurses, social workers, chaplains, and hospice administration and management. Participants worked for one of two large NYC metro hospices and one outpatient palliative care practice serving the five boroughs of NYC and the surrounding suburbs. Rapid qualitative analysis was used to identify themes. Results: Thirty hospice professionals were interviewed, spanning a variety of clinical and administrative roles. Most (21 out of 30) reported that social determinants affected access and/or delivery of equitable hospice care. Two key themes emerged from interviews: (1) SDOH exist and affect the delivery of high-quality care and (2) disparities were exacerbated during the COVID-19 pandemic resulting in barriers to care. Subthemes outline barriers described by hospice professionals: decreased hospice enrollment, telehealth challenges, resulting in deficient patient/family education, shortages of nursing assistants in some neighborhoods, and diminished overall quality of hospice care for some patients. SDOH created barriers to hospice care through neighborhood factors, resource barriers, and system challenges. Conclusion: SDOH provide a context to understand disparity in the provision of hospice care. COVID-19 exacerbated these conditions. Addressing multidimensional barriers created by SDOH is key in creating high-quality and equitable hospice care, particularly during a crisis.

A Case for a Maternal Culturally Tailored Smoking Cessation Research Agenda

Background/Objectives: Despite national efforts, smoking rates during pregnancy remain high among certain demographics, particularly American Indian/Alaska Native and younger women. This study examines the causal link between maternal smoking, maternal and fetal mortality, and social determinants of health, highlighting disparities faced by Black, Indigenous, and People of Color (BIPOC) and American Indian/Alaskan Native (AIAN) pregnant persons. Methods: Data from various sources, including national reports and committee findings, were analyzed to assess trends in maternal smoking, mortality rates, and associated factors. While smoking rates among all groups have declined, disparities persist. Young women, BIPOC, and American Indian/Alaska Native women, and those with lower educational attainment, have higher smoking rates. Black women exhibit significantly higher maternal mortality rates, often linked to cardiac/coronary conditions. Stress, exacerbated by social determinants of health like poverty and housing insecurity, emerges as a key factor driving smoking behavior, particularly among African Americans. The leading causes of pregnancy-related deaths vary by race and ethnicity, with preventability noted in 80% of cases. Perinatal exposure to cigarette smoking is also identified as a leading cause of poor infant health outcomes, emphasizing the importance of addressing smoking behavior during and after pregnancy. Results: This report advocates for a comprehensive approach to reducing maternal and fetal mortality rates, with a focus on adapting existing smoking cessation programs to adopt culturally tailored agendas in order to address social and political determinants of health as well as behavioral drivers of tobacco use among pregnant persons.