Social Determinants Of Health Research Articles

Lower Opportunity ZIP Code Is Associated with Worse Outcomes after Listing in Pediatric Heart Transplantation

BackgroundThe Child Opportunity Index (COI) comprehensively measures children’s social determinants of health. We describe association between COI and outcomes after listing for heart transplantation. MethodsWe conducted a retrospective review of the United Network for Organ Sharing (UNOS) database for U.S. children listed for heart transplant between 2012 and 2020. ZIP codes were utilized to assign COI. Primary outcome was survival from time of listing. Secondary outcomes included waitlist survival, one-year post-transplant survival, and conditional one-year post-transplant survival. Cox regression was performed adjusting for payor, age, race, diagnosis, and support at listing for all outcomes except waitlist survival, for which Fine-Gray competing risk analysis was performed. ResultsOf 5723 children listed, 109 were excluded due to missing ZIP codes. Race/ethnicity and payor were associated with COI (p<0.001). Patients living in very low COI ZIP codes compared to all others had increased mortality from time of listing (HR 1.16, CI 1.03 – 1.32, p=0.02) with 1-, 5-, and 9-year survival of 79.3% vs 82.2%, 66.5% vs 73.0%, and 53.6% vs 64.7% respectively, were more likely to be removed from the waitlist due to death or being too sick (subdistribution HR 1.26, 95% CI 1.10-1.42), and had increased mortality conditional on one-year post-transplant survival (HR 1.38, 1.09 – 1.74, p=0.008) with 1-, 3-, and 5- year survival of 94.7% vs 97.3%, 87.0% vs 93.1%, and 78.6% vs 86.9%. ConclusionsChildren living in lower opportunity ZIP codes had poorer survival from time of listing, poorer waitlist survival, and poorer conditional one-year post-transplant survival.

Multidimensional Approach to Exploring Neighborhood Determinants and Symptom Severity Among Individuals With Psychosis.

The impact of cumulative exposure to neighborhood factors on psychosis, depression, and anxiety symptom severity prior to specialized services for psychosis is unknown. To identify latent neighborhood profiles based on unique combinations of social, economic, and environmental factors, and validate profiles by examining differences in symptom severity among individuals with first episode psychosis (FEP). This cohort study used neighborhood demographic data and health outcome data for US individuals with FEP receiving services between January 2017 and August 2022. Eligible participants were between ages 14 and 40 years and enrolled in a state-level coordinated specialty care network. A 2-step approach was used to characterize neighborhood profiles using census-tract data and link profiles to mental health outcomes. Data were analyzed March 2023 through October 2023. Economic and social determinants of health; housing conditions; land use; urbanization; walkability; access to transportation, outdoor space, groceries, and health care; health outcomes; and environmental exposure. Outcomes were Community Assessment of Psychic Experiences 15-item, Patient Health Questionnaire 9-item, and Generalized Anxiety Disorder 7-item scale. The total sample included 225 individuals aged 14 to 36 years (mean [SD] age, 20.7 [4.0] years; 152 men [69.1%]; 9 American Indian or Alaska Native [4.2%], 13 Asian or Pacific Islander [6.0%], 19 Black [8.9%], 118 White [55.1%]; 55 Hispanic ethnicity [26.2%]). Of the 3 distinct profiles identified, nearly half of participants (112 residents [49.8%]) lived in urban high-risk neighborhoods, 56 (24.9%) in urban low-risk neighborhoods, and 57 (25.3%) in rural neighborhoods. After controlling for individual characteristics, compared with individuals residing in rural neighborhoods, individuals residing in urban high-risk (mean estimate [SE], 0.17 [0.07]; P = .01) and urban low-risk neighborhoods (mean estimate [SE], 0.25 [0.12]; P = .04) presented with more severe psychotic symptoms. Individuals in urban high-risk neighborhoods reported more severe depression (mean estimate [SE], 1.97 [0.79]; P = .01) and anxiety (mean estimate [SE], 1.12 [0.53]; P = .04) than those in rural neighborhoods. This study found that in a cohort of individuals with FEP, baseline psychosis, depression, and anxiety symptom severity differed by distinct multidimensional neighborhood profiles that were associated with where individuals reside. Exploring the cumulative effect of neighborhood factors improves our understanding of social, economic, and environmental impacts on symptoms and psychosis risk which could potentially impact treatment outcomes.

The association between disability and mortality: a mixed-methods study

Globally, 1·3 billion people have a disability and are more likely to experience poor health than the general population. However, little is known about the mortality or life expectancy gaps experienced by people with disabilities. We aimed to undertake a systematic review and meta-analysis of the association between disability and mortality, compare these findings to the evidence on the association of impairment types and mortality, and model the estimated life expectancy gap experienced by people with disabilities. We did a mixed-methods study, which included a systematic review and meta-analysis, umbrella review, and life expectancy modelling. For the systematic review and meta-analysis, we searched MEDLINE, Global Health, PsycINFO, and Embase for studies published in English between Jan 1, 2007, and June 7, 2023, investigating the association of mortality and disability. We included prospective and retrospective cohort studies and randomised controlled trials with a baseline assessment of disability and a longitudinal assessment of all-cause mortality or cause-specific mortality. Two reviewers independently assessed study eligibility, extracted the data, and assessed risk of bias. We did a random-effects meta-analysis to calculate a pooled estimate of the mortality rate ratio for people with disabilities compared with those without disabilities. We did an umbrella review of meta-analyses examining the association between different impairment types and mortality. We used life table modelling to translate the mortality rate ratio into an estimate of the life expectancy gap between people with disabilities and the general population. The systematic review and meta-analysis is registered with PROSPERO, CRD42023433374. Our search identified 3731 articles, of which 42 studies were included in the systematic review. The meta-analysis included 31 studies. Pooled estimates showed that all-cause mortality was 2·24 times (95% CI 1·84-2·72) higher in people with disabilities than among people without disabilities, although heterogeneity between the studies was high (τ2=0·28, I2=100%). Modelling indicated a median gap in life expectancy of 13·8 years (95% CI 13·1-14·5) by disability status. Cause-specific mortality was also higher for people with disabilities, including for cancer, COVID-19, cardiovascular disease, and suicide. The umbrella review identified nine meta-analyses, which showed consistently elevated mortality rates among people with different impairment types. Mortality inequities experienced by people with disabilities necessitate health system changes and efforts to address inclusion and the social determinants of health. National Institute for Health and Care Research, Rhodes Scholarship, Indonesia Endowment Funds for Education, Foreign, Commonwealth and Development Office (Programme for Evidence to Inform Disability Action), and the Arts and Humanities Research Council.

Social determinants of health that impact the time to diagnosis and treatment of infertility in Taiwan.

Taiwan is one of the countries with the lowest birth rate in the world. We investigated factors associated with the time to diagnosis and treatment of infertility in Taiwan. The study was conducted through an online questionnaire in December 2021. The questionnaire was adapted from a previously published multinational survey, and culture-specific questions were added. 91 infertile patients and 89 partners of patients in Taiwan, aged 20- to 45- year-old, were included. The average duration before diagnosis was 2.9 years, followed by 1.5 years before treatment. Older age at marriage (p=0.0024), higher education level (P=0.0001), and a higher gender equality score (p=0.0031) were associated with earlier diagnosis. Conversely, folk therapy use was linked to later diagnosis (p<0.0001) and treatment (p<0.0001). Notably, in the female (p=0.039) and patient (p=0.0377) subgroups, a higher gender equality score was associated with a shorter duration of folk therapy. Subjectively, the most frequent factor influencing treatment decision was affordability or lack thereof. The government subsidy for in vitro fertilization led to increased treatment willingness for 46.3% of respondents, and 47.3% reported more likely to pursue earlier treatment. This study highlights the influence of education, gender equality, folk therapy, and government subsidy on fertility care decisions. To improve the timeliness of infertility healthcare in Taiwan, potential strategies include promoting education, fostering gender equality, providing financial support, and raising awareness on the association between folk therapy and delayed medical care.

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.

Geospatial and Socioeconomic Disparities Influencing the Management of Craniosynostosis.

Various social determinants of health have been described as predictors of clinical outcomes for the craniosynostosis population. However, literature lacks a granular depiction of socioeconomic factors that impact these outcomes, and little is known about the relationship between patients' proximity to the care center and management of the condition. This study retrospectively evaluated patients with craniosynostosis who presented to a tertiary children's hospital between 2000 and 2019. Outcomes of interest included age at presentation for surgery, incidence of reoperation, and length of follow-up. Patient addresses were geocoded and plotted on two separate shapefiles containing block group information within San Diego County. The shapefiles included percent parental educational attainment (bachelor's degree or higher) and median household income from 2010. The year 2010 was chosen for the shapefiles because it is the median year of data collection for this study. Multivariate linear, logistic, and polynomial regression models were used to analyze the relationship between geospatial and socioeconomic predictors and clinical outcomes. There were 574 patients with craniosynostosis included in this study. The mean ± SD Haversine distance from the patient's home coordinates to the hospital coordinates was 107.2 ± 321.2 miles. After adjusting for the suture fused and insurance coverage, there was a significant positive correlation between distance to the hospital and age at index surgery (P = 0.018). There was no correlation between distance and incidence of reoperation (P = 0.266) or distance and duration of follow-up (P = 0.369). Using the same statistical adjustments, lower parental percent educational attainment and lower median household income correlated with older age at index surgery (P = 0.008 and P = 0.0066, respectively) but were not correlated with reoperation (P = 0.986 and P = 0.813, respectively) or duration of follow-up (P = 0.107 and P = 0.984, respectively). The results offer evidence that living a greater distance from the hospital and socioeconomic disparities including parental education and median household income may serve as barriers to prompt recognition of diagnosis and timely care in this population. However, the geospatial and socioeconomic factors studied do not seem to hinder incidence of reoperation or length of follow-up, suggesting that, once care has been initiated, longitudinal outcomes may be less impacted.

Social Determinants of Health in Cardio-Oncology

Social Determinants of Health in Cardio-Oncology

“We are Always in Self-Isolation”: Navigating COVID-19 as a Young Person in Canada with Cystic Fibrosis

The pandemic disproportionately influenced marginalized communities in North America. However, the social and spatial inequalities impacting marginalized rare genetic disease communities – such as those living with cystic fibrosis – have not been heard in mainstream pandemic narratives. Sensitized by the social determinants of health, this qualitative study explored the experiences of 12 youth with Cystic Fibrosis (CF) during the pandemic. Content analysis revealed four themes. Youth with CF experienced changes across physical spaces, faced pandemic anxiety, and struggled with access to digital and medical spaces. Youth also reflected on being “used to” life-long physical distancing as a result of CF. Our findings show the complexity of environments for youth with CF during the pandemic while demonstrating how Covid-19 shaped the lives of rare disease communities. Our findings also illustrate spatial and social inequities among marginalized, rare genetic disease communities.

Fatherhood and Cardiovascular Health, Disease, and Mortality: Associations From the Multi-Ethnic Study of Atherosclerosis

IntroductionEmerging literature links fatherhood to men's health, but lacks comprehensive assessment of health outcomes, especially among multi-ethnic populations. Our objective was to evaluate the associations of fatherhood (age at onset and status) with cardiovascular health (CVH) scores, incident cardiovascular disease (CVD), CVD death and all-cause mortality, examining differences by race/ethnicity. MethodsWe included men from Multi-Ethnic Study of Atherosclerosis (MESA), prospective cohort study which enrolled adults aged 45 to 84 years without known CVD at baseline. CVH was defined using the American Heart Association Life's Essential 8 (LE8) scores (0-100), excluding sleep (CVH score). ResultsIn this sample of 2,814 men, mean age at CVH assessment was 62.2 years, 82% were fathers, 24% self-identified as Black, 13% Chinese, 22% Hispanic, and 41% White. Fathers who were <20 and 20-24 years old at their oldest child's birth had worse overall CVH compared with fathers who were >35 years old (adjusted mean score 61.1 vs 64.7, p=0.01 and 61.0 vs 64.7, p<0.001 respectively). Fathers had worse overall CVH (adjusted mean score 63.2 vs 64.7, p=0.03) and more nicotine exposure (63.1 vs 66.6, p=0.04), than non-fathers. In age-adjusted models, fathers overall (hazard ratio [HR]=0.82; 95%CI, 0.69–0.98) and Black fathers (HR=0.73; 95%CI, 0.53–0.999) had a lower rate of all-cause mortality rate than non-fathers, but these associations were no longer significant in fully adjusted models. ConclusionFatherhood is a social determinant of health and understanding its influence may provide opportunities to improve men's health, particularly among men of color.

Rural Living and Social Determinates of Health

Rural Living and Social Determinates of Health

Social Determinants of Health, Infant Brain Development and Early Childhood Social-Emotional Development

Social Determinants of Health, Infant Brain Development and Early Childhood Social-Emotional Development

Factors associated with family decision-making after pediatric out-of-hospital cardiac arrest

AimThis study aims to identify demographic factors, area-based social determinants of health (SDOH), and clinical features associated with medical decision-making after pediatric out-of-hospital cardiac arrest (OHCA). MethodsThis is a retrospective, exploratory, descriptive analysis of patients < 18 years old admitted to the pediatric intensive care unit (ICU) after OHCA from 2011 to 2022 (n = 217) at an urban tertiary care, free-standing children’s hospital. Outcomes of interest included: (1) whether a new advance care plan (ACP) (defined as a written advance directive including do not resuscitate and/or do not intubate) was ordered during hospitalization, and (2) whether the patient was discharged with new medical technology (defined as tracheostomy and/or feeding tube). Logistic regression models identified features associated with these outcomes. ResultsOf the 217 patients, 78 patients (36%) had a new ACP placed during their admission. Of the survivors, 26% (27/102) were discharged home with new medical technology. Factors associated with ACP were greater change in Pediatric Cerebral Performance Category (PCPC) score (aOR = 1.49, 95% CI [1.28–1.73], p-value < 0.001) and palliative care consultation (aOR = 2.39, 95% CI [1.16–4.89], p-value 0.018). Factors associated with new medical technology were lower change in PCPC score (aOR = 0.76, 95% C.I. [0.61–0.95], p-value = 0.015) and palliative care consultation (aOR = 7.07, 95% CI [3.01–16.60], p-value < 0.001). There were no associations between area-based SDOH and outcomes. ConclusionsUnderstanding factors associated with decision-making related to ACP after OHCA is critical to optimize counseling for families. Multi-institutional studies are warranted to identify whether these findings are generalizable.

Social Determinants of Mental Health in Depression: Comparison of Relative Impact on Prevalence of Major Depressive Disorder

Social Determinants of Mental Health in Depression: Comparison of Relative Impact on Prevalence of Major Depressive Disorder

Advances in the Understanding of Social Determinants of Health in Stroke.

Advances in the Understanding of Social Determinants of Health in Stroke.

Deep Learning-Based Assessment of Built Environment From Satellite Images and Cardiometabolic Disease Prevalence.

Built environment plays an important role in development of cardiovascular disease. Large scale, pragmatic evaluation of built environment has been limited owing to scarce data and inconsistent data quality. To investigate the association between image-based built environment and the prevalence of cardiometabolic disease in urban cities. This cross-sectional study used features extracted from Google satellite images (GSI) to measure the built environment and link them with prevalence of cardiometabolic disease. Convolutional neural networks, light gradient-boosting machines, and activation maps were used to assess the association with health outcomes and identify feature associations with coronary heart disease (CHD), stroke, and chronic kidney disease (CKD). The study obtained aerial images from GSI covering census tracts in 7 cities (Cleveland, Ohio; Fremont, California; Kansas City, Missouri; Detroit, Michigan; Bellevue, Washington; Brownsville, Texas; and Denver, Colorado). The study used census tract-level data from the US Centers for Disease Control and Prevention's 500 Cities project. The data were originally collected from the Behavioral Risk Factor Surveillance System that surveyed people 18 years and older across the country. Analyses were conducted from February to December 2022. GSI images of built environment and cardiometabolic disease prevalence. Census tract-level estimated prevalence of CHD, stroke, and CKD based on image-based built environment features. The study obtained 31 786 aerial images from GSI covering 789 census tracts. Built environment features extracted from GSI using machine learning were associated with prevalence of CHD (R2 = 0.60), stroke (R2 = 0.65), and CKD (R2 = 0.64). The model performed better at distinguishing differences between cardiometabolic prevalence between cities than within cities (eg, highest within-city R2 = 0.39 vs between-city R2 = 0.64 for CKD). Addition of GSI features both outperformed and improved the model that only included age, sex, race, income, education, and composite indices for social determinants of health (R2 = 0.83 vs R2 = 0.76 for CHD; P <.001). Activation maps from the features revealed certain health-related built environment such as roads, highways, and railroads and recreational facilities such as amusement parks, arenas, and baseball parks. In this cross-sectional study, a significant portion of cardiometabolic disease prevalence was associated with GSI-based built environment using convolutional neural networks.

Assessment of socioeconomic and racial differences in patients undergoing concurrent gynecologic oncology and urogynecology surgeries: a National Inpatient Sample (NIS) database study

ObjectiveTo assess social determinants of health impacting patients undergoing gynecologic oncology versus combined gynecologic oncology and urogynecology surgeries.MethodsWe identified patients who underwent gynecologic oncology surgeries from 2016 to 2019 in...

The design and implementation of a multi-center, pragmatic, individual-level randomized controlled trial to evaluate Baby2Home, an mHealth intervention to support new parents

BackgroundBecoming a parent is a transformative experience requiring multiple transitions, including the need to navigate several components of health care, manage any mental health issues, and develop and sustain an approach to infant feeding. Baby2Home (B2H) is a digital intervention built on the collaborative care model (CCM) designed to support families during these transitions to parenthood. ObjectivesWe aim to investigate the effects of B2H on preventive healthcare utilization for the family unit and patient-reported outcomes (PROs) trajectories with a focus on mental health. We also aim to evaluate heterogeneity in treatment effects across social determinants of health including self-reported race and ethnicity and household income. We hypothesize that B2H will lead to optimized healthcare utilization, improved PRO trajectories, and reduced racial, ethnic, and income-based disparities in these outcomes as compared to usual care. MethodsB2H is a multi-center, pragmatic, individual-level randomized controlled trial. We will enroll 640 families who will be randomized to: [1] B2H + usual care, or [2] usual care alone. Preventive healthcare utilization is self-reported and confirmed from medical records and includes attendance at the postpartum visit, contraception use, depression screening, vaccine uptake, well-baby visit attendance, and breastfeeding at 6 months. PRO trajectories will be analyzed after collection at 1 month, 2 months, 4 months, 6 months and 12 months. PROs include assessments of stress, depression, anxiety, self-efficacy and relationship health. ImplicationsIf B2H proves effective, it would provide a scalable digital intervention to improve care for families throughout the transition to new parenthood.

Coding Hotline

This month’s Coding Hotline addresses coding for social determinants of health and COVID-19 vaccination.

Nurse informaticists' role in promoting health equity.

Nurse informaticists (NIs) play a pivotal role in addressing health-related social needs through integrating technology into electronic health records. NIs navigate regulatory landscapes, emphasizing screening for social determinants of health during hospital encounters. This article underscores NIs' strategic contributions to optimizing data collection, supporting health equity, and utilizing innovative technologies to bridge gaps in healthcare outcomes.

Addressing Social Determinants in the Era of Precision Medicine in Breast Cancer: Is It Sufficient to Reduce Disparities?

The Oncotype DX (ODX) assay predicts recurrence risk and demonstrates the benefits of adjuvant therapy in patients with early-stage, hormone receptor (HR)-positive/HER2-negative breast cancer. ODX uptake varies by patients' racial/ethnic backgrounds and socioeconomic status (SES). However, community-level variability remains unknown, and research regarding the association between testing status and receipt of adjuvant chemotherapy is limited. To fill these knowledge gaps, Van Alsten and colleagues found a 6% lower prevalence of ODX uptake among patients residing in high SES-deprived areas than among those residing in low SES-deprived areas. Among patients with low and median ODX recurrence scores, those who underwent testing were 28% and 21% less likely to receive adjuvant chemotherapy than those who did not, respectively. The findings emphasize the role of social determinants of health. However, to further reduce or eliminate racial/ethnic disparities and SES inequities, we would need sufficient and effective multi-level approaches. These involve lower ODX testing costs, health insurance coverage expansion, re-classification and validation of ODX recurrence scores in patients of minority ancestry, and the development of a faster, more accurate, and affordable test. See related article by Van Alsten et al., p. 654.