Social Determinants Research Articles

Access to Network Social Capital and Health Outcomes in Later Life: Understanding the Role of Tie Strength

Our study contributes to the scholarship by examining the concrete ways in which two distinct types of interpersonal connection—strong/close versus weak/distant—are independently related to self-rated health and life satisfaction cross-nationally. In addition, we explore whether and how the two types of interpersonal connection modify the magnitude of the associations between subjective social status (SSS) and health and well-being of older populations cross-nationally. According to results from our multilevel analysis, social capital available through strong ties (family and friends) is positively associated with both outcomes. On the other hand, social capital via weak ties (acquaintances) is positively related to health but negatively related to well-being. We also find that social capital mediated by strong ties significantly buffers the harmful implications of status disadvantage or low SSS on health and well-being of older adults. In comparison, weak tie-mediated social capital provides buffering against status disadvantage only for well-being.

Prevalence of Cardiovascular-Kidney-Metabolic Syndrome Stages by Social Determinants of Health

ImportanceCardiovascular-kidney-metabolic (CKM) syndrome—a novel, multistage, multisystem disorder as defined by the American Heart Association—is highly prevalent in the US. However, the prevalence of CKM stages by social determinants of health (SDOH) remains unclear.ObjectiveTo investigate whether the prevalence of CKM stages varies by SDOH in US adults.Design, Setting, and ParticipantsThis cross-sectional study used data from the National Health and Nutrition Examination Survey (1999-2018) and included a nationally representative sample of adults aged 30 to 79 years through complex, multistage probability sampling. Data were analyzed from April 1 to June 15, 2024.ExposuresThe exposures included 5 CKM stages (ie, stages 0-4) reflecting progressive pathophysiology, with advanced (stages 3 or 4) and nonadvanced (stages 0, 1, or 2) disease. CKM stages were defined based on risk factors for metabolic syndrome, cardiovascular disease, and chronic kidney disease.Main Outcome and MeasuresThe main outcome was the age-standardized prevalence of CKM stages and advanced CKM stages across SDOH, including education, marital status, family income, food security, health insurance, employment, home ownership, and health care access.ResultsAmong 29 722 participants (weighted mean [SE] age, 50.8 [0.1] years; weighted 50.7% male), the age-standardized prevalence of CKM stages 0 to 4 was 13.6% (95% CI, 13.0%-14.3%), 29.9% (95% CI, 29.1%-30.7%), 43.7% (95% CI, 42.9%-44.5%), 4.7% (95% CI, 4.4%-5.0%), and 8.1% (95% CI, 7.6%-8.5%), respectively. Significant differences were observed in the prevalence of CKM stages across all unfavorable SDOH of interest compared with their favorable counterparts, with unemployment (18.8% [95% CI, 17.7%-20.1%] vs 11.4% [95% CI, 11.0%-11.9%]), low family income (16.1% [95% CI, 15.4%-16.8%] vs 10.1% [95% CI, 9.5%-10.7%]), and food insecurity (18.3% [95% CI, 17.1%-19.6%] vs 11.7% [95% CI, 11.2%-12.2%]) associated with an increased likelihood of advanced CKM stages. Participants with 2 or more unfavorable SDOH were more likely to have advanced CKM stages (age-standardized prevalence, 15.8% [95% CI, 15.2%-16.5%] vs 10.5% [95% CI, 9.9%-11.1%] with <2 unfavorable SDOH). Living in a rented home (15.9% [95% CI, 14.7%-17.0%] vs 9.3% [95% CI, 8.7%-9.9%] owning the home) or not living with a partner (13.2% [95% CI, 12.3%-14.3%] vs 9.2% [95% CI, 8.5%-9.8%] living with a partner) increased the likelihood of advanced CKM stages in female but not male participants.Conclusions and RelevanceIn this cross-sectional study, disparities in the prevalence of CKM stages by SDOH, particularly family income, food security, and employment, with notable sex differences, were observed in US adults. These findings highlight the need to address inequities in CKM syndrome through targeted interventions.

Abstract B037: Expression of MRTFA facilitates an immunosuppressive tumor microenvironment via upregulation of VSIR

Abstract Breast cancer, the second highest cause of cancer-related deaths in women, accounts for 31% of female cancer diagnoses. African American women have lower survival rates than White American women, influenced by both biological factors (age, family history, genetic factors, tumor biology) and social determinants (socio-economic status, insurance status, health care access). However, precise biological determinants remain unclear. The primary reason for breast cancer mortality is metastasis to organs like the lung, liver, and brain, with transcription factors playing a key role in this process. Myocardin related transcription factor A/B (MRTFA/B) are co-activators of serum-response factor (SRF), and the MRTF-SRF complex promotes breast cancer cell migration, invasion, and metastasis by regulating genes involved in actin cytoskeleton remodeling. MRTFA also supports tumor growth by modulating cancer-associated fibroblasts (CAFs) and remodeling the extracellular matrix (ECM) in the tumor microenvironment. While the pro-metastatic role of MRTFA/B is established in vitro and in mice, their impact on human cancer progression and metastasis requires further investigation. Therefore, understanding MRTFA's role in breast cancer metastasis is crucial for improving patient outcomes, making it essential to investigate MRTFA/B expression patterns in both tumor cells and the tumor microenvironment (TME). To explore the clinical, demographic, tumor-intrinsic, and tumor microenvironmental patterns of MRTFA/B’s expression and activation, we utilized multiplex imaging methods on multiple racially diverse tissue microarrays (TMA) and bioinformatics analyses of The Cancer Genome Atlas (TCGA), Molecular Taxonomy of Breast Cancer International Consortium (METABRIC), and available single-cell RNA sequencing datasets. Strikingly, MRTFA expression levels were higher in African American patients than in White American patients. Next, we investigated MRTFA expression patterns in the TME by using single-cell sequencing databases and found more abundant MRTFA expression in dendritic cells (DCs) within the TME compared to any other cell subtype. Moreover, our multiplex-imaging of tumor microarray (TMA) samples showed prominent MRTFA expression in HLA-DRA+CD45+ cells, indicative of antigen-presenting cells (APC). Notably, public single-cell RNA sequencing data indicated that breast cancer DCs strongly express the V-set immunoregulatory receptor (VSIR), an immune checkpoint protein, implying the immunosuppressive nature of the TME and we found that this increased VSIR expression is mediated by the MRTF-SRF complex. These findings suggest that DCs expressing MRTFA in breast cancer microenvironment contribute to creating the immunosuppressive TME via upregulation of VSIR expression, resulting in racial breast cancer disparities. Citation Format: Kihak Lee, Stephanie M. Wilk, Alexa M. Gajda, Mohamed Haloul, Virgilia Macias, Elizabeth L. Wiley, Zhengjia Chen, Xinyi Liu, Xiaowei Wang, Maria Sverdlov, Kent F. Hoskins, Ekrem Emrah Er. Expression of MRTFA facilitates an immunosuppressive tumor microenvironment via upregulation of VSIR [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Tumor-body Interactions: The Roles of Micro- and Macroenvironment in Cancer; 2024 Nov 17-20; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2024;84(22_Suppl):Abstract nr B037.

Mediatization of medicine and health: dysfunctional aspects

In this article, based on the results of empirical research conducted by employees of the Faculty of Sociology, Doctor of Sociological Sciences, Associate Professor T.V. Semina and graduate student A.A. Belov, the destructive influence of electronic and digital media on the health of Russian citizens is considered. In fact, we are talking about the “mediatization of medicine”, which is understood as “the process caused by the emergence of digital communication tools, as a result of which the masses have free access to medical information, and all issues related to human and social health are somehow mediated by electronic media”. The author emphasizes that quite often the media practices uncontrolled submission of quasi-medical information, signs of economic bias present in the media are expressed in the fact that the main source of income for the media is advertising, especially medicines and pharmaceuticals. At the same time, commercials advertising medicines on television are the most effective in influencing the audience. In 2019, T.V. Semina, Doctor of Sociology, Associate Professor of the Faculty of Sociology at Lomonosov Moscow State University, proved the destructive role of the media in the genesis of social conflict in the doctor–patient system. In April–July 2024, the author also undertook an empirical sociological study on the problems of constructing public health in the Russian Federation, in particular, the effectiveness of the impact of advertising materials placed in the media on the health-saving attitudes of Russians, he results of which are presented in the article. In general, the results of empirical studies conducted by T.V. Semina and confirmed by the author’s research convincingly prove the dysfunctionality of the media in relation to the health of Russian citizens, their negative impact on the consciousness of both healthy and sick people. The author emphasizes that it is not so difficult to protect health, but, unfortunately, many people do not even try to do this, guided by certain stereotypes imposed by the media. For example, that after a certain age, absolutely everyone has high blood pressure, overweight, hormonal and other disorders and should regularly take appropriate (widely advertised) medications or dietary supplements, the benefits of which have not been scientifically proven. Most importantly, the author notes, changes are needed in the development of self-preservation behavior among the population. The main task of the state is not only to develop an effective health care system, but also to promote a responsible attitude of citizens to their own health, which implies regular medical examinations, giving up bad habits, leading a healthy lifestyle involving “life on the move”, full sleep and cognitive activity.

Integrating informal and formal care: An innovative, scalable program blueprint.

People have infinite needs, including illness prevention, wellness, self-care, practical support, and quality of life. This article describes community-based, informal care programs that help people identify their needs, set goals, and organize networks of care to address their needs holistically in a way that can also significantly reduce healthcare costs. Approaches can be customized for primary care, home and community, hospice, and other care sectors to facilitate low-cost, high impact adoption. We provide a blueprint for programs that integrate informal and formal care across social, physical, and mental health domains as a key part of healthcare system transformation.

COVID-19, social determinants, and African American-White disparities: policy response and pathways forward.

COVID-19 translated African Americans' greater social, economic, and health-related risk, reflecting adverse Social Determinants of Health (SDOH), into greater COVID morbidity, hospitalization, and mortality, and it threatened to enlarge the very risks causing greater COVID suffering. However, following a federal policy response injecting trillions of dollars into the US economy, longstanding African American-White disparities ineconomic well-being, insurance coverage, vaccination rates, and evictions declined. On the other hand, troubling and consequential disparities in k-12 academic achievement and college attendance disparities widened. Continuous monitoring and careful research are needed to document and explain trajectories in social determinant disparities and to offer insight into how policy intervention can decrease continuing disparities in economic well-being, health care, and housing stability.

Editorial: Diabetes and mental health: from understanding biomedical and social determinants, to promoting wellness in diabetes

Editorial: Diabetes and mental health: from understanding biomedical and social determinants, to promoting wellness in diabetes

Addressing social norms for adolescent timing and spacing of pregnancy in low and middle-income countries: Developing a global research agenda.

Social norms shape adolescent sexual and reproductive health behaviours contributing to contraceptive and pregnancy outcomes. No global research agendas exist to guide research on adolescent social norms shifting in low- and middle-income countries (LMICs). We developed a social norms research agenda to improve adolescent healthy timing and spacing of pregnancy in LMICs. We adapted and applied the Child Health and Nutrition Research Initiative (CHNRI) method. A group of researchers guided the process, and consulted with diverse experts to develop a list of 21 research questions for global stakeholders to score via an online survey. Survey participants scored each research question according to four criteria (fills key gap, feasible, impactful, equitable). Research priority scores (RPS) and average expert agreement (AEA) statistics were calculated for each question and analysed overall and by stakeholder region and profession. We received 185 survey responses. Participants were, on average, 44 years old, 64% were women, 70% were from LMICs and 47% were implementers. The RPS ranged from 52 to 81% (74% median) and the AEA ranged from 49 to 70% (58% median). Nearly 70% of stakeholders gave the same score to each of the top five research questions. The top five research priorities focused on effective norm-shifting interventions (NSIs) strategies, processes and indicators to NSIs, and NSI adaptation and scale-up. Using a collaborative and rigorous process with diverse representation from LMICs and implementers, we reached consensus on five priority research questions to guide future adolescent social norms research to improve healthy timing and spacing of pregnancy in LMICs.

The correlation between social class and public health: The mediating role of health self-management

The relationship between health and social class has been a topic of research for many years. However, the exact mechanism linking them with health self-management is still not completely clear. The main indicators of the independent variable social class are income and education level. The study used a descriptive approach using a social survey method, and collected data from a random sample of 699 individuals from the northern region of Jordan. The data were analyzed using SPSS 26 and EOMS, and we performed regression analysis and Pearson correlation test to examine the relationship between the independent and dependent variables. The results show a positive relationship between social class and health, with lower social classes producing unfavorable health. Although the health self-management of the lower social class has access to good food and self-evaluation, they are less able to provide health care compared to the upper class. Thus, this discrepancy contributes to health inequalities between members of the upper and lower social classes.

What is the Relationship Between Older People's Housing Characteristics and Their Care Needs?

ABSTRACT Housing conditions and quality are well-established structural or social determinants of health. Poor quality housing also has the potential to affect care needs, but there is much less research on the topic, particularly on nonspecialist housing. Based on analysis of in-depth interviews with 44 people aged 65 and older living in England, their unpaid carers (N = 22), or as a carer-care recipient dyad (N = 6), (total N = 72), this study sought to explore the perceived relationship between people’s housing conditions and characteristics and their care needs. Findings indicate three key themes within this relationship: condition of home (cold and damp; state of repair; cleanliness and clutter); space and design (space, access); and legal relationship with the home (ability to carry out remedial work; precarity). There was variation in how and whether housing affected care needs by housing tenure, financial resources, and the type and level of care need. Care needs can increase requirement for warmer, less damp homes and be a barrier to improving homes. In turn, housing has a role to play in preventing the occurrence or worsening of care needs. Improving housing through policy and practice actions could reduce care needs and improve the lives of older people now and in the future.

A cross-sectional evaluation of knowledge and attitudes of medical interns regarding social service practices in healthcare institutions

Abstract Interprofessional collaboration is essential for holistic healthcare, yet social work remains under-integrated in medical curricula, particularly in Türkiye. Neoliberal policies have weakened community-based services, increasing the need to address gaps in medical education regarding social work’s role in addressing social determinants of health. This is especially critical given Türkiye’s demographic shifts, such as an aging population and rising social inequalities. This study aimed to assess the knowledge and attitudes of intern doctors at a university in Izmir, Türkiye, regarding social work practices in healthcare and to identify associated factors. A sample of 181 was selected through simple random sampling. Data analysis included descriptive statistics, t-test, Spearman correlation, and factor analyses. The Cronbach’s alpha for the attitude scale was 0.87. A significant portion (34.8 percent) had not heard of the social work profession, and 56.4 percent were unaware of social workers in their institution. Female students and those encountering underserved patients showed higher knowledge scores. There was a weak positive correlation between knowledge and attitudes. Factors influencing attitudes included gender, familiarity with social work, encountering underserved patients and financial status. Changes in medical education are needed to enhance interprofessional collaboration, with further research recommended on gender roles and attitudes towards social work.

Disparities in Vaccination Amongst Socially Vulnerable Patients with Inflammatory Bowel Disease.

Social determinants of health (SDOH) have a known impact on disparities in vaccination. Despite an increased risk for infection in patients with inflammatory bowel disease (IBD), SDOH and vaccination in this population have not been studied. Using census tract-level data from the Centers for Disease Control's social vulnerability index (SVI), we aimed to understand the relationship between SDOH and adherence to guideline-recommended vaccinations in patients with IBD. A single-center retrospective cohort of patients with IBD was used to geocode patient addresses to their individual census tract and corresponding SVI and subthemes (Socioeconomic Status, Household Composition, Minority Status, and Housing/Transportation). We used separate multivariable logistic regressions to examine the relationship between SVI and vaccination against influenza, COVID-19, pneumococcal pneumonia, and herpes zoster. A total of 7,036 patients were included. Rates of vaccination varied across vaccine-types: influenza (57%), COVID-19 (65%), pneumococcal pneumonia (58%), and herpes zoster (11%). High social vulnerability was associated with lower odds of vaccination against influenza (OR 0.47, p < 0.001), COVID-19 (OR 0.54, p < 0.001), pneumonia (OR 0.73, p = 0.012), and herpes zoster (OR 0.39, p < 0.001). Within the SVI subthemes, Socioeconomic Status, Household Composition, and Minority Status were important factors associated with differences in vaccine uptake. Higher social vulnerability was associated with lower rates of vaccination across all vaccine types. Identifying these disparities in vaccination for socially vulnerable patients with IBD is the first step to reducing preventable infections and ensuring all patients receive high quality, equitable care.

Impact of Physicians’ Perception of Social Determinants of Health (SDoH) on the Practice of Lifestyle Medicine. Findings From a Family Physicians Survey

Lifestyle Medicine emphasizes evidence-based lifestyle changes to address chronic conditions Yet, concerns have emerged regarding its ability to address broader social determinants of health (SDoH). This study examines how family physicians’ perceptions of SDoH relate to their use of lifestyle medicine competencies. This cross-sectional survey was administered to 5770 family physicians. Participants rated the importance of LM core competencies and the impact of community conditions on patient health. Data analysis involved descriptive statistics, factor analysis, regression models, and t-tests. This study encompassed 447 responses. The findings revealed that while respondents recognized the effect of certain SDoH, such as access to unhealthy food (89%), alcohol (86%), and tobacco (83%), they showed less awareness of factors like racism and discrimination (53%), and access to parks (56%) or education (60%). Gender and the level of social deprivation in their area were significant factors influencing respondents’ perception of SDoH impact. Additionally, those who valued and used lifestyle medicine core competencies were more likely to acknowledge the influence of SDoH on patient health. Our findings suggest that comprehensive education on SDoH, especially with a focus on community aspects, is crucial across all levels of medical training to address this gap and ensure equitable care.

Medicaid Waivers to Address Homelessness: Political Development and Policy Trajectories.

This article reviews the role of Medicaid Waivers in homeless policy, and their emerging role as a mechanism to address homelessness. We evaluate the political development of Waivers in housing and homeless policy over the past thirty years, and investigate the status of current and approved Waivers targeting homelessness. We then consider how Waivers may shape homeless policy governance going forward, including the success of existing systems, and ethical questions related to the role of healthcare payers in solutions to homelessness. We find that the scope of Medicaid Waivers to address homelessness has always been present, but significantly expanded post Affordable Care Act (ACA) and more notably following the COVID-19 pandemic. These expansions brought new opportunities for states to fund responses to homelessness through Medicaid social determinants of health (SDoH) provisions providing wrap-around medical services for populations at-risk of or experiencing homelessness, and now through time-limited direct housing costs paired with essential medical services. Over one third of states have an 1115 Waiver specifically targeting homelessness, with nearly one in five states including provisions that cover direct housing costs (e.g., rent). Going forward, Medicaid's involvement in homeless policy has the potential to reshape state and local responses to homelessness.

Religion as a Social Determinant of Health: Perceived Role of Religiosity in Risky Behavior and Social Problems

Background: Religion as a social determinants of health(SDOH) has long been a topic of fascination and debate, affecting various aspects of human life, including behavior. Some behaviors cause social problems due to harmful consequences they have when they become popular. Risky health behaviors are part of these social issues Method: This study employs Interpretative Phenomenological Analysis (IPA) to explore individuals' perceptions of the role of religiosity in social problems in Shiraz in 2022 . To gain deeper insights into this relationship, we conducted semi- structured in-depth interviews with 14 participants, who engaged in various forms of risky behavior. Results: The study revealed four distinct themes: a constructive viewpoint, where religion was seen as integral to addressing social issues, guiding individuals towards positive behavior; a destructive viewpoint, where religion was perceived as a source of harm and risky behavior; a separation between social issues and religion, indicating that certain social problems and behavior transcend religious definitions; and the interaction of religion with some factors which underscores the interplay between religion and other determinants, such as economic status, in shaping perceptions of social problems. Economic status emerged as a significant factor influencing participants' perspectives on social issues and risky behavior. Conclusion: This study showed that understanding of people involved in high-risk behaviors about the role of religion in the occurrence of these behaviors and social damages are very different. Some consider religion to be very effective in preventing these behaviors, and some consider religion to be the cause of social damage, emphasizing the importance of considering these diverse perspectives in addressing social issues in contemporary society.

"Will I survive this?": A qualitative exploration of the wider impacts of the COVID-19 pandemic on the health and well-being of pregnant and parenting youth and their children in Canada.

Pregnant and parenting youth in Canada face multiple challenges in fulfilling their parenting responsibilities while meeting their own unique needs. The COVID-19 pandemic and its associated public health restrictions exacerbated their challenges by reducing access to support networks, limiting opportunities to promote growth and well-being, and destabilizing their financial and economic standing. The impacts of the pandemic on the mental, physical, and emotional health of individuals are well-documented in the literature. However, there is limited research on how the pandemic influenced the lives, health, and well-being of pregnant and parenting youth and their children in Canada. Therefore, we aimed to examine the wider impacts (social and structural determinants that directly or indirectly impact health and well-being) of the pandemic and its implications for this population. We used a constructivist grounded theory approach to explore the experiences of pregnant and parenting youth during the pandemic and how certain social determinants of health intersected to shape health outcomes and influence their ability to access services. We conducted qualitative interviews using a semi-structured interview guide over Zoom. Using grounded theory principles, we inductively analyzed the data and categorized our findings into themes. We recruited a total of 50 participants from different regions in Canada. The findings from the interviews were categorized into the following themes: (1) "They bear the burden alone": Struggles of pregnant and parenting youth, (2) "How will I live the next day?": Concerns and consequences arising from the pandemic, and (3) "Try to keep your mask on": Navigating healthcare services while maintaining public health guidelines. Our findings highlight the various challenges encountered by the youth during the pandemic, particularly those associated with financial and economic constraints, lack of accessible health and social services, and increased stress from parenting responsibilities. Pregnant and parenting youth in Canada encountered various barriers while accessing health and social services, maintaining their well-being, and connecting with reliable sources of support during the pandemic. Our study findings emphasize the urgent need for adaptable and comprehensive support systems explicitly catering to the needs of pregnant and parenting youth during crises, such as the pandemic.

Social Determinants of Health and Language and Academic Outcomes in Pediatric Cochlear Implantation: A Systematic Review and Meta-Analysis.

Cochlear implants can restore sound and enable speech and language development for children with severe to profound sensorineural hearing loss. Long-term outcomes of pediatric cochlear implant recipients are variable. Although the association between social determinants of health (SDH) and pediatric cochlear implant outcomes has been explored, the strength of this association has not been quantitatively synthesized in the literature. To determine the association of SDH with language and academic outcomes in pediatric cochlear implant recipients. In August 2023, the following databases were searched: Embase.com, Ovid MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, Cumulated Index to Nursing and Allied Health Literature Plus, APA PsycINFO, and ClinicalTrials.gov. Following duplicate exclusion of 8687 results, 5326 records were finalized. Abstract screening, full-text review, and risk of bias assessment was performed by 1 to 2 reviewers. Articles were included if an effect size for an SDH variable that was associated with measures of language, communication, reading, academics, and quality of life was reported. A random-effects meta-analysis was performed, with standardized regression coefficients measuring the relative direction and magnitude of a variable association with the outcome of interest. Of 5326 articles, 40 articles that included a total of 3809 children were included in the systematic review; 20 articles that included a total of 1905 children were included in the meta-analysis. Parental involvement, education level, and low socioeconomic status were moderately to strongly associated with language outcomes (β = 0.30; 95% CI, 0.13-0.48; β = 0.45; 95% CI, 0.29-0.62; β = -0.47; 95% CI, -0.83 to -0.10, respectively). Known determinants of language outcomes, such as the age of cochlear implantation and duration of cochlear implant use, demonstrated moderate to no associations with language outcomes (β = -0.30; 95% CI, -0.43 to -0.17; β = 0.19; 95% CI, -0.26 to 0.63, respectively). The results of this systematic review and meta-analysis suggest that SDH are associated with childhood language development and academic achievement. In addition to efforts to expedite cochlear implant placement in eligible children, optimal outcomes may be achieved with interventions centered on the child's home, primary medical care, and school environment.

California Mortality and the Healthy Places Index.

We investigated California mortality and social determinants of health, as measured by the Healthy Places Index (HPI), which is a composite measure of 23 indicators of neighborhood (census tract) economic conditions, education, transportation, housing, social capital, environmental pollution, built-environment, and access to health care. We aggregated deaths to 2010 census tract boundaries for leading causes, 2015 to 2019, and COVID-19, 2020-2021, from death certificates and populations from the American Community Survey, 2015 to 2019. We age-adjusted and stratified death rates by HPI deciles, age, gender, and race/ethnicity, and examined HPI dose-response with segmental regression. For all causes, cancer, cardiovascular disease, COVID-19, diabetes, cirrhosis of the liver, injuries, and Alzheimer's disease (ages 65-74 years), mortality rates were inversely related to HPI decile. For all causes mortality, the rate ratio between the 1st and 10th decile (reference) was 1.63 (CI95%: 1.60-1.66), and, for COVID-19, the rate ratio was 7.61 (CI95%: 7.14-8.12). The population attributable fraction was 24% for all causes and 72% for COVID-19. Age, gender, race/ethnicity modified the steepness and shape of dose-response curves. The findings illustrate opportunities to incorporate area-based socioeconomic measures in routine public health surveillance, and to reinforce policies and programs that reduce health inequities.

Supporting diversity in clinical trials: the equitable breakthroughs in medicine site maturity model.

Among the most powerful barriers to broader inclusion of diverse participants in clinical trials are social determinants of health, trustworthiness of health care providers and research institutions, and competing pressures on potential participants. Nevertheless, current tools to assess organizational capabilities for clinical trial diversity focus primarily on trial infrastructure, rely solely on quantitative self-reported data, and lack meaningful assessment of capabilities related to community engagement. The Equitable Breakthroughs in Medicine (EQBMED) initiative developed a holistic, collaborative, site-driven formative model and accompanyingassessment to catalog sites' current capabilities and identify opportunities for growth in both conducting industry-sponsored clinical trials and enriching diversity of those trials. The model builds upon prior work and reflects unification of two historically distinct components-research operations and community engagement-since sustainable clinical trial diversity efforts must overcome these silos. Here we present the methodology we used to develop the model and accompanyingassessment, describe how findings can support clinical trial diversity efforts, and report findings from early field testing at three U.S. sites. The first three sites were diverse in size (e.g., < 250-1K beds), with varying levels of clinical trial capabilities and community engagement. The maturity assessment laid the foundation for sites to identify and prioritize key areas to advance clinical trial diversity capabilities, and each has made tangible progress. In parallel to completing the assessment with these early sites to understand their maturity and set actionable goals, we also collected their feedback on content validity (e.g., clarity, comprehensiveness, terminology) and feasibility (e.g., ability to collect needed information and data, time required). We describe refinements made to improve the assessment and streamline the process. The EQBMED program will deploy the assessment across various site types (e.g., FQHCs, safety net hospitals) and make further refinements as warranted. Strategic investment in clinical trial diversity requires structured assessment of site maturity as a starting point for collaborative action. We propose the EQBMED maturity model as a first step toward informing efforts to increase representation of diverse populations in clinical research.

Cross-Sector Support for a Policy Framework to Tackle Social Determinants of Health.

This JAMA Forum discusses 4 focus areas developed by a collaborative of more than 40 organizations and experts in health care, social services, and other sectors designed to find ways to support and address social determinants of health with better program coordination and partnerships and novel financing approaches.