Socioeconomic Determinants Of Health Research Articles

Socioeconomic and Racial Disparities Affect Access to High-Volume Centers During Meningioma Treatment

Studies examining the relationship between hospital case volume, socioeconomic determinants of health, and patient outcomes are lacking. We sought to evaluate these associations in the surgical management of intracranial meningiomas. We queried the National Inpatient Sample (NIS) database for patients who underwent craniotomy for the resection of meningioma in 2013. We categorized hospitals into high (HVC) or low (LVC) volume centers. We compared outcomes in 2016 to assess the potential impact of the Affordable Care Act (ACA) on healthcare equity. Primary outcome measures included hospital mortality, length of stay (LOS), complications, and disposition. A total of 10270 encounters were studied (LVC: n=5730 [55.8%], HVC n=4340 [44.2%]). 62.9% of LVC patients identified as white compared to 70.2% at HVC (p<0.01). A higher percentage of patients at LVC came from the lower two quartiles of median household income than HVC (49.9% vs 44.2% p<0.001). Higher mortality (1.3% vs 0.9% p = 0.041) was in LVCs. Multivariable regression analysis showed LVCs were significantly associated with increased complication (OR 1.36, 95% CI 1.30-1.426, p<0.001) and longer hospital LOS (OR -0.05, 95% CI -0.92,-0.45, p=<0.001). There was a higher proportion of white patients at HVCs in 2016 compared to 2013 (67.9% vs. 72.3%). More patients from top income quartiles (24.2% vs. 40.5%) were treated at HVC in 2016 compared to 2013. This study demonstrated notable racial and socioeconomic disparities in LVC as well as access to HVCs over time. Disparities in meningioma treatment may persistent and require further study.

Demographics and socioeconomic determinants of health predict continued participation in a CT lung cancer screening program

PurposeWe developed machine learning (ML) models to assess demographic and socioeconomic status (SES) variables’ value in predicting continued participation in a low-dose CT lung cancer screening (LCS) program. Materials and Methods480 LCS subjects were retrospectively examined for the following outcomes: (#1) no follow-up (single LCS scan) vs. multiple follow-ups (220 and 260 subjects respectively) and (#2) absent or delayed (>1 month past the due date) follow-up vs timely follow-up (356 and 124 subjects respectively). We quantified the contributions of 14 socioeconomic, demographic, and clinical predictors to LCS adherence, and validated and compared prediction performances of multivariate logistic regression (MLR), support vector machine (SVM) and shallow neural network (NN) models. ResultsFor outcome #1, age, sex, race, insurance status, personal cancer history, and median household income were found to be associated with returning for follow-ups. For outcome #2, age, sex, race, and insurance status were significant predictor of absent/delayed LCS follow-up. Across 5-fold cross-validation, the MLR model achieved an average AUC of 0.732 (95% CI, 0.661-0.803) for outcome #1 and 0.633 (95% CI, 0.602-0.664) for outcome #2 and is the model with best predictive performance overall, whereas NN and SVM tended to overfit training data and fell short on testing data performance for either outcome. ConclusionsWe identified significant predictors of LCS adherence, and our ML models can predict which subjects are at higher risk of receiving no or delayed LCS follow-ups. Our results could inform data-driven interventions to engage vulnerable populations and extend the benefits of LCS.

Social Determinants of Outcomes Disparity among Pediatric Patients with Solid Tumor.

Socioeconomic factors have a significant impact on healthcare outcomes. Metrics such as area deprivation index (ADI) are used to quantify the anticipated influence of these factors. Here, we sought to assess the impact of socioeconomic factors on clinical outcomes among pediatric patients with solid tumor in our region. We identified 3,863 pediatric patients who were diagnosed with a malignant solid tumor in the Texas Cancer Registry between 1995 and 2019. ADI was used to quantify socioeconomic determinants of health. These outcome variables were determined: stage of disease at diagnosis, time between diagnosis and treatment initiation, and overall mortality. Statistical analysis was performed using logistic regression, linear regression, Cox proportional hazards regression, and Kaplan-Meier survival curves. A total of 53.5% of patients were male and the average age at diagnosis was 4.5 years. Forty-seven percent of patients were White, 13.3% were Black, 36.2% were Hispanic, 1.7% were Asian, and other rare minority groups made up 1.8%. On multivariable analysis, increased risk of death was associated with Black race, rare minority race, residence in a border county, and increasing ADI score, with the risk of death at 5 years rising 4% with each increasing ADI point. Social determinants of health are associated with disparate outcomes among pediatric patients with solid tumor. Our results suggest that patients who are part of racial minority groups and those who reside in socioeconomically disadvantaged neighborhoods or regions near the Texas-Mexico border are at an increased risk of death. This information may be useful in strategizing outreach and expanding resources to improve outcomes in at-risk communities.

A Randomized Controlled Trial to Improve Unmet Social Needs and Clinical Outcomes Among Adults with Diabetes.

Adults with type 1 or type 2 diabetes often face financial challenges and other unmet social needs to effective diabetes self-management. Whether a digital intervention focused on addressing socioeconomic determinants of health improves diabetes clinical outcomes more than usual care. Randomized trial from 2019 to 2023. A total of 600 adults with diabetes, HbA1c ≥ 7.5%, and self-reported unmet social needs or financial burden from a health system and randomized to the intervention or standard care. CareAvenue is an automated, e-health intervention with eight videos that address unmet social needs contributing to poor outcomes. Primary outcome was HbA1c, measured at baseline, and 6 and 12months after randomization. Secondary outcomes included systolic blood pressure and reported met social needs, cost-related non-adherence (CRN), and financial burden. We examined main effects and variation in effects across predefined subgroups. Seventy-eight percent of CareAvenue participants completed one or more modules of the website. At 12-month follow-up, there were no significant differences in HbA1c changes between CareAvenue and control group (p = 0.24). There were also no significant between-group differences in systolic blood pressure (p = 0.29), met social needs (p = 0.25), CRN (p = 0.18), and perceived financial burden (p = 0.31). In subgroup analyses, participants with household incomes 100-400% FPL (1.93 (SE = 0.76), p < 0.01), 201-400% FPL (1.30 (SE = 0.62), p < 0.04), and > 400% FPL (1.27 (SE = 0.64), p < 0.05) had significantly less A1c decreases compared to the control group. On average, CareAvenue participants did not achieve better A1c lowering, met needs, CRN, or perceived financial burden compared to control participants. CareAvenue participants with higher incomes achieved significantly less A1c reductions than control. Further research is needed on social needs interventions that consider tailored approaches to population subgroups. ClinicalTrials.gov ID NCT03950973, May 2019.

Where we live matters: a comparison of chronic pain treatment between remote and non-remote regions of Quebec, Canada.

Where a person lives is a recognized socioeconomic determinant of health and influences healthcare access. This study aimed to compare the pain treatment profile of persons with chronic pain (CP) living in remote regions to those living in non-remote regions (near or in major urban centers). A cross-sectional study was performed among persons living with CP across Quebec. In a web-based questionnaire, participants were asked to report in which of the 17 administrative regions they were living (six considered "remote"). Pain treatment profile was drawn up using seven variables: use of prescribed pain medications, over-the-counter pain medications, non-pharmacological pain treatments, multimodal approach, access to a trusted healthcare professional for pain management, excessive polypharmacy (≥10 medications), and use of cannabis for pain. 1,399 participants completed the questionnaire (women: 83.4%, mean age: 50 years, living in remote regions: 23.8%). As compared to persons living in remote regions, those living in non-remote regions were more likely to report using prescribed pain medications (83.8% vs. 67.4%), a multimodal approach (81.5% vs. 75.5%), experience excessive polypharmacy (28.1% vs. 19.1%), and report using cannabis for pain (33.1% vs. 20.7%) (bivariable p < 0.05). Only the use of prescribed medications as well as cannabis remained significantly associated with the region of residence in the multivariable models. There are differences in treatment profiles of persons with CP depending on the region they live. Our results highlight the importance of considering remoteness, and not only rurality, when it comes to better understanding the determinants of pain management.

Associations between income and survival in cholangiocarcinoma: A comprehensive subtype-based analysis.

Socioeconomic determinants of health are incompletely characterized in cholangiocarcinoma (CCA). We assessed how socioeconomic status influences initial treatment decisions and survival outcomes in patients with CCA, additionally performing multiple sub-analyses based on anatomic location of the primary tumor. Observational study using the 2018 submission of the Surveillance, Epidemiology, and End Results (SEER)-18 Database. In total, 5,476 patients from 2004-2015 with a CCA were separated based on median household income (MHI) into low income (< 25th percentile of MHI) and high income (> 25th percentile of MHI) groups. Seventy-three percent of patients had complete follow up data, and were included in survival analyses. Survival and treatment outcomes were calculated using R-studio. When all cases of CCA were included, the high-income group was more likely than the low-income to receive surgery, chemotherapy, and local tumor destruction modalities. Initial treatment modality based on income differed significantly between tumor locations. Patients of lower income had higher overall and cancer-specific mortality at 2 and 5 years. Non-cancer mortality was similar between the groups. Survival differences identified in the overall cohort were maintained in the intrahepatic CCA subgroup. No differences between income groups were noted in cancer-specific or overall mortality for perihilar tumors, with variable differences in the distal cohort. Lower income was associated with higher rates of cancer-specific mortality and lower rates of surgical resection in CCA. There were significant differences in treatment selection and outcomes between intrahepatic, perihilar, and distal tumors. Population- based strategies aimed at identifying possible etiologies for these disparities are paramount to improving patient outcomes.

How do socioeconomic determinants of health affect the likelihood of living with HTLV-1 globally? A systematic review with meta-analysis.

Human T Lymphotropic Virus type 1 (HTLV-1) is a neglected retrovirus associated with many clinical disorders, most notably Adult T-cell Leukemia/Lymphoma and HTLV-1-Associated Myelopathy (HAM). Found in endemic clusters across the world, high prevalence has been reported in minoritized groups who suffer from health inequities. This study investigates the association between HTLV-1 prevalence and the following socioeconomic determinants of health: education, income, and employment, which are markers of health inequity. A systematic review was conducted by searching the following databases: Ovid/Medline, Embase, Global Health Database, Web of Science, LILACS and SciELO. Primary studies in English, Spanish and Portuguese mentioning HTLV-1 and one of education, income and/or employment were included. A random-effects meta-analysis was performed, and odds ratios (OR) were calculated to determine the association between these socioeconomic determinants of health and HTLV-1 prevalence. 42 studies were included. The likelihood of having HTLV-1 was higher in individuals with less than completed primary education compared to those who completed primary education (OR 1.86 [95% CI 1.34-2.57]; p < 0.01). This may be because individuals with low education have reduced access to and understanding of health information, thus increasing the prevalence of risk factors associated with HTLV-1 infection. No other determinants were found to be statistically significant. Fewer years of schooling are associated with increased likelihood of contracting HTLV-1. Therefore, health promotion materials and public health policies regarding HTLV-1 must consider those with lower educational levels to effectively reduce disease transmission. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=335004, identifier (CRD42022335004).

Time-series analysis of the health outcomes-financial development nexus: Evidence from South Africa

This study contributes to the literature by investigating the health and financial development nexus in South Africa. The ‘health is wealth’ debate was again exemplified by the outbreak of the COVID-19 pandemic, thereby raising awareness of the inescapable links between poor health and diverse threats to global socioeconomic prosperity. Thus, the influencing factors of health have continued to be studied. Accounting for structural breaks, the study estimates annual time series data sourced from the World Development Indicators within the autoregressive distributed lag error correction model (ARDL-ECM). The regression outcomes show that financial development has differential impacts on health outcomes. In particular, financial development proxied by domestic credit to the private sector has a negative effect on life expectancy at birth while reducing child mortality, thereby fostering better child health outcomes. This research engages health policy strategists on the right policy mix to achieve better health outcomes. While the financial development drive is ongoing, efforts should be intensified to improve socioeconomic determinants of health, and policy strategies aimed at solving national priority health challenges should be logically pursued.

Cohort profile: Beijing Healthy Aging Cohort Study (BHACS).

The Beijing Healthy Aging Cohort Study (BHACS) was established to supplement the limited data of a large representative cohort of older people based on the general population and was designed to evaluate the prevalence, incidence, and natural history of cognitive decline, functional disability, and conventional vascular risk factors. The aim was to determine the evolution of these conditions by estimating the rates and determinants of progression and regression to adverse outcomes, including dementia, cardiovascular events, cancer, and all-cause death. It can therefore provide evidence to help policy makers develop better policies to promote healthy aging in China. BHACS consisted of three cohorts (BLSA, CCHS-Beijing, and BECHCS) in Beijing with a total population of 11 235 (6281 in urban and 4954 in rural areas) and an age range of 55 years or older (55-101 years) with a mean age of 70.35 ± 7.71 years (70.69 ± 7.62 years in urban and 69.92 ± 7.80 years in rural areas). BHACS-BLSA conducted the baseline survey in 2009 with a multistage stratification-random clustering procedure for people aged 55 years or older; BHACS-CCHS-Beijing conducted the baseline survey in 2013-2015 with a stratified multistage cluster random sampling method for people aged 55 years or older; and BHACS-BECHCS conducted the baseline survey in 2010-2014 with two-stage cluster random sampling method for people aged 60 years or older. Data were collected through questionnaires, physical measurements, and laboratory analyses. Topics covered by BHACS include a wide range of physical and mental health indicators, lifestyles and personal, family, and socio-economic determinants of health. There are no immediate plans to make the cohort data freely available to the public, but specific proposals for further collaboration are welcome. For further information and collaboration, please contact the corresponding author Yao He (e-mail: yhe301@x263.net).

Some aspects of socio-economic determinants of health

Нерівність щодо здоров'я включає різницю між найбільш благополучною групою – наприклад, найбагатшими, найвпливовішими - і всіма іншими, а не тільки між найбільш забезпеченими та найменш забезпеченими групами. Досягнення справедливості щодо здоров'я означає прагнення усунути такі відмінності/нерівності щодо здоров'я. Мета: Визначити вплив соціально-економічних детермінант на здоров’я людини. Завданням є подолання нерівності щодо здоров'я – це систематичні відмінності у стані здоров'я серед соціальних груп, спричинені нерівним впливом та розподілом соціальних детермінант здоров'я. Вони зберігаються між країнами та всередині країн, незважаючи на дії щодо їх скорочення. Пропаганда є засобом просування політики, яка покращує справедливість щодо здоров’я.&#x0D; Методологічно використаний системний підхід, структуризація, розглядається вплив економічної нерівності на здоров’я людини: нерівні умови життя, зайнятість, умови праці.&#x0D; Результати роботи: Забезпечуючи справедливу зайнятість і гідні умови праці, уряд, роботодавці та працівники можуть допомогти викорінити бідність, зменшити соціальну нерівність, знизити схильність до фізичних і психологічних небезпек і розширити можливості для здоров'я та благополуччя. І, звичайно, здорова робоча сила сприяє підвищенню продуктивності. Установи охорони здоров'я можуть вирішувати проблеми бідності та здоров'я в рамках концепції, що охоплює питання справедливості та прав людини, п'ятьма загальними способами: (1) інституціоналізація систематичного та регулярного застосування принципів рівності та прав людини у всіх діях сектору охорони здоров’я; (2) зміцнення та розширення функцій охорони здоров'я; (3) запровадження справедливого фінансування охорони здоров'я, яке має допомогти знизити рівень бідності та одночасно розширити доступ для бідних верств населення; (4) забезпечення того, щоб служби охорони здоров'я ефективно реагували на основні причини запобігання захворюванням серед бідних і знедолених верств населення; та (5) моніторинг, пропаганда та вжиття заходів щодо усунення потенційних наслідків політики щодо справедливості щодо здоров'я та прав людини у всіх секторах, що впливають на здоров'я, а не лише у секторі охорони здоров'я.Зробити здоров'я та справедливість щодо здоров'я загальною цінністю для всіх секторів є політично складною стратегією, але вона необхідна у всьому світі. Досягнення справедливості щодо здоров'я означає прагнення усунути відмінності/нерівності щодо здоров'я. Висновки: Дії щодо соціальних детермінант здоров'я будуть більш ефективними, якщо будуть створені базові системи даних, включаючи регулярний моніторинг нерівності щодо здоров'я та соціальних детермінант здоров'я, а також механізми, які забезпечують розуміння та застосування даних розробляти більш ефективну політику, системи та програми. Освіта та підготовка щодо соціальних детермінантів здоров'я мають життєво важливе значення.

Investigating the role of symptom valorisation in tuberculosis patient delay in urban areas in Portugal

BackgroundDiagnosis delay contributes to increased tuberculosis (TB) transmission and morbimortality. TB incidence has been decreasing in Portugal, but median patient delay (PD) has risen. Symptom valorisation may determine PD by influencing help-seeking behaviour. We aimed to analyse the association between symptom valorisation and PD, while characterising individuals who disregarded their symptoms.MethodsA cross-sectional study was conducted among TB patients in Lisbon and Oporto in 2019 – 2021. Subjects who delayed seeking care because they did not value their symptoms or thought these would go away on their own were considered to have disregarded their symptoms. PD was categorised using a 21-day cut-off, and a 30-day cut-off for sensitivity analysis. We estimated the effect of symptom valorisation on PD through a directed acyclic graph. Then, a multivariable regression analysis characterised patients that disregarded their symptoms, adjusting for relevant variables. We fitted Poisson regression models to estimate crude and adjusted prevalence ratios (PR).ResultsThe study included 75 patients. Median PD was 25 days (IQR 11.5–63.5), and 56.0% of participants had PD exceeding 21 days. Symptom disregard was reported by 38.7% of patients. Patients who did not value their symptoms had higher prevalence of PD exceeding 21 days compared to those who valued their symptoms [PR 1.59 (95% CI 1.05–2.42)]. The sensitivity analysis showed consistent point estimates but wider confidence intervals [PR 1.39 (95% CI 0.77–2.55)]. Being a smoker was a risk factor for symptom disregard [PR 2.35 (95% CI 1.14–4.82)], while living in Oporto [PR 0.35 (95% CI 0.16–0.75)] and having higher household incomes [PR 0.39 (95% CI 0.17–0.94)] were protective factors.ConclusionsThese findings emphasise the importance of symptom valorisation in timely TB diagnosis. Patients who did not value their symptoms had longer PD, indicating a need for interventions to improve symptom recognition. Our findings also corroborate the importance of the socioeconomic determinants of health, highlighting tobacco as a risk factor both for TB and for PD.

Government, governance, and place-based approaches: lessons from and for public policy

BackgroundPlace-based approaches are increasingly applied to address the determinants of health, many of which are complex problems, to ultimately improve population health outcomes. Through public policy, government actions can affect the effectiveness of place-based approaches by influencing the conceptualisation, development, implementation, governance, and/or evaluation of place-based approaches. Despite the important role of public policy, there has been limited examination of public policy related to place-based approaches. We add to the limited knowledge base by analysing Australian national public policy, to explore: (1) the definitions, conceptualisations, and characteristics of place-based approaches in public policy; (2) the government’s perception and communication of its role in place-based approaches; and (3) the extent to which government policy reflects the necessary conditions for successful place-based governance developed by Marsh and colleagues, namely localised context, embedded learning, and reciprocal accountability.MethodsThis research was underpinned by the Theory of Systems Change and methodologically informed by the READ approach to document analysis. Ritchie and Spencer’s framework method was utilised to analyse the data.ResultsWe identified and reviewed 67 policy documents. In terms of conceptualisation, common characteristics of place-based approaches related to collaboration, including community in decision-making, responsiveness to community needs, and suitability of place-based approaches to address complex problems and socio-economic determinants of health. Three roles of government were identified: funder, partner, and creator of a supportive policy environment. From the three criteria for successful place-based governance, localisedcontext was the most dominant across the documents and reciprocalaccountability the least.ConclusionsBased on our findings, we drew key implications for public policy and research. There was a disproportionate emphasis on the bottom-up approach across the documents, which presents the risk of diminishing government interest in place-based approaches, potentially burdening communities experiencing disadvantage beyond their capacities. Governments engaged in place-based approaches should work towards a more balanced hybrid approach to place-based approaches that maintain the central functions of government while allowing for successful place-based governance. This could be achieved by promoting consistency in conceptualisations of ‘place-based’, employing an active role in trust building, advancing the creation of a supportive policy environment, and embedding ‘learning’ across place-based approaches.

The Impact of Socio-Economic Determinants of Health on PedsQL and Pain Outcomes Among Individuals with Sickle Cell Disease

Background: Pain in sickle cell disease (SCD) is the most visible symptom in patients. Many recent studies have shown that socio-economic status such as low income, educational achievement or even less affluent neighborhoods may contribute to the pain experience, with those of lower socioeconomic status (SES) reporting both acute and chronic pain more frequently. Furthermore, living in a less affluent area was associated with frequent use of analgesics after adjustment for pain intensity. The relationships between SES variables, pain-related anxiety, frequency of vaso-occlusive crises and/or acute care utilization have been explored; nevertheless, the relationship between SES and quality of life pain-related measures (pain hurt, pain interference, etc.) has yet to be reported. Methods: The St. Jude Children's Research Hospital Sickle Cell Clinical Research and Intervention Program (SCCRIP) is an observation cohort study of clinical outcomes in patients with SCD. Patients enrolled in SCCRIP were retrospectively evaluated based on various SES measurements. Household SES was evaluated using the Barratt Simplified Measure of Social Status (BSMSS), a composite index of parent education and occupation. The Social Vulnerability Index (SVI) was used to classify individuals based on social vulnerabilities at the neighborhood level. The area deprivation index (ADI) ranks neighborhood in a region of interest based on social risk factors that may predispose individuals to worse clinical outcomes Quality of life measures, Pain Hurt, Pain Impact, and Pain Management/Control, were extracted from the PedsQL SCD Module. High scores on the SVI and ADI are associated with low SES and high scores on the PedsQL indicate better SCD related quality of life (QoL) with lower burden and impact of pain on function. Multivariate linear regression models were used to evaluate the associations of SES with QoL pain-related outcomes, based on a stepwise model selection strategy, with potential covariates including age, gender, disease-modifying therapy (e.g., Hydroxyurea and chronic transfusions), hemoglobin, hemoglobin F (HbF)%, and each SES variable. Results: 944 patients between the ages of 5-61 (Mean=13.75, Standard Deviation=7.57) years diagnosed with SCD completed PedsQL testing and were assessed for SVI and ADI. Multivariate models demonstrated that patients with lower SVI (i.e., higher neighborhood SES) at the neighborhood level displayed higher scores with regards to Pain Hurt (est=-7.44, standard error (SE)=2.84, p=0.01), Pain Impact (est=-9.56, SE=3.18, p=0.003) and Pain Management/Control (est=-9.35, SE=3.81, p=0.01). Similar relationships were observed for patients with lower ADI. Additionally, there was a significant association between pain impact and BSMSS (est=0.20, SE=0.10, p=0.04), suggesting that individuals with higher BSMSS (higher household SES) also had higher pain impact scores (better quality of life). Conclusions: This study demonstrated that neighborhood and household SES have an impact on pain experience in youth with SCD. Patients with increased social vulnerability and area deprivation experienced lower health-related quality of life-related to SCD pain. Increased household SES was associated with greater SCD pain impact independent of the effects of patient age, gender, SCD therapy, and HbF. Our study suggests that social determinants of health, such as SES, play a role in pain experience and QOL related to SCD pain and should be explored further.

Impact of sociodemographic and economic determinants of health on COVID-19 infection: incidence variation between reference periods

ObjectivesThe COVID-19 pandemic hit Portugal in March 2020, causing widespread disruption to various aspects of society. While extensive research has been conducted on the significance of socio-economic disparities in infection risk, this study aims to enhance our understanding of their evolving relationship over time by analysing four distinct periods in 2020. Study design and methodsThis retrospective observational ecological study included individuals residing in the Primary Healthcare Cluster areas of Almada-Seixal and Western Lisbon and Oeiras, who tested positive for SARS-CoV-2 through a polymerase chain reaction (PCR) test between the 2nd of March and the 8th of November of 2020. Using incidence rates for each specific neighbourhood (n = 29) and period, we explored the relationship between neighbourhood-level socio-economic variables and the risk of infection using negative-binomial regression models. ResultsIn the analysed period, a total of 8562 confirmed COVID-19 cases were identified. Overall incidence rates for each period were sequentially 2.74, 5.03, 3.99 and 14.29 COVID-19 cases per 100,000 person-days. Housing overcrowding, illiteracy rate and place of birth were associated with increased risk of infection, while age, congregate living, and employment in the secondary sector exhibited the opposite association. No association was consistent across all time periods. ConclusionsOur findings support the idea that the influence of socio-economic determinants of health is not immutable throughout time. In a pandemic context where information, knowledge, beliefs, and behaviours are ever-changing and evolving, a dynamic, inclusive, and adaptable approach to disease control can lead to a more equitable distribution of improved outcomes, benefiting all strata of society.

Abstract 15973: Ambient Air Pollution is Associated With Coronary Artery Disease and Adverse Outcomes in Patients With Stable Chest Pain Across the U.S.: Insights From the PROMISE Trial

Introduction: Air pollution is associated with coronary artery disease (CAD) and cardiovascular (CV) outcomes. Hypothesis: The relationships of air pollutants to CAD and outcomes are independent of traditional CV risk factors and socioeconomic determinants of health (SDoH) and vary by pollutant type. Methods: Clinical and CT data from stable chest pain patients without known CAD in the PROMISE trial, were linked by home zip code to U.S. EPA-derived PM 2.5 and PM 10 (Figure 1a) . CT metrics included any plaque, obstructive CAD (≥50%), and high-risk plaque (HRP); major adverse CV events were defined as death (all cause or CV), myocardial infarction, or unstable angina. Logistic and Cox regressions were adjusted for age, sex, obesity, ASCVD risk, statins, and US Census-based SDoH by zip code. We conducted a mediation analysis for the effect of pollutants on events using obstructive CAD as mediator. Results: In 4,343 individuals (48% men; age: 61±8 years), 46.9% were exposed to PM 2.5 above the standard cut point of 9.5 μg/m 3 and 62.1% to PM 10 ≥15 μg/m 3 . Participants exposed to PM 2.5 ≥9.5 μg/m 3 had 27% higher odds of obstructive CAD (aOR=1.27, 95%CI: 1.03-1.56, p=0.026), not significant for PM 10 . No associations existed between pollutants and any plaque or HRP. PM 2.5 and PM 10 were independently associated with CV events in fully adjusted models (Figure 1b) . In mediation analysis, the effects of PM 2.5 on events were significant (direct effect: OR=1.66, 95%CI: 1.11-2.50, p=0.014; indirect effect: OR=1.06, 95%CI: 1.01-1,12, p=0.022) with comparable results for PM 10 . Conclusions: Air pollution relates independently to adverse events in stable chest pain patients, only partly driven by CAD phenotypes, specifically an association between small particular matter and obstructive CAD. Further studies investigating the pathogenesis of atherosclerotic disease in people exposed to pollution may help form strategies to reduce exposure.

Abstract 16466: Sex-Specific Risks of Air Pollution on Coronary Artery Disease and Adverse Events: Insights From the PROMISE Trial

Introduction: Sex-specific differences in coronary artery disease (CAD) have significant implications, yet the potential sex-specific impact of air pollution on CAD and adverse outcomes remains unexplored. Hypothesis: The association between air pollution and CT-derived CAD phenotype or cardiovascular (CV) events varies by sex. Methods: We assessed annual average exposure to particulate matter (PM 2.5 &amp; PM 10 ) and ozone by home zip codes in the CT arm of the PROMISE trial. Pollutant exposure was related to CAD measures on CT (any plaque, obstructive CAD (stenosis ≥50%), high-risk plaque (HRP)) and composite endpoint (death, myocardial infarction, unstable angina), adjusting for age, obesity, ASCVD risk, and Socioeconomic Determinants of Health, using sex-stratified regression analyses. Results: We analyzed 2,252 (52%) women and 2,091 (48%) men (62±8 vs. 59±8 years, p&lt;0.001) with intermediate ASCVD risk (12% vs. 17%, p&lt;0.001). Women were less frequently exposed to PM 2.5 ≥9.5 μm/m 3 (45.1% vs. 48.8%, p=0.011) but more frequently to ozone &gt;45 ppb (40.5% vs. 36.8%, p=0.011) compared to men. Exposure to PM 2.5 ≥9.5 μm/m 3 related to 42% higher odds of obstructive CAD (aOR 1.42, 95%CI: 1.02-1.97, p=0.040) in women but not in men. High PM 10 and ozone exposures did not relate to stenosis or HRP in either sex (p&gt;0.14) (Figure 1a) . Exposure to ozone &gt;45 ppb was related to a higher hazard of events in men (aHR 2.20, 95%CI: 1.36-3.55, p=0.001) but not in women (aHR 1.05, 95%CI: 0.58-1.90, p=0.88). Exposure to high PM 2.5 and PM 10 levels was not associated with events in sex-stratified analysis (Figure 1b) . Conclusions: Sex significantly influences pollutant impact on CAD. High PM 2.5 exposure increases obstructive CAD risk exclusively in women, while high ozone exposure raises CV event risk in men. Findings stress the need for sex-specific strategies in combating pollution's cardiovascular effects.

Child mortality inequalities and socioeconomic determinants of health in Iran, 2016-2018.

Measuring health inequalities is essential to inform policy making and for monitoring implementation to reduce avoidable and unfair differences in health status. We conducted a geospatial analysis of child mortality in Iran using death records from the Ministry of Health and Medical Education from 2016 to2018 stratified by sex, age, province, and district, and household expenditure and income survey data from the Statistical Center of Iran collected in 2017. We applied multilevel mixed-effect models and detected significant inequality in child mortality and the impact of socioeconomic factors, especially household income. We advocate for using mortality rate for young children (< 5 years old) as an indicator for assessing the impact of interventions to reduce inequalities among various socioeconomic groups. We also recommend to design and implement comprehensive and longitudinal data collection systems for accurate, regular, and specific monitoring of health inequalities.

Inequalities in accessing COVID-19 healthcare for migrants and ethnic minorities: a systematic review

Abstract The COVID19 pandemic has had a major impact on lower socioeconomic groups and minorities in terms of risk of SARS-CoV-2 infection, morbidity and mortality. It was defined as a syndemic because of its interaction with pre-existing socioeconomic determinants of health, worsening health outcomes. The study aims to investigate whether Migrants and Ethnic Minority populations (MEMs) faced more inequalities in access to prevention, diagnosis and treatment for COVID19 compared to the native population in the WHO European region. We conducted a systematic review searching the following databases: Medline, Embase, Biosis, Scisearch, Esbiobase. Quantitative and quali-quantitative studies on MEMs’ access to healthcare for COVID19 in the WHO European Region published from January 2020 to February 2022 were eligible. A total of 19 studies were included, around 65% of the studies were conducted in UK. Most studies (11) investigated vaccine hesitancy, five were about vaccine execution, three on access to information and to testing for COVID19. All studies reported greater vaccine hesitancy among the target population compared to white ethnicity and all of those investigating vaccination uptake pointed out that MEMs had lower odds of being vaccinated; finally, MEMs population resulted to face more difficulties in accessing COVID19 information and testing. These findings highlight the inequalities MEMs population faced accessing healthcare services for COVID19. Social determinants of health are one of the main factors involved in the genesis of health inequalities: a framework of structural racism leading to lower trust in government choices, together with a disadvantaged socio-economic status, determined inequalities in accessing healthcare services and health information. Our study underlines the need for policymakers to prioritize strategies for building trust and engage MEMs, and to overcome the socio-economic barriers when designing health promotion programs. Key messages • MEMs population faced higher barriers to the access to vaccination, turned out to be more vaccine hesitant and faced more difficulties in access to Covid-19 information and testing. • The study underlines the need of finding strategies for building trust and engage ethnic minorities, and to overcome the socio-economic barriers when designing health promotion programs.

Unplanned urbanization and health risks of Dhaka City in Bangladesh: uncovering the associations between urban environment and public health.

Dhaka City, the capital of Bangladesh, has experienced rapid and unplanned urbanization over the past few decades. This process has brought significant challenges to public health as the urban environment has become a breeding ground for various health risks. Understanding the associations between unplanned urbanization, the urban environment, and public health in Dhaka City is crucial for developing effective interventions and policies. This review paper aims to uncover the associations between unplanned urbanization and health risks in Dhaka City, with a specific focus on the urban environment and its impact on public health. The objectives of this study are to examine the health challenges faced by the city's population, explore the specific urban environmental factors contributing to health risks, analyze the socioeconomic determinants of health in unplanned urban areas, evaluate existing policies and governance structures, identify research and data gaps, and provide recommendations for future interventions. A comprehensive literature review was conducted to gather relevant studies, articles, reports, and policy documents related to unplanned urbanization, the urban environment, and public health in Dhaka City. Various databases and online resources were searched, and the selected literature was critically analyzed to extract key findings and insights. The findings reveal that unplanned urbanization in Dhaka City has led to a range of public health risks, including air pollution, inadequate water and sanitation, poor waste management, overcrowding, slums, and substandard housing conditions. These environmental factors are strongly associated with respiratory diseases, waterborne illnesses, and other adverse health outcomes. Socioeconomic determinants such as poverty, income inequality, and limited access to healthcare further exacerbate the health risks faced by the urban population. Unplanned urbanization in Dhaka City has significant implications for public health. Addressing the associations between unplanned urbanization, the urban environment, and public health requires comprehensive policies and interventions. Improved urban planning, enhanced infrastructure, and better policy governance are essential for mitigating health risks. Furthermore, addressing socioeconomic disparities and ensuring equitable access to healthcare services are crucial components of effective interventions.

155 Socioeconomic Determinants of Health on Rates of Appendicitis and Computed Tomography for Diagnosis in United States Emergency Departments

155 Socioeconomic Determinants of Health on Rates of Appendicitis and Computed Tomography for Diagnosis in United States Emergency Departments