Synergistic effects of social determinants of health and race-ethnicity on 30-day all-cause readmission disparities: a retrospective cohort study.

OBJECTIVE: The objective of this study is to assess the effects of social determinants of health (SDOH) and race-ethnicity on readmission and to investigate the potential for geospatial clustering of patients with a greater burden of SDOH that could lead to a higher risk of readmission. DESIGN: A retrospective study of inpatients at five hospitals within Henry Ford Health (HFH) in Detroit, Michigan from November 2015 to December 2018 was conducted. SETTING: This study used an adult inpatient registry created based on HFH electronic health record data as the data source. A subset of the data elements in the registry was collected for data analyses that included readmission index, race-ethnicity, six SDOH variables and demographics and clinical-related variables. PARTICIPANTS: The cohort was composed of 248 810 admission patient encounters with 156 353 unique adult patients between the study time period. Encounters were excluded if they did not qualify as an index admission for all payors based on the Centers for Medicare and Medicaid Service definition. MAIN OUTCOME MEASURE: The primary outcome was 30-day all-cause readmission. This binary index was identified based on HFH internal data supplemented by external validated readmission data from the Michigan Health Information Network. RESULTS: Race-ethnicity and all SDOH were significantly associated with readmission. The effect of depression on readmission was dependent on race-ethnicity, with Hispanic patients having the strongest effect in comparison to either African Americans or non-Hispanic whites. Spatial analysis identified ZIP codes in the City of Detroit, Michigan, as over-represented for individuals with multiple SDOH. CONCLUSIONS: There is a complex relationship between SDOH and race-ethnicity that must be taken into consideration when providing healthcare services. Insights from this study, which pinpoint the most vulnerable patients, could be leveraged to further improve existing models to predict risk of 30-day readmission for individuals in future work.

Addition of Social Determinants of Health to Coronary Heart Disease Risk Prediction: The Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Social determinants of health (SDoH) are associated with cardiovascular risk factors and outcomes; however, they are absent from risk prediction models. We aimed to assess if the addition of SDoH improves the predictive ability of the MESA (Multi-Ethnic Study of Atherosclerosis) Risk Score. METHODS AND RESULTS: This was a community-based prospective population cohort study that enrolled 6286 men and women, ages 45-84 years, who were free of clinical coronary heart disease (CHD) at baseline. Data from 10-year follow-up were examined for CHD events, defined as myocardial infarction, fatal CHD, resuscitated cardiac arrest, and revascularization in cases of anginal symptoms. Participants included 53% women with average age of 62 years. When adjusting for traditional cardiovascular risk factors, SDoH, and coronary artery calcium, economic strain, specifically low family income, was associated with a greater risk of CHD events (hazard ratio [HR], 1.42 [95% CI, 1.17-1.71], P value<0.001). Area under the curve of risk prediction with SDoH was 0.822, compared with 0.816 without SDoH. The calibration slope was 0.860 with SDoH and 0.878 in the original model. CONCLUSIONS: Significant associations were found between economic/financial SDoH and CHD risk factors and outcomes. Incorporation of SDoH into the MESA Risk Score did not improve predictive ability of the model. Our findings do not support the incorporation of SDoH into current risk prediction algorithms.

Cognitive Impairment and Social Determinants of Health Among Indigenous Women.

BACKGROUND AND OBJECTIVES: Cognitive impairment and Alzheimer's disease and related dementias (ADRD) pose significant challenges for Indigenous populations, necessitating urgent research. Limited evidence suggests that high rates of ADRD among Indigenous peoples are associated with social determinants of health (SDOH), such as education, income, health literacy, religion, and social engagement. RESEARCH DESIGN AND METHODS: Collaborating with a Northern Plains tribe, participants were recruited 123 self-identified Indigenous women aged 40-70 through a comprehensive recruitment strategy. Employing the SDOH framework, the research assessed cognitive impairment and Alzheimer's disease knowledge (ADK), utilizing the Ascertain Dementia 8 and Alzheimer's disease knowledge scales (ADK-30). The investigation examined the relationships between selected SDOH variables and cognitive impairment status. RESULTS: More than half of the participants showed signs of cognitive impairment, which correlated with lower income and education levels. Increased knowledge about Alzheimer's disease, particularly in terms of treatment management and its life impact subscales, was associated with lower odds of cognitive impairment. Conversely, higher levels of depressive symptoms and participation in religious activities were linked to increased odds of cognitive impairment. DISCUSSION AND IMPLICATIONS: The findings underscore the importance of culturally grounded tools and SDOH frameworks tailored to Indigenous contexts in addressing ADRD disparities. Future research should integrate historical and cultural factors to advance health equity within Indigenous communities, ultimately mitigating the impact of ADRD and promoting overall well-being.

Brochure: Diálogos de saberes

Los diálogos de saberes, también llamados diálogos interculturales, son procesos de comunicación e intercambio entre personas, grupos o comunidades que provienen de diferentes orígenes o culturas. En el caso del sector de la salud, los intercambios se realizan entre determinados grupos o personas y personal de salud capacitado. Su objetivo es, entre otros, mejorar el acceso a los servicios de salud y construir una salud intercultural, con énfasis en la resolución de problemas previamente planteados y sus causas, la comprensión mutua y la creación de vínculos sólidos. Este brochure describe de manera general el proceso que tienen los diálogos de saberes.

Social Determinants of Health and Incident Apparent Treatment-Resistant Hypertension Among White and Black US Adults: The REGARDS Study.

BACKGROUND: We examined the association of multilevel social determinants of health with incident apparent treatment-resistant hypertension (aTRH). METHODS AND RESULTS: We analyzed data from 2774 White and 2257 Black US adults from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study taking antihypertensive medication without aTRH at baseline to estimate the association of social determinants of health with incident aTRH. Selection of social determinants of health was guided by the Healthy People 2030 domains of education, economic stability, social context, neighborhood environment, and health care access. Blood pressure (BP) was measured during study visits, and antihypertensive medication classes were identified through a pill bottle review. Incident aTRH was defined as (1) systolic BP ≥140 mm Hg or diastolic BP ≥90 mm Hg, or systolic BP ≥130 mm Hg or diastolic BP ≥80 mm Hg for those with diabetes or chronic kidney disease while taking ≥3 classes of antihypertensive medication or (2) taking ≥4 classes of antihypertensive medication regardless of BP level, at the follow-up visit. Over a median 9.5 years of follow-up, 15.9% of White and 24.0% of Black adults developed aTRH. A percent of the excess aTRH risk among Black versus White adults was mediated by low education (14.2%), low income (16.0%), not seeing a friend or relative in the past month (8.1%), not having someone to care for them if ill or disabled (7.6%), lack of health insurance (10.6%), living in a disadvantaged neighborhood (18.0%), and living in states with poor public health infrastructure (6.0%). CONCLUSIONS: Part of the association between race and incident aTRH risk was mediated by social determinants of health.

Socioeconomic status as a potential mediator of arterial aging in marginalized ethnic and racial groups: current understandings and future directions.

Cardiovascular diseases (CVDs) are the leading cause of death in the United States. However, disparities in CVD-related morbidity and mortality exist as marginalized racial and ethnic groups are generally at higher risk for CVDs (Black Americans, Indigenous People, South and Southeast Asians, Native Hawaiians, and Pacific Islanders) and/or development of traditional CVD risk factors (groups above plus Hispanics/Latinos) relative to non-Hispanic Whites (NHW). In this comprehensive review, we outline emerging evidence suggesting these groups experience accelerated arterial dysfunction, including vascular endothelial dysfunction and large elastic artery stiffening, a nontraditional CVD risk factor that may predict risk of CVDs in these groups with advancing age. Adverse exposures to social determinants of health (SDOH), specifically lower socioeconomic status (SES), are exacerbated in most of these groups (except South Asians-higher SES) and may be a potential mediator of accelerated arterial aging. SES negatively influences the ability of marginalized racial and ethnic groups to meet aerobic exercise guidelines, the first-line strategy to improve arterial function, due to increased barriers, such as time and financial constraints, lack of motivation, facility access, and health education, to performing conventional aerobic exercise. Thus, identifying alternative interventions to conventional aerobic exercise that 1) overcome these common barriers and 2) target the biological mechanisms of aging to improve arterial function may be an effective, alternative method to aerobic exercise to ameliorate accelerated arterial aging and reduce CVD risk. Importantly, dedicated efforts are needed to assess these strategies in randomized-controlled clinical trials in these marginalized racial and ethnic groups.

Social determinants of health and long-term conditions in people of Black African and Black Caribbean ethnicity living with HIV in London: A qualitative study.

BACKGROUND: People living with human immunodeficiency virus (HIV) are disproportionately impacted by socioeconomic deprivation and are at increased risk of developing other long-term conditions (LTCs). These illnesses require transformative action to tackle the adverse effects on their health. Data on lived experiences of LTCs among people living with HIV of Black African and Black Caribbean ethnicities are sparse, and how people with LTCs are impacted by social determinants of health (SDoH). METHODS: Through a phenomenological study design this qualitative study, conducted in 2022, comprised four focus group discussions (FGDs) with 20 people of Black ethnicities living with HIV were purposively invited from a community organisation (CO) in London, including four semistructured interviews with CO staff. Following transcription, qualitative data were analysed thematically and measures to validate the findings were implemented. RESULTS: The findings are presented in terms of the following four levels of SDoH: (1) individual determinants (such as the impact of SDoH on lifestyle modification and self-management); (2) interpersonal determinants (such as positive experiences of accessing healthcare for LTCs); (3) clinical determinants (such as care pathway barriers) and (4) systemic determinants (such as systemic barriers related to race/ethnicity). CONCLUSIONS: It is necessary to provide ongoing and interactive education to community members who live with HIV, focusing on risks and management of LTCs. Additionally, individuals would benefit from support to navigate increasingly complex and fragmented health services. Health Service staff require cultural competence when caring for patients of Black African and Black Caribbean ethnicities with complex health and psychosocial needs. PATIENT OR PUBLIC CONTRIBUTION: The research team collaborated with an HIV CO in South London from the very start of the project to agree the study design and learn about the realities of their daily lived experiences. Community collaborators helped to develop the semistructured interview and FGD topic guides, and were directly involved in the data gathering, analysis and validation.

Reducing CVD health disparities in Black women through addressing social determinants of health (SDOH): a scoping review.

Cardiovascular disease (CVD) disparities among Black American women can be linked directly to social determinants of health (SDOH). This scoping review examines the breadth and depth of existing literature on CVD risk reduction interventions in young-to-middle-aged women that address SDOH. We searched PubMed, CINAHL, Scopus and Google Scholar for relevant peer-reviewed articles published in English. We included studies if they reported on the feasibility, acceptability, or findings of a CVD risk reduction intervention, addressed at least one SDOH domain, and included Black women 18-45 years of age. Of the 2,533 studies screened, 5 studies were eligible for inclusion. Specific SDOH domains addressed included: social and community context and health-care access and quality. All but one study reported culturally tailored intervention components. Feasibility and acceptability of culturally tailored interventions was high among included studies examining this outcome. Recommendations for future research focused on the need for additional interventions that were culturally tailored to young- and middle-aged Black women. Future research should work to address existing evidence gaps via development and implementation of culturally tailored, CVD risk reduction and disease prevention interventions for young-to-middle-aged Black women that focus addressing SDOH, as these types of interventions demonstrate promise for reducing CVD health disparities among Black women.

Cardiovascular Disease in Hispanic Women: JACC Review Topic of the Week.

Cardiovascular disease affects 37% of Hispanic women and is the leading cause of death among Hispanic women in the United States. Hispanic women have a higher burden of cardiovascular risk factors, are disproportionally affected by social determinants of health, and face additional barriers related to immigration, such as discrimination, language proficiency, and acculturation. Despite this, Hispanic women show lower rates of cardiovascular disease and mortality compared with non-Hispanic White women. However, this "Hispanic paradox" is challenged by recent studies that account for the diversity in culture, race, genetic background, country of origin, and social determinants of health within Hispanic subpopulations. This review provides a comprehensive overview of the cardiovascular risk factors in Hispanic women, emphasizing the role of social determinants, and proposes a multipronged approach for equitable care.

Race/Ethnicity and Social Determinants of Health and Their Impact on the Timely Receipt of Appropriate Operative Treatment of Colon Cancer.

INTRODUCTION: Rates of appropriate surgical treatment of colon cancer are historically worse in traditionally marginalized populations. We sought to examine which social determinants of health may be associated with longer time to appropriate operative intervention. METHODS: The National Cancer Databank was queried for this retrospective study. Adult patients (18 to 90 years of age) diagnosed between 2004 and 2018 with single or primary, stage III colon cancer were included. Patient demographic variables included age at diagnosis, sex, ethnicity (Hispanic or non-Hispanic), comorbidity score, median household income, education status, rural/urban status, treatment facility type and location, and insurance status. Disease characteristics include stage (stage 3), primary site, surgical margins, tumor size, and number of nodes resected. Reported descriptive statistics include means and 95% confidence intervals for continuous variables and frequency and proportions for categorical variables. Univariate and multivariate analyses were performed. RESULTS: A total of 134,601 individuals diagnosed with stage 3 colon cancer were included. Time to surgery in all cases had a mean of 26.4 ± 19.0 days. Multivariate analysis of time to surgery indicated that receiving surgery at a Community Cancer Program, Charlson-Deyo Score of 0, younger age, and non-Hispanic-White race/ethnicity are associated with decreased time to surgery (P < .001). CONCLUSION: Patients who receive surgery at a Community Cancer Program, have fewer comorbidities, have lower household income, are younger, and receive surgery within 50 miles of their primary residence are more likely to have timely surgery.

Determinants, Prevention, and Incidence of Cardiovascular Disease Among Immigrant and Refugee Populations.

Immigration policies shape the composition, socioeconomic characteristics, and health of migrant populations. The health of migrants is also influenced by a confluence of social, economic, environmental, and political factors. Immigrants and refugees often face various barriers to accessing health care because of factors such as lack of familiarity with navigating the health care system, language barriers, systemic racism, and gaps in health insurance. Social determinants of health and access to primary care health services likely influence the burden of cardiovascular risk factors among immigrants. The relatively low burden of many cardiovascular risk factors in many immigrant populations likely contributes to the generally lower incidence rates of acute myocardial infarction, heart failure, and stroke in immigrants compared with nonimmigrants, although cardiovascular disease incidence rates vary substantially by country of origin. The "healthy immigrant effect" is the hypothesis that immigrants to high-income countries, such as Canada, are healthier than nonimmigrants in the host population. However, this effect may not apply universally across all immigrants, including recent refugees, immigrants without formal education, and unmarried immigrants. As unfolding sociopolitical events generate new waves of global migration, policymakers and health care providers need to focus on addressing social and structural determinants of health to better manage cardiovascular risk factors and prevent cardiovascular disease, especially among the most marginalized immigrants and refugees.

The social determinants of Aboriginal and Torres Strait Islander adults who do not smoke in regional Australia.

INTRODUCTION: Commercial tobacco use was systematically embedded as a valuable commodity through colonisation that continues to be exploited for profit by the Tobacco Industry. There have been significant declines in current smoking prevalence among Aboriginal and Torres Strait Islander peoples 18 years and over, from 55% in 1994 to 43% in 2018-2019. This paper seeks to better understand smoke-free behaviours, and to systematically quantify associations between a range of SDOH and non-smoking/never-smoking among Aboriginal and Torres Strait Islander adults (≥18) living in regional Australia. OBJECTIVE: To explore the social determinants of health (SDOH) related to non- and never-smoking among Aboriginal and Torres Strait Islander peoples in regional Australia. DESIGN: Cross-sectional analysis of the NATSIHS, weighted to the Aboriginal and Torres Strait Islander adult population living in regional Australia, was conducted. Participants were characterised as people who were current smokers, never-smokers and non-smokers (ex- and never-smokers). The social determinants of health exposures related to socioeconomic position, well-being and access to healthcare. SETTING: Regional Australia is distinct from urban and remote areas, based on the ASGS Remoteness Structure (ABS) 2018-2019. PARTICIPANTS: Aboriginal and Torres Strait Islander adults (≥18 years) who were selected, consented and asked questions about smoking in the National Aboriginal and Torres Strait Islander Health Survey (NATSIHS 2018/19). RESULTS: High income was associated with non-smoking (Prevalence Ratio [PR] = 2.07; 95% CI: 1.66-2.57) and never-smoking (PR = 2.02; 1.46-2.79), as was completing year 10 (non-smoking PR = 1.34; 1.12-1.61 and never-smoking PR = 1.56; 1.20-2.03). Better food security was associated with a higher prevalence of never-smoking (PR = 2.42; 1.48-3.98). Lower psychological distress scores were associated with non-smoking (PR = 1.30; 1.10-1.53) and never-smoking (PR = 1.56; 1.21-2.01). Never-smoking was more frequent in participants reporting no experiences of unfair treatment (PR = 1.59; 1.22-2.06). Having a usual healthcare provider was associated with non-smoking (PR = 1.38; 1.02-1.86). Positive exposure to the SDOH were associated with non- and never-smoking among Aboriginal and Torres Strait Islander adults in regional Australia. Structural and systemic changes to address the SDOH, including discrimination and racism, are expected to accelerate non-smoking behaviours and improve health outcomes for Aboriginal and Torres Strait Islander peoples.

Cardiorespiratory fitness and physical activity in the lens of social justice - Reporting on the disparities that exist.

Cardiorespiratory fitness (CRF), heavily influenced by physical activity (PA), represents a strong and independent risk factor for a wide range of health conditions, most notably, cardiovascular disease. Substantial disparities in CRF have been identified between white and non-white populations. These disparities may partly account for group differences in susceptibility to poor health outcomes, including non-communicable disease. Race and ethnic differences in CRF may partly be explained by social injustices rooted in persistent structural and systemic racism. These forces contribute to environments that are unsupportive for opportunities to achieve optimal CRF levels. This review aims to examine, through the lens of social justice, the inequities in key social ecological factors, including socioeconomic status, the built environment, and structural racism, that underly the systemic differences in CRF and PA in vulnerable communities. Further, this review highlights current public health initiatives, as well as opportunities in future research, to address inequities and enhance CRF through the promotion of regular PA.

Public Health Accountability in Action: The King County Pandemic and Racism Community Advisory Group.

After a tumultuous 3 years of pandemic-, political-, and race-related unrest in the United States, the public is demanding accountability to communities of color (defined here as American Indian/Alaska Native, Asian, Black, Native Hawaiian/Pacific Islander, and Hispanic people) to rectify historic and contemporary injustices that perpetuate health inequities and threaten public health. Structural racism pervades all major societal systems and exposes people to detrimental social determinants of health. Disrupting structural racism within public health systems is essential to advancing health equity and requires organized partnerships between health departments and community leaders. As those who are most affected by structural racism, communities of color are the experts in knowing its impacts. This case study describes the King County Pandemic and Racism Community Advisory Group (PARCAG) and its use of an innovative accountability tool. The tool facilitated institutional transparency and accountability in the adoption of community recommendations. PARCAG was influential in shaping Public Health-Seattle & King County's COVID-19 and antiracism work, with 66 of 75 (88%) recommendations adopted partially or fully. For example, a fully adopted recommendation in May 2020 was to report King County COVID-19 case data by race and ethnicity, and a partially adopted recommendation was to translate COVID-19 information into additional languages. PARCAG members were recruited from a 2019 advisory board on Census 2020 and were adept at shifting to advising on COVID-19 and equitable practices and policies. Organizations that have made declarations that racism is a public health crisis should center the experiences, expertise, and leadership of communities of color in accountable ways when developing and implementing strategies to disrupt and repair the effects of structural racism and efforts to promote and protect public health.

Gentrification Yields Racial And Ethnic Disparities In Exposure To Contextual Determinants Of Health.

This article examines racial and ethnic disparities in the relationship between gentrification and exposure to contextual determinants of health. In our study, we focused on changes in selected contextual determinants of health (health care access, social deprivation, air pollution, and walkability) and life expectancy during the period 2006-21 among residents of gentrifying census tracts in six large US cities that have experienced different gentrification patterns and have different levels of segregation: Chicago, Illinois; Los Angeles, California; New York, New York; Philadelphia, Pennsylvania; San Francisco, California; and Seattle, Washington. We found that gentrification was associated with overall improvements in the likelihood of living in Medically Underserved Areas across racial and ethnic groups, but it was also associated with increased social deprivation and reduced life expectancy among Black people, Hispanic people, and people of another or undetermined race or ethnicity. In contrast, we found that gentrification was related to better (or unchanged) contextual determinants of health for Asian people and White people. Our findings can inform policies that target communities identified to be particularly at risk for worsening contextual determinants of health as a result of gentrification.

Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model.

Importance: The End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model. Objective: To examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients' social risk. Design, Setting, and Participants: A cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021. Exposure: Composition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics. Main Outcomes and Measures: Use of home dialysis, waitlisting, or transplant; model performance score; and financial penalization. Results: Using data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001). Conclusions: In the first year of the Centers for Medicare & Medicaid Services' ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.

Exploring Social Determinants of Mental Health of Older Unforced Migrants: A Systematic Review.

BACKGROUND AND OBJECTIVES: Although the vulnerabilities stemming from the intersection of aging and migration are widely recognized, the migration contexts and the factors influencing the mental health of older unforced migrants have received scant attention. This review explores the drivers of unforced migrations in later life and the individual, relational, and structural factors influencing their mental health and well-being. RESEARCH DESIGN AND METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search of 7 databases for English peer-reviewed journal articles was conducted. A total of 21 studies were identified and analyzed inductively. RESULTS: The review classified motivations for migration as push factors and pull factors: push factors such as escaping structural inequities in the homeland and pull factors included seeking better lifestyle opportunities and reuniting with family. The positive determinants of mental health included cordial family relationships, paid employment, the presence of a partner, and strong support networks. Advanced age, absence of a partner, lifestyle changes, lack of intergenerational support, poor language proficiency, unfavorable policies, lack of access to resources, and systemic biases negatively affected the mental health of older unforced migrants. DISCUSSION AND IMPLICATIONS: The review highlights the need to recognize the diversity among older migrants to develop policies and programs that address their specific circumstances. Recognizing their strengths, rather than focusing solely on their vulnerabilities will help create a more positive and supportive environment, enabling them to thrive in their new communities.