Accelerated Health Declines among African Americans in the USA.

The weathering hypothesis, an explanation for race disparities in the USA, asserts that the health of African Americans begin to deteriorate prematurely compared to whites as a consequence of long-term exposure to social and environmental risk factors. Using data from 2000-2009 National Health Interview Surveys (NHIS), we sought to describe differences in age-related health outcomes in 619,130 African Americans and whites. Outcome measures included hypertension, diabetes, stroke, and cardiovascular disease. Using a mixed models approach to age-period-cohort analysis, we calculated age- and race-specific prevalence rates that accounted for the complex sampling design of NHIS. African Americans exhibited higher prevalence rates of hypertension, diabetes, and stroke than whites across all age groups. Consistent with the weathering hypothesis, African Americans exhibited equivalent prevalence rates for these three conditions 10 years earlier than whites. This suggests that African Americans are acquiring age-related conditions prematurely compared to whites.

Editorial: COVID-19 pandemic and the social determinants of health.

As we learn to co-exist with COVID-19, this Research Topic highlights significant research contributions that examine the interaction of COVID-19 and the social determinants of health. To emphasize the impactful research in this area, this Research Topic features scholarly contributions in the fields of Epidemiology, specifically Aging and Life-course Epidemiology, and Public Health, specifically Public Health Policy. This theme is intentionally broad in scope, and our editorial provides an overview of the key findings of the papers published in the Research Topic on COVID-19 pandemic and the social determinants of health. The types of articles received in response to this Research Topic are summarized below.

Cognition and Wealth Changes in Mid-to-later Life: A Latent Class Trajectories Approach Using the Health and Retirement Study.

ObjectivesTo assess how cognitive trajectories from mid-to-later life relate to wealth change, overall and by mid-life income. Methods: Data were from participants (51-64 years) in the 2000-2018 U.S. Health and Retirement Study who were cognitively healthy at baseline (year 2000; unweighted n = 3821). Longitudinal latent class analyses generated cognitive and wealth trajectories, independently, and multinomial logistic regressions estimated the association between cognitive trajectories and wealth profiles, overall and by median income. Results: We identified three cognitive: cognitively healthy (CH), increasing cognitive impairment (ICI), and increasing dementia (ID) and four wealth profiles: stable wealth loss (SWL), delayed gradual wealth loss (DGWL), stable wealth gain (SWG), and gradual wealth gain (GWG). The ID group had higher probability of being in the SWL group and lower probability of SWG, which was more pronounced in respondents with greater median income. Discussion: Individuals with ID may be vulnerable to wealth loss, particularly for middle-class households.

US Hospital Service Availability and New 340B Program Participation.

Importance: The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended. Objective: To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership. Design, Setting, and Participants: Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024. Exposures: New enrollment in 340B between 2012 and 2018. Main Outcomes and Measures: Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services. Results: The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05). Conclusions and Relevance: The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.

The intersectional importance of race/ethnicity, disability, and age in flu vaccine uptake for U.S. adults.

Improving vaccination rates among marginalized populations is an important priority among public policy makers and healthcare providers in the United States of America (U.S.). Racial/ethnic minorities have a long history of reduced vaccination rates relative to white Americans (Khan, Hall, Tanner, & Marlow, 2018), while people with disabilities (PWD) have varied rates of vaccine use (Diab & Johnston, 2004; O'Neill, Newall, Antolovich, Lima, & Danchin, 2019). Yet, little is known about vaccine use among individuals who belong to both groups. This study examines the intersectional effects of race/ethnicity and disability on flu vaccine use. We used the 2015-2018 National Health Interview Survey to examine the odds of flu vaccine use by race/ethnicity, disability, and their interaction among adults aged 18+ in the U.S. non-institutionalized, civilian population stratified by age groups. For each unit increase in disability scores, we found a significant race-by-disability interaction for young black adults (18-39 years) who had higher odds of getting the flu vaccine compared to white adults in the same age group. A significant interaction occurred for middle-aged Hispanic vs. white adults (40-64 years) who had higher odds of getting the flu vaccine as their disability scores increased. Black vs. white adults were less likely to get the flu vaccine across all age groups irrespective of disability and other covariates, while results were more mixed among other racial/ethnic groups. Additionally, people with disabilities had higher odds of flu vaccination. Further, race/ethnicity had a moderating effect on the relationship between disability and flu vaccination and an interaction effect occurred between disability and certain racial/ethnic groups when stratified by age.

Use of Health Information Varies by Region Among Older Adults in the U.S.

Objective: To examine geographic variations in health information use among older adults in the United States. Methods: We compared 15,531 adults (age 45 and older) across four U.S. regions. Descriptive analyses were conducted to assess health information seeking and use by year. The relationship between health information seeking or use and regional changes were assessed using binomial logistic regression. Binomial models were adjusted by socio-demographics, chronic conditions, and health information sources. Magnitude and direction of relationships were assessed using adjusted odds ratios (aORs), 95% confidence intervals (CIs), and p-values. Results: Only the Northeast region showed increases in health information seeking (3.8%) and use (4.5%) among older adults. However adjusted models showed those living in the Northeast were 28% less likely to use health information to maintain their health and 32% less likely to use health information to treat illness. Conclusion: As a result of the current pandemic, older adults are facing a growing burden from health care expenses. Inability to gather and use health information for personal safety or self care can potentially increase inequalities in health, especially for older adults without personal health care providers.

Intersections of Adverse Childhood Experiences, Race and Ethnicity and Asthma Outcomes: Findings from the Behavioral Risk Factor Surveillance System.

Racial and ethnic minority subpopulations experience a disproportionate burden of asthma and adverse childhood experiences (ACEs). These disparities result from systematic differences in risk exposure, opportunity access, and return on resources, but we know little about how accumulated differentials in ACEs may be associated with adult asthma by racial/ethnic groups. We used Behavioral Risk Factor Surveillance System data (N = 114,015) from 2009 through 2012 and logistic regression to examine the relationship between ACEs and adult asthma using an intersectional lens, investigating potential differences for women and men aged 18 and older across seven racial/ethnic groups. ACEs were significantly related to asthma, adjusting for race/ethnicity and other covariates. Compared to the reference group (Asians), asthma risk was significantly greater for Black/African American, American Indian and Alaska Native (AIAN), White, and multiracial respondents. In sex-stratified interactional models, ACEs were significantly related to asthma among women. The relationship between ACEs and asthma was significantly weaker for Black/African American and AIAN women compared to the reference group (Asian women). The findings merit attention for the prevention and early detection of ACEs to mitigate long-term health disparities, supporting standardized screening and referrals in clinical settings, evidence-based prevention in communities, and the exploration of strategies to buffer the influence of adversities in health.

Chronic Conditions May Be More Important Than Race or Ethnicity in Relation to Health Information Seeking and Use.

OBJECTIVE: This research examines health information (HI) seeking and use among middle-aged and older adults with chronic health conditions. METHOD: We used logistic regression models to analyze HI seeking ( N = 7,822) and use (N = 4,541-4,547) among participants (aged 45+ years) with chronic conditions from the nationally-representative Health Tracking Household Survey. RESULTS: Adults aged 45+ years with chronic conditions were significantly more likely to seek and use HI; however, these results varied based on the age and education. Compared with Whites, Latinos were less likely to seek HI but more likely to use HI to treat illness, and African Americans were more likely to use HI to maintain health. CONCLUSION: Middle-aged and older adults with chronic conditions are prominent HI seekers and users. Proficient HI seeking and use may have the potential to enhance control over one's own health, maintain independence in the community, and reduce the impact of negative health consequences on the health care system.

Racial disparities in health care access and cardiovascular disease indicators in Black and White older adults in the Health ABC Study.

OBJECTIVE: Black adults consistently exhibit higher rates of and poorer health outcomes due to cardiovascular disease (CVD) than other racial groups, independent of differences in socioeconomic status (SES). Whether factors related to health care access can further explain racial disparities in CVD has not been thoroughly examined. METHOD: Using logistic regression, the authors examined racial and health care (i.e., health insurance and access to care) associations with CVD indicators (i.e., hypertension, low ankle-arm index, and left ventricular hypertrophy) in the Health, Aging, and Body Composition Study, a longitudinal study of well-functioning older adults. RESULTS: Older Black versus White adults had significantly worse health care. Overall, health care reduced the significant association between being Black and CVD only slightly, while race remained strongly associated with CVD after adjusting for demographics, SES, body mass index, and comorbidity. DISCUSSION: Research on health care quality may contribute to our understanding of these disparities.

Who Works Among Older Black and White, Well-Functioning Adults in the Health, Aging, and Body Composition Study?

Objective: The aim of this study is to examine social, economic, and health factors related to paid work in well-functioning older adults and if and how these factors vary by race. Method: We used sex-stratified logistic and multinomial logistic regression to examine cross-sectional data in the Health, Aging, and Body Composition cohort study. The sample included 3,075 community-dwelling Black (42%) and White adults aged 70 to 79 at baseline. Results: Multinomial logistic regression analyses show Black men were more likely to work full-time, and Black women were more likely to work part-time. Men with ≥US$50,000 family income were more likely to work full-time. Men with better physical functioning were more likely to work full- and part-time. Women with ≥US$50,000 family income and fewer chronic diseases were more likely to work full-time. Women who were overweight and had fewer chronic diseases were more likely to work part-time. Discussion: Results suggest that well-functioning, older Black adults were more likely to work than their White counterparts, and working relates to better health and higher income, providing support for a productive or successful aging perspective.

Neighborhood Influences and BMI in Urban Older Adults.

OBJECTIVE: Increases in body weight and declining physical activity that may accompany aging are linked to a range of problems affecting daily life (i.e., decreased mobility and overall quality of life). This study investigates the actual and perceived neighborhood environment on overweight and obese urban older adults. METHOD: We selected 217 individuals aged 65+ who answered questions about their neighborhood on the 2009 Speak to Your Health survey. Using multinomial regression models and geospatial models, we examined relationships between neighborhood environment and BMI. RESULTS: We found that obese older adults were 63% less likely to have a park within their neighborhood ( p = .04). Our results also show that older adults who perceive their neighborhood crime as very high are 12 times more likely to be overweight ( p = .04). DISCUSSION: Findings suggest that parks may affect BMI in older adults; however, neighborhood perceptions play a greater role.

Limited literacy in older people and disparities in health and healthcare access.

OBJECTIVES: To determine the relationship between health literacy, demographics, and access to health care. DESIGN: Cross-sectional study, Health, Aging and Body Composition data (1999/2000). SETTING: Memphis, Tennessee, and Pittsburgh, Pennsylvania. PARTICIPANTS: Two thousand five hundred twelve black and white community-dwelling older people who were well functioning at baseline (without functional difficulties or dementia). MEASUREMENTS: Participants' health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine. Scores were categorized into 0 to sixth-, seventh- to eighth-, and ninth-grade and higher reading levels (limited health literacy defined as <9th grade). Participants' demographics, socioeconomic status, comorbidities, and three indicators of healthcare access (whether they had a doctor/regular place of medical care, an influenza vaccination within the year, or insurance for medications) were also assessed. RESULTS: Participants' mean age was 75.6, 52% were female, 38% were black, and 24% had limited health literacy. After adjusting for sociodemographics, associations remained between limited health literacy and being male, being black, and having low income and education, diabetes mellitus, depressive symptoms, and fair/poor self-rated health (P<.02). After adjusting for sociodemographics, health status, and comorbidities, older people with a sixth-grade reading level or lower were twice as likely to have any of the three indicators of poor healthcare access (odds ratio=1.96, 95% confidence interval=1.34-2.88). CONCLUSION: Limited health literacy was prevalent and was associated with low socioeconomic status, comorbidities, and poor access to health care, suggesting that it may be an independent risk factor for health disparities in older people.

Limited literacy and mortality in the elderly: the health, aging, and body composition study.

BACKGROUND: While limited literacy is common and its prevalence increases with age, no prospective study has assessed whether limited literacy is associated with mortality in older adults. OBJECTIVE: To assess the association of limited literacy with mortality. DESIGN AND SETTING: Five-year prospective study from 1999 to 2004 of community-dwelling elders from Memphis, TN, and Pittsburgh, PA, who were from the Health, Aging, and Body Composition study. Subjects' literacy was assessed with the Rapid Estimate of Adult Literacy in Medicine. Scores were categorized into limited (0 to 8th grade reading level) or adequate literacy (> or = 9th grade reading level). PARTICIPANTS: Two thousand five hundred and twelve black and white elders without baseline functional difficulties or dementia. MEASUREMENTS: Time to death. RESULTS: Participants' mean age was 75.6 years, 48% were male, 38% were black, and 24% had limited literacy; the median follow-up time was 4.2 years. Compared with those with adequate literacy, those with limited literacy had a higher risk of death (19.7% vs 10.6%) with a hazard ratio (HR) of 2.03 (95% confidence intervals [CI], 1.62 to 2.55). After adjusting for demographics and socioeconomic status, co-morbid conditions, self-rated health status, health-related behaviors, health care access measures, and psychosocial status, limited literacy remained independently associated with mortality (HR 1.75; 95% CI, 1.27 to 2.41). CONCLUSIONS: Limited literacy is independently associated with a nearly 2-fold increase in mortality in the elderly. Given the growth of the aging population and the prevalence of chronic diseases, the mechanisms by which limited literacy is associated with mortality in the elderly warrant further investigation.

Association of inflammatory markers with socioeconomic status.

BACKGROUND: This study examines the association between socioeconomic status (SES) and inflammatory markers in well-functioning older adults and seeks to determine whether any association remains after adjusting for biomedical and behavioral factors typically related to elevated serum levels of inflammatory markers. METHODS: Data were obtained from 3044 men and women, aged 70-79 from Pittsburgh, Pennsylvania and Memphis, Tennessee participating in the Health, Aging and Body Composition study. Three indicators of SES were used: education, income, and ownership of financial assets. Serum levels of interleukin-6, C-reactive protein, and tumor necrosis factor-alpha were measured. RESULTS: Low SES was associated with significantly elevated levels of interleukin-6, C-reactive protein, and tumor necrosis factor-alpha compared to high SES. Behavioral factors (including smoking, drinking, obesity) explained a substantial part of the inverse association between SES and inflammatory markers. Adjustment for prevalent diseases (including heart diseases, lung disease, and diabetes) associated with inflammation explained less of the association. CONCLUSIONS: This study suggests that interventions to improve health behaviors, even in old age and especially in low SES groups, may be useful in reducing risks associated with inflammation.

Socioeconomic differences in cognitive decline and the role of biomedical factors.

PURPOSE: This study examines the association between socioeconomic status and cognitive decline in a community-based cohort of well-functioning older adults and seeks to determine whether this link could be explained by biomedical factors. METHODS: Data are from 2574 men and women aged 70 to 79 years from Pittsburgh, PA, and Memphis, TN, participating in the Health, Aging and Body Composition study (Health ABC). Three indicators of socioeconomic status were used: education, income, and ownership of financial assets. Cognitive decline over 4 years was defined as a decrease of five points or more in the Modified Mini-Mental State Examination (3MS) score. Biomedical factors measured at baseline, included heart disease, cerebrovascular disease, diabetes, hypertension, poor pulmonary function, and high serum levels of inflammatory markers. RESULTS: Adjusted odds ratios were significantly higher in those with low education, low income, and few assets. Odds ratios ranged from 1.51 to 2.16 in the lowest socioeconomic groups. Additional adjustment for biomedical factors reduced the odds ratios of cognitive decline by an average of 2% for education, 5% for income, and 8% for the number of assets. CONCLUSIONS: Low socioeconomic status predicts a decline in cognitive function in older adults and this relationship is not mediated by biomedical factors.

Is there a biomedical explanation for socioeconomic differences in incident mobility limitation?

BACKGROUND: The association between low socioeconomic status and poor physical functioning has been well described; biomedical factors may play an important role in explaining these differences. This study examines the association between socioeconomic status and incident mobility limitation in well-functioning older adults, and seeks to determine whether this link could be explained by biomedical factors. METHODS: Data were obtained from 3066 men and women, aged 70--79 years from Pittsburgh, Pennsylvania and Memphis, Tennessee participating in the Health, Aging and Body Composition (Health ABC) study. Three indicators of socioeconomic status were used: education, income, and ownership of financial assets. Mobility limitation was defined as reporting difficulty walking 1/4 mile or climbing 10 steps during two consecutive semiannual assessments over 4.5 years. Biomedical factors included a wide range of diseases (e.g., heart and cerebrovascular disease) and biological risk factors (e.g. hypertension, poor pulmonary function, and high serum levels of inflammatory markers). RESULTS: Adjusted hazard ratios of incident mobility limitation were significantly higher in those persons with low education, low income, and few assets. Hazard ratios ranged from 1.66 to 2.80 in the lowest socioeconomic groups. Additional adjustment for biomedical factors reduced the hazard ratios by an average of 41% for education, 17% for income, and 29% for assets. CONCLUSION: Biomedical factors can account for some of the association between socioeconomic status and incident mobility limitation. However, to reduce physical disabilities and, in particular, the socioeconomic differences therein, it may not be sufficient to solely intervene upon biological risk factors and risks of diseases.

Racial differences in glycemic control in a well-functioning older diabetic population: findings from the Health, Aging and Body Composition Study.

OBJECTIVE: To evaluate racial differences and factors associated with worse glycemic control in well-functioning older individuals with type 2 diabetes. Our hypothesis was that glycemic control would be worse among black than white diabetic individuals but that this association would be explained by differences in severity of diabetes, health status, health care indicators, and social, psychological, or behavioral factors. We further hypothesized that the association of race with poorer glycemic control would be limited to those with lower education or lower income. RESEARCH DESIGN AND METHODS: Cross-sectional analysis of 468 diabetic participants among a cohort of 3,075 nondisabled blacks and whites aged 70-79 years living in the community enrolled in the Health, Aging and Body Composition Study. Glycemic control was measured by the level of HbA(1c). RESULTS: A total of 58.5% of the diabetic individuals were black. Although control was poor in all diabetic participants (HbA(1c) > or =7% in 73.7%), blacks had worse glycemic control than whites (age- and sex-adjusted mean HbA(1c), 8.4% in blacks and 7.4% in whites; P < 0.01). Race differences in glycemic control remained significant, even after adjusting for current insulin therapy, cardiovascular disease, higher total cholesterol, and not receiving a flu shot in the previous year, all of which were associated with higher HbA(1c) concentrations. Controlling for these factors reduced the association by 27%. Race remained an important factor in glycemic control, even when results were stratified by education or income. CONCLUSIONS: HbA(1c) concentrations were higher in older black diabetic individuals. Differences in glycemic control by race were associated with disease severity, health status, and poorer quality of care, but these factors did not fully explain the higher HbA(1c) levels in older black diabetic individuals.

Improving the Neighborhood Environment for Urban Older Adults: Social Context and Self-Rated Health.

OBJECTIVE: By 2030, older adults will account for 20% of the U.S. POPULATION: Over 80% of older adults live in urban areas. This study examines associations between neighborhood environment and self-rated health (SRH) among urban older adults. METHODS: We selected 217 individuals aged 65+ living in a deindustrialized Midwestern city who answered questions on the 2009 Speak to Your Health survey. The relationship between neighborhood environment and self-rated health (SRH) was analyzed using regression and GIS models. Neighborhood variables included social support and participation, perceived racism and crime. Additional models included actual crime indices to compare differences between perceived and actual crime. RESULTS: Seniors who have poor SRH are 21% more likely to report fear of crime than seniors with excellent SRH (p = 0.01). Additional analyses revealed Black seniors are 7% less likely to participate in social activities (p = 0.005) and 4% more likely to report experiencing racism (p < 0.001). DISCUSSION: Given the increasing numbers of older adults living in urban neighborhoods, studies such as this one are important for well-being among seniors. Mitigating environmental influences in the neighborhood which are associated with poor SRH may allow urban older adults to maintain health and reduce disability.

Neighborhood Environment and Self-Rated Health Among Urban Older Adults.

Objective: This study examines associations between neighborhood environment and self-rated health (SRH) among urban older adults. Method: We selected 217 individuals aged 65+ living in a de-industrialized Midwestern city who answered questions on the 2009 Speak to Your Health survey. The relationship between neighborhood environment and SRH was analyzed using regression models. Neighborhood variables included social support and participation, perceived racism, and crime. Additional models included actual crime indices to compare differences between perceived and actual crime. Results: Seniors who have poor SRH are 21% more likely to report fear of crime than seniors with excellent SRH (p = .01). Additional analyses revealed Black seniors are 7% less likely to participate in social activities (p = .005) and 4% more likely to report experiencing racism (p < .001). Discussion: More than 80% of older adults live in urban areas. By 2030, older adults will account for 20% of the U.S. POPULATION: Given the increasing numbers of older adults living in urban neighborhoods, studies such as this one are important. Mitigating environmental influences in the neighborhood that are associated with poor SRH may allow urban older adults to maintain health and reduce disability.