Identifying Individuals with Highest Social Risk in Adults with Type 2 Diabetes Using Item Response Theory.

OBJECTIVE: The aim of this analysis was to create a parsimonious tool to screen for high social risk using item response theory to discriminate across social risk factors in adults with type 2 diabetes. METHODS: Cross-sectional data of 615 adults with diabetes recruited from two primary care clinics were used. Participants completed assessments including validated scales on economic instability (financial hardship), neighborhood and built environment (crime, violence, neighborhood rating), education (highest education, health literacy), food environment (food insecurity), social and community context (social isolation), and psychological risk factors (perceived stress, depression, serious psychological distress, diabetes distress). Item response theory (IRT) models were used to understand the association between a participant's underlying level of a particular social risk factor and the probability of that response. A two-parameter logistic IRT model was used with each of the 12 social determinant factors being added as a separate parameter in the model. Higher values in item discrimination indicate better ability of a specific social risk factor in differentiating participants from each other. RESULTS: Rate of crime reported in a neighborhood (discrimination 3.13, SE 0.50; item difficulty - 0.68, SE 0.07) and neighborhood rating (discrimination 4.02, SE 0.87; item difficulty - 1.04, SE 0.08) had the highest discrimination. CONCLUSIONS: Based on these findings, crime and neighborhood rating discriminate best between individuals with type 2 diabetes who have high social risk and those with low social risk. These two questions can be used as a parsimonious social risk screening tool to identify high social risk.

Independent Correlates of Glycemic Control among Adults with Diabetes in South Africa.

BACKGROUND: Globally, the prevalence of diabetes is increasing, especially in low- and middle-income countries (LMICs), including those in the sub-Saharan African region. However, the independent socioeconomic correlates of glycemic control as measured by hemoglobin A1C have yet to be identified. Therefore, the aim of this analysis was to understand the independent correlates of glycemic control in South Africa. METHODS: Data from the 2016 South Africa Demographic and Health Survey on adults with diabetes were used for this analysis. The dependent variable, glycemic control, was defined using hemoglobin A1c (HbA1c). Independent variables included: age, gender, ethnicity, marital status, region, urban/rural residence, ability to read, education, insurance, wealth, occupation, and employment in the last year. Analysis of variance was used to test for differences in mean HbA1c for each category of all independent variables, and a fully adjusted linear regression model was used to identify independent correlates of glycemic control (HbA1c). RESULTS: Among the 772 people included in this analysis, there were significant differences in mean HbA1c by age (p < 0.001), ethnicity (p < 0.001), place of residence (p = 0.024), wealth index (p = 0.001), and employment in the last year (p = 0.008). Independent correlates of HbA1c included age, ethnicity, and wealth index. CONCLUSIONS: This study used data from a large diverse population with a high prevalence of diabetes in sub-Saharan Africa and provides new evidence on the correlates of glycemic control and potential targets for interventions designed to lower HbA1c and improve diabetes-related health outcomes of adults in South Africa.

Understanding the Relationship Between Wealth and Cognitive Function by Race/Ethnicity Among Older United States Adults with Diabetes.

Background: The prevalence of type 2 diabetes is increasing with the burden disproportionately falling on older adults and racial/ethnic minorities. Older adults with diabetes show greater cognitive decline and there are disparities in cognitive function by race/ethnicity that can be explained by social determinants such as wealth. Objective: To understand whether there is a differential relationship between wealth and cognitive function by race/ethnicity among older U.S. adults with diabetes. Methods: Data on 9,006 adults aged 50+ with diabetes from the Health and Retirement Study (2006-2016) were analyzed. The primary outcome, cognitive function, was a score ranging from range 0-27 categorized as: normal [12-27], mild cognitive impairment (MCI) [7-11], and dementia including Alzheimer's disease [0-6]. Three modeled outcomes were: 1) normal versus MCI, 2) normal versus dementia, 3) MCI versus dementia. Wealth was log transformed and used as continuous and binary (≥median,

Catastrophic health expenditures: a disproportionate risk in uninsured ethnic minorities with diabetes.

BACKGROUND: Chargemaster prices are the list prices that providers and health systems assign to each of their medical services in the US. These charges are often several factors of magnitude higher than those extended to individuals with either private or public insurance, however, these list prices are billed in full to uninsured patients, putting them at increased risk of catastrophic health expenditures (CHE). The objective of this study was to examine the risk of CHE across insurance status, diabetes diagnosis and to examine disparity gaps across race/ethnicity. METHODS: We perform a retrospective observational study on a nationally representative cohort of adult patients from the Medical Expenditure Panel Survey for the years 2002-2017. Using logistic regression models we estimate the risk of CHE across insurance status, diabetes diagnosis and explore disparity gaps across race/ethnicity. RESULTS: Our fully adjusted results show that the relative odds of having CHE if uninsured is 5.9 (p < 0.01) compared to if insured, and 1.1 (p < 0.01) for patients with a diabetes diagnosis (compared to those without one). We note significant interactions between insurance status and diabetes diagnosis, with uninsured patients with a diabetes diagnosis being 9.5 times (p < 0.01) more likely to experience CHE than insured patients without a diabetes diagnosis. In terms of racial/ethnic disparities, we find that among the uninsured, non-Hispanic blacks are 13% (p < 0.05), and Hispanics 14.2% (p < 0.05), more likely to experience CHE than non-Hispanic whites. Among uninsured patients with diabetes, we further find that Hispanic patients are 39.3% (p < 0.05) more likely to have CHE than non-Hispanic white patients. CONCLUSIONS: Our findings indicate that uninsured patients with diabetes are at significantly elevated risks for CHE. These risks are further found to be disproportionately higher among uninsured racial/ethnic minorities, suggesting that CHE may present a channel through which structural economic and health disparities are perpetuated.

Historic Redlining and Impact of Structural Racism on Diabetes Prevalence in a Nationally Representative Sample of U.S. Adults.

OBJECTIVE: We investigated direct and indirect relationships between historic redlining and prevalence of diabetes in a U.S. national sample. RESEARCH DESIGN AND METHODS: Using a previously validated conceptual model, we hypothesized pathways between structural racism and prevalence of diabetes via discrimination, incarceration, poverty, substance use, housing, education, unemployment, and food access. We combined census tract-level data, including diabetes prevalence from the Centers for Disease Control and Prevention PLACES 2019 database, redlining using historic Home Owners' Loan Corporation (HOLC) maps from the Mapping Inequality project, and census data from the Opportunity Insights database. HOLC grade (a score between 1 [best] and 4 [redlined]) for each census tract was based on overlap with historically HOLC-graded areas. The final analytic sample consisted of 11,375 U.S. census tracts. Structural equation modeling was used to investigate direct and indirect relationships adjusting for the 2010 population. RESULTS: Redlining was directly associated with higher crude prevalence of diabetes within a census tract (r = 0.01; P = 0.008) after adjusting for the 2010 population (χ2(54) = 69,900.95; P < 0.001; root mean square error of approximation = 0; comparative fit index = 1). Redlining was indirectly associated with diabetes prevalence via incarceration (r = 0.06; P < 0.001), poverty (r = -0.10; P < 0.001), discrimination (r = 0.14; P < 0.001); substance use (measured by binge drinking: r = -0.65, P < 0.001; and smoking: r = 0.35, P < 0.001), housing (r = 0.06; P < 0.001), education (r = -0.17; P < 0.001), unemployment (r = -0.17; P < 0.001), and food access (r = 0.14; P < 0.001) after adjusting for the 2010 population. CONCLUSIONS: Redlining has significant direct and indirect relationships with diabetes prevalence. Incarceration, poverty, discrimination, substance use, housing, education, unemployment, and food access may be possible targets for interventions aiming to mitigate the impact of structural racism on diabetes.

Differential Effect of Patient- and Provider-Level Factors on Patient Satisfaction Scores in Academic General Internal Medicine Clinics.

OBJECTIVE: Determine whether patient-level or provider-level factors have greater influence on patient satisfaction scores in an academic general internal medicine clinic. METHODS: Two years of data (2017-2019) from the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS) surveys from ambulatory internal medicine clinic visits in an academic health center located in the Midwest United States were used. Patient satisfaction was measured using the overall provider satisfaction score (0-10), dichotomized with 9-10 defined as satisfactory and 0-8 as unsatisfactory. Provider-level independent variables included age, sex, race/ethnicity, provider type, service type, clinical effort, academic rank, and years since graduation. Patient-level factors included age, sex, race/ethnicity, education, and Epic Risk Score. Generalized mixed-effects logistic regression models were used to investigate associations between top-box satisfaction score and patient- and provider-level factors, accounting for the nesting of patients within providers. RESULTS: Thirty-three providers and 4597 patients were included in the analysis. Male providers (OR, 1.57; 95% CI, 1.00, 2.47), minority group 2 (OR, 3.54; 95% CI, 1.24, 10.07) and minority group 3 (OR, 6.04; 95% CI, 1.45, 25.12), faculty (OR, 3.83; 95% CI, 1.56, 9.36), and primary care providers (OR, 5.60; 95% CI, 1.62, 19.34) had increased odds of having a top-box rating compared with females, minority group 1, advanced practice providers, and perioperative providers respectively. Age was the only patient independent correlate of top-box rating with a 3% increased odds of top-box rating for every year increase in age (OR, 1.03; 95% CI 1.02, 1.03). CONCLUSIONS: In this academic general internal medicine clinic, top-box satisfaction scores were more strongly associated with provider-level factors, including provider race/ethnicity, provider type, and service type, as opposed to patient-level factors. Further research is needed to confirm these findings and identify potential system-level interventions.

Intimate partner violence in the lives of Indigenous and Black women in the upper Midwest of the United States during the COVID-19 pandemic: A mixed-methods protocol examining help-seeking behaviours and experiences.

Violent behaviour perpetrated against women has long-lasting negative physical and mental health consequences for women, their children, their families, and their communities. Intimate partner violence (IPV) is associated with many adverse physical, psychological, and emotional consequences. Structural racism and historical trauma affect women's trust and further hinder the ability of Indigenous and Black women to seek help after experiencing IPV. The availability of IPV support services, which can include shelter, food, group therapy, legal assistance, and advocacy, can be inaccessible to women due to the inability to access often limited resources in urban environments and reasons compounded by potential geographic distance if living in rural areas or living in community. Understanding the unique reasons why Indigenous and Black women do not seek help, and the barriers they experience when seeking help after IPV, is critical. Pandemics have the potential to create further complexities on how IPV is experienced. Black and Indigenous women experiencing IPV were therefore at even greater risk for IPV-related harm because of state and local "stay at home" measures put in place to minimise the spread COVID-19. The purpose of this manuscript is to explicate the methods for a large R01 study in the Upper Midwest.

Understanding the relationship between social risk factors and functional limitation among stroke survivors in the US.

BACKGROUND: Stroke is the fifth leading cause of death and disability in the United States. Social risk factors contribute to recovery from stroke, however the relationship between social risk factors and functional limitation among stroke survivors remains unknown. METHODS: Data on 2,888 adults with stroke from the National Health Interview Survey from 2016-2018 was analyzed. The primary independent variables included six social risk factors: economic instability, lack of community, educational deficit, food insecurity, social isolation, and inadequate access to care. The outcome measure was functional limitation count. Negative binomial regression models were run to test the relationship between the independent and dependent variables adjusting for covariates. RESULTS: Overall, 56% of the study participants were aged 65+, 70% were Non-Hispanic White, and 95% had at least one comorbidity. The mean functional limitation count was 1.8. In the unadjusted model, each social risk factor was significantly associated with functional limitation. In the fully adjusted model, significant association with functional limitation was found in individuals reporting economic instability (Incidence rate ratio [IRR] 1.65, 95% CI 1.33, 2.06), food insecurity (IRR 1.28, 95% CI 1.15, 1.42), and social isolation (IRR 1.64, 95% CI 1.48, 1.82). CONCLUSIONS: Social risk factors such as economic instability, food insecurity and social isolation are significantly associated with functional limitation in adults with stroke. Interventions designed to address both social and medical needs have the potential to improve physical functioning and other clinical outcomes in stroke survivors.

Racial/Ethnic and Geographic Disparities in Comorbid Traumatic Brain Injury-Renal Failure in US Veterans and Associated Veterans Affairs Resource Costs, 2000-2020.

Studies have identified disparities by race/ethnicity and geographic status among veterans with traumatic brain injury (TBI) and renal failure (RF). We examined the association of race/ethnicity and geographic status with RF onset in veterans with and without TBI, and the impact of disparities on Veterans Health Administration resource costs. METHODS: Demographics by TBI and RF status were assessed. We estimated Cox proportional hazards models for progression to RF and generalized estimating equations for inpatient, outpatient, and pharmacy cost annually and time since TBI + RF diagnosis, stratified by age. RESULTS: Among 596,189 veterans, veterans with TBI progressed faster to RF than those without TBI (HR 1.96). Non-Hispanic Black veterans (HR 1.41) and those in US territories (HR 1.71) progressed faster to RF relative to non-Hispanic Whites and those in urban mainland areas. Non-Hispanic Blacks (-$5,180), Hispanic/Latinos ($-4,984), and veterans in US territories (-$3,740) received fewer annual total VA resources. This was true for all Hispanic/Latinos, while only significant for non-Hispanic Black and US territory veterans < 65 years. For veterans with TBI + RF, higher total resource costs only occurred ≥ 10 years after TBI + RF diagnosis ($32,361), independent of age. Hispanic/Latino veterans ≥ 65 years received $8,248 less than non-Hispanic Whites and veterans living in US territories < 65 years received $37,514 less relative to urban veterans. CONCLUSION: Concerted efforts to address RF progression in veterans with TBI, especially in non-Hispanic Blacks and those in US territories, are needed. Importantly, culturally appropriate interventions to improve access to care for these groups should be a priority of the Department of Veterans Affairs priority for these groups.

Relationship between delay discounting, delay aversion and psychosocial domains of diabetes care.

PURPOSE: Delay discounting and aversion are important areas for diabetes management; however, little has been done to understand the relationship with psychosocial outcomes among adults with type 2 diabetes. METHODS: This study used data from 365 adults with type 2 diabetes to evaluate relationships between delay discounting and aversion and psychosocial outcomes. Delay discounting and aversion were measured with the validated Quick Delay Questionnaire. Psychosocial outcomes included depression, measured by the PHQ, anxiety by the GAD scale, perceived stress by the PSS, and social support by the Duke Social Support and Stress Scale. Multiple linear regression was used to assess the relationship between delay discounting and aversion on psychological health and social support controlling for relevant covariates. RESULTS: Mean age of the sample was 61.8 years, 54.5 % were NHB, 41.8 % NHW, and 3.7 % Hispanic/Other. After adjusting for covariates, delay aversion was significantly associated with depression (beta = 0.35; p < 0.001), anxiety (beta = 0.52; p < 0.001), perceived stress (beta = 0.22; p < 0.001), and lower family support (beta = -0.62; p < 0.05). Delay discounting was significantly associated with depression (beta = 0.32; p < 0.001), anxiety (beta = 0.46; p < 0.001), and perceived stress (beta = 0.26; p < 0.001). LIMITATIONS: This data is cross-sectional, future work should examine the longitudinal relationship while also including additional psychosocial outcomes. CONCLUSIONS: Delay discounting and aversion are significantly associated with poor psychosocial outcomes, including lower social support. As the body of evidence grows, additional research is needed to better understand the construct, mechanisms, and the impact of choice settings to better inform intervention development.

Addressing Structural Inequalities, Structural Racism, and Social Determinants of Health: a Vision for the Future.

Significant national discourse has focused on the idea of structural inequalities and structural racism within a variety of societal sectors, including healthcare. This perspective provides an understanding of the historic and pervasive nature of structural inequalities and structural racism; uses well-known frameworks in health equity research for conceptualizing structural inequality and structural racism; offers a summary of the consequences of structural inequalities and structural racism on modern-day health outcomes; and concludes with strategies and suggestions for a way forward. Recommended strategies across different sectors of influence include (a) employment and economic empowerment sector: creating capacity for individuals to earn livable wages; (b) education sector: developing new funding structures to ensure equal opportunities are offered to all; (c) healthcare sector: prioritizing universal access to high-quality health care, including mental health treatment; (d) housing sector: improving access to affordable, safe housing through public-private partnerships; (e) criminal justice sector: focusing reform on restorative justice that is people-centric instead of punitive; and (f) environmental sector: creating sustainable systems that alleviate downstream consequences of climate change. The recommended strategies account for the mutually reinforcing and pervasive nature of structural inequalities/structural racism and target key sectors of influence to enhance overall health outcomes and achieve equity regardless of race, ethnicity, or socioeconomic status.

Substance Use Disorders, Mental Illness, and Health Care Utilization Among Adults With Recent Criminal Legal Involvement.

OBJECTIVE: Individuals involved with the criminal legal system have higher rates of mental illness, addiction, and health care utilization. The authors examined whether substance use disorders and mental illness alone or in combination drive health care utilization among those with recent criminal legal involvement. METHODS: This cross-sectional analysis used nationally representative data from U.S. adults with past-year criminal legal involvement (N=9,039) recorded in the National Survey on Drug Use and Health (2015-2019). Using adjusted negative binomial regression models, the authors estimated relative risks for health care utilization. Primary independent variable categories included neither substance use disorder nor mental illness, substance use disorder only, mental illness only, and both conditions. Health care utilization included emergency department (ED) visits and nights spent in inpatient care. RESULTS: Relative to neither mental illness nor substance use disorder, mental illness alone was associated with significantly increased acute health care services use: for ED visits, incidence risk ratio (IRR)=1.43 (95% CI=1.18-1.75) and for inpatient stays, IRR=2.14 (95% CI=1.47-3.11). Having both conditions was associated with increased ED visits (IRR=1.62, 95% CI=1.38-1.91) and inpatient stays (IRR=4.16, 95% CI=2.98-5.82). Substance use disorder alone was associated only with higher risk for ED visits compared with neither condition (IRR=1.23, 95% CI=1.01-1.50). CONCLUSIONS: Mental illness with or without co-occurring substance use disorder is a strong driver of acute health care utilization after interaction with the criminal legal system. Interventions tailored to the unique needs of individuals with mental illness or substance use disorder are needed for those with recent criminal legal involvement.

The Associations Between Medical and Mental Health Conditions and Health Care Utilization in US Adults with Past-Year Criminal Legal Involvement.

BACKGROUND: Every year, millions of US adults return home from prison or jail, and they visit the emergency department and experience hospitalizations at higher rates than the general population. Little is known about the primary conditions that drive this acute care use. OBJECTIVE: To determine the individual and combined associations between medical and mental health conditions and acute health care utilization among individuals with recent criminal legal involvement in a nationally representative sample of US adults. DESIGN: We examined the association between having medical or mental, or both, conditions (compared to none), and acute care utilization using negative binomial regression models adjusted for relevant socio-demographic covariates. PARTICIPANTS: Adult respondents to the National Survey of Drug Use and Health (2015-2019) who reported past year criminal legal involvement. MAIN MEASURES: Self-reported visits to the emergency department and nights spent hospitalized. RESULTS: Among 9039 respondents, 12.4% had a medical condition only, 34.6% had a mental health condition only, and 19.2% had both mental and medical conditions. In adjusted models, incident rate ratio (IRR) for ED use for medical conditions only was 1.32 (95% CI 1.05, 1.66); for mental conditions only, the IRR was 1.36 (95% CI 1.18, 1.57); for both conditions, the IRR was 2.13 (95% CI 1.81, 2.51). For inpatient use, IRR for medical only: 1.73 (95% CI 1.08, 2.76); for mental only, IRR: 2.47 (95% CI 1.68, 3.65); for both, IRR: 4.26 (95% CI 2.91, 6.25). CONCLUSION: Medical and mental health needs appear to contribute equally to increased acute care utilization among those with recent criminal legal involvement. This underscores the need to identify and test interventions which comprehensively address both medical and mental health conditions for individuals returning to the community to improve both health care access and quality.

Prevalence and correlates of pre-diabetes in Sub-Saharan Africa using Demographic and Health Survey Data: a cross-sectional study.

OBJECTIVE: The objective is to investigate the prevalence of pre-diabetes in Namibia and South Africa and to determine sociodemographic correlates of disease using population data. DESIGN: Cross-sectional study. SETTING: Demographic and Health Survey for emerging (Namibia) and established (South Africa) economies in Sub-Saharan Africa collected laboratory data that allowed determination of pre-diabetes status. PARTICIPANTS: 3141 adults over age 18 from the 2013 Namibia survey, weighted to a population of 2176, and 4964 adults over age 18 from the 2016 South Africa survey, weighted to a population of 4627 had blood glucose/glycated haemoglobin (HbA1c) and diabetes information were included in the analysis. OUTCOME MEASURES: Pre-diabetes was defined as not being diagnosed with diabetes and having a blood sugar measurement of 100-125 mg/dL in Namibia or an HbA1c measurement of 5.7%-6.4%. Logistic models were run for each country separately, with pre-diabetes as the outcome and a series of sociodemographic variables (age, gender, urban/rural residence, number of children, employment status, wealth index, education level, and ethnicity (in South Africa) or religion (in Namibia)) entered as variables to investigate the independent relationship of each. RESULTS: The weighted prevalence of pre-diabetes was 18.7% in Namibia and 70.1% in South Africa. Rural residence was independently associated with higher odds of pre-diabetes in Namibia (1.47, 95% CI 1.05 to 2.06), while both younger age (0.98, 95% CI 0.97 to 0.99) and urban residence (0.80, 95% CI 0.66 to 0.99) were independently associated with odds of pre-diabetes in South Africa. CONCLUSIONS: The prevalence of pre-diabetes was 18.7% in Namibia and 70.1% in South Africa. Correlates of pre-diabetes differed between the two countries with rural residents having higher odds of pre-diabetes in Namibia and urban residents with higher odds in South Africa. Aggressive interventions, including population level education and awareness programmes, and individual level education and lifestyle interventions that account for country-specific contextual factors are urgently needed to prevent progression to diabetes.

Relationship between Satisfaction Scores and Racial/Ethnic and Sex Concordance in Primary Care.

Racial/ethnic and sex concordance between patients and providers has been suggested as an important consideration in improving satisfaction and increasing health equity. We aimed to guide local efforts by understanding the relationship between satisfaction with care and patient-provider racial/ethnic and sex concordance within our academic medical center's primary care clinic. METHODS: Satisfaction data for encounters from August 2016 to August 2019 were matched to data from the medical record for patient demographics and comorbidities. Data on 33 providers were also obtained, and racial/ethnic and sex concordance between patients and providers was determined for each of the 3672 unique encounters. The primary outcome was top-box scoring on the CGCAHPS overall satisfaction scale (0-8 vs. 9-10). Generalized mixed-effects logistic regression, including provider- and patient-level factors as fixed effects and a random intercept effect for providers, were used to determine whether concordance had an independent relationship with satisfaction. RESULTS: 89.0% of the NHW-concordant pairs and 90.4% of the Minority Race/Ethnicity-concordant pairs indicated satisfaction, while 90.1% of the male-concordant and 85.1% of the female-concordant pairs indicated satisfaction. When fully adjusted, the female-concordant (OR = 0.58, 95% CI 0.35-0.94) and male-discordant (OR = 0.68, 95% CI 0.51-0.91) pairs reported significantly lower top-box satisfaction compared to the male-concordant pairs. Significant differences did not exist in racial/ethnic concordance. CONCLUSIONS: In this sample, differences in sex concordance were noted; however, patient- and provider-level factors may be more influential in driving patient satisfaction than race/ethnicity in this health system.

Community Social Capital and Population Health Outcomes.

Importance: While the association between economic connectedness and social mobility has now been documented, the potential linkage between community-level economic connectedness and population health outcomes remains unknown. Objective: To examine the association between community social capital measures (defined as economic connectedness, social cohesion, and civic engagement) and population health outcomes (defined across prevalence of diabetes, hypertension, high cholesterol, kidney disease, and obesity). Design, Setting, and Participants: This cross-sectional study included communities defined at the zip code tabulation area (ZCTA) level in all 50 US states. Data were collected from January 2021 to December 2022. Main Outcomes and Measures: Multivariable regression analyses were used to examine the association between population health outcomes and social capital. Adjusted analyses controlled for area demographic variables and county fixed effects. Heterogeneities within the associations based on the racial and ethnic makeup of communities were also examined. Results: In this cross-sectional study of 17 800 ZCTAs, across 50 US states, mean (SD) economic connectedness was 0.88 (0.32), indicating friendship sorting on income; the mean (SD) support ratio was 0.90 (0.10), indicating that 90% of ties were supported by a common friendship tie; and the mean (SD) volunteering rate was 0.08 (0.03), indicating that 8% of individuals within a given community were members of volunteering associations. Mean (SD) ZCTA diabetes prevalence was 10.8% (2.9); mean (SD) high blood pressure prevalence was 33.2% (6.2); mean (SD) high cholesterol prevalence was 32.7% (4.2), mean (SD) kidney disease prevalence was 3.0% (0.7), and mean (SD) obesity prevalence was 33.4% (5.6). Regression analyses found that a 1% increase in community economic connectedness was associated with significant decreases in prevalence of diabetes (-0.63%; 95% CI, -0.67% to -0.60%); hypertension (-0.31%; 95% CI, -0.33% to -0.29%); high cholesterol (-0.14%; 95% CI, -0.15% to -0.12%); kidney disease (-0.48%; 95% CI, -0.50% to -0.46%); and obesity (-0.28%; 95% CI, -0.29% to -0.27%). Second, a 1% increase in the community support ratio was associated with significant increases in prevalence of diabetes (0.21%; 95% CI, 0.16% to 0.26%); high blood pressure (0.16%; 95% CI, 0.13% to 0.19%); high cholesterol (0.16%; 95% CI, 0.13% to 0.19%); kidney disease (0.17%; 95% CI, 0.13% to 0.20%); and obesity (0.08%; 95% CI, 0.06% to 0.10%). Third, a 1% increase in the community volunteering rate was associated with significant increases in prevalence of high blood pressure (0.02%; 95% CI, 0.01% to 0.02%); high cholesterol (0.03%; 95% CI, 0.02% to 0.03%); and kidney disease (0.02%; 95% CI, 0.01% to 0.02%). Additional analyses found that the strength of these associations varied based on the majority racial and ethnic population composition of communities. Conclusions and Relevance: In this study, higher economic connectedness was significantly associated with better population health outcomes; however, higher community support ratios and volunteering rates were both significantly associated with worse population health. Associations also differed by majority racial and ethnic composition of communities.

Examining the Relationship between Social Determinants of Health and Adverse Pregnancy Outcomes in Black Women.

OBJECTIVE: Our objective was to examine associations between social determinants of health (cultural, neighborhood, and psychosocial factors) and adverse pregnancy outcomes (gestational age at birth [GAB], preterm birth [PTB], and preeclampsia) in Black women. STUDY DESIGN: Cross-sectional data (n = 204) comprised adult Black women aged ≥18 years who delivered between 2013 and 2022 in Milwaukee,Wisconsin. Sequential unadjusted linear and logistic regression models were run to evaluate associations between social determinants of health and pregnancy outcomes. Stepwise regressions with forward selection were run to test the contribution of the social determinants of health to adverse pregnancy outcomes, independent of the contribution of established risk factors. RESULTS: Mean GAB was 37.9 weeks, 19.6% had a PTB and 17.7% had preeclampsia. In all fully adjusted models, education (ß0.15, 95% confidence interval [CI]: 0.005, 0.29), nulliparity (ß -1.26, 95%CI: -2.08, -0.44), multifetal gestation (ß -2.67, 95% CI: -4.29, -1.05), and exposure to neighborhood violence (ß -0.13, 95%CI: -0.25, -0.005) were associated with shortened GAB. Education (adjusted odds ratio [aOR]: 0.83, 95%CI: 0.69, 0.99), provider trust (aOR: 0.94, 95%CI: 0.88, 0.99), chance health locus of control (aOR: 0.88, 95%CI: 0.78, 0.99), and anxiety (aOR: 0.81, 95%CI: 0.69, 0.95) were associated with reduced odds of PTB. Powerful others health locus of control (aOR: 1.16, 95%CI: 1.03, 1.32), depression (aOR: 1.17, 95%CI: 1.01, 1.34), nulliparity (aOR: 4.73, 95%CI: 1.79, 12.55), multifetal gestation (aOR: 17.78, 95%CI: 3.49, 90.50), diabetes (aOR: 4.71, 95%CI: 1.17, 19.00), and obstructive sleep apnea (aOR: 44.28, 95%CI: 2.50, 783.12) were associated with increased odds of PTB. Internal health locus of control (aOR: 1.13, 95%CI: 1.01, 1.25), depression (aOR: 1.09, 95%CI: 1.01, 1.17), preeclampsia in a previous pregnancy (aOR: 5.96, 95% CI: 2.22, 16.01), and kidney disease (aOR: 34.27, 95% CI: 1.54, 763.75) were associated with preeclampsia. CONCLUSION: Provider trust, health locus of control, neighborhood violence, depression, and anxiety were associated with adverse pregnancy outcomes in Black women, independent of demographic and clinical risk factors. KEY POINTS: · We identified associations between exposure to neighborhood violence and gestational age at birth.. · Trust, locus of control, depression, and anxiety were associated with preterm birth and preeclampsia.. · Future research should focus on interventions that address social and clinical factors..

Historic Residential Redlining and Present-Day Social Determinants of Health, Home Evictions, and Food Insecurity within US Neighborhoods.

OBJECTIVE: Examine the association between historic residential redlining and present-day racial/ethnic composition of neighborhoods, racial/ethnic differences in social determinant of health domains, and risk of home evictions and food insecurity. RESEARCH DESIGN AND METHODS: We examined data on 12,334 (for eviction sample), and 8996 (for food insecurity sample), census tracts in 213 counties across 37 states in the USA with data on exposure to historic redlining. First, we examined relationships between Home Owners' Loan Corporation (HOLC) redlining grades (A="Best", B="Still Desirable", C="Definitely Declining", D="Hazardous") and present-day racial/ethnic composition and racial/ethnic differences in social determinant of health domains of neighborhoods. Second, we examined whether historic redlining is associated with present-day home eviction rates (measured across eviction filings rates, and eviction judgment rates for 12,334 census tracts in 2018) and food insecurity (measured across low supermarket access, low supermarket access and income, low supermarket access and low car ownership for 8996 census tracts in 2019). Multivariable regression models were adjusted for census tract population, urban/rural designation, and county level fixed effects. RESULTS: Relative to areas with a historic HOLC grading of "A (Best)", areas with a "D (Hazardous)" grading had a 2.59 (95%CI=1.99-3.19; p-value<0.01) higher rate of eviction filings, and a 1.03 (95%CI=0.80-1.27; p-value<0.01) higher rate of eviction judgments. Compared to areas with a historic HOLC grading of "A (Best)", areas rated with a "D (Hazardous)" had a 16.20 (95%CI=15.02-17.79; p-value<0.01) higher rate of food insecurity based on supermarket access and income, and a 6.15 (95%CI =5.53-6.76; p-value<0.01) higher rate of food insecurity based on supermarket access and car ownership. CONCLUSIONS: Historic residential redlining is significantly associated with present-day home evictions and food insecurity, highlighting persistent associations between structural racism and present-day social determinants of health.

The role of structural racism and geographical inequity in diabetes outcomes.

Diabetes is pervasive, exponentially growing in prevalence, and outpacing most diseases globally. In this Series paper, we use new theoretical frameworks and a narrative review of existing literature to show how structural inequity (structural racism and geographical inequity) has accelerated rates of diabetes disease, morbidity, and mortality globally. We discuss how structural inequity leads to large, fixed differences in key, upstream social determinants of health, which influence downstream social determinants of health and resultant diabetes outcomes in a cascade of widening inequity. We review categories of social determinants of health with known effects on diabetes outcomes, including public awareness and policy, economic development, access to high-quality care, innovations in diabetes management, and sociocultural norms. We also provide regional perspectives, grounded in our theoretical framework, to highlight prominent, real-world challenges.

Interventions to address global inequity in diabetes: international progress.

Diabetes is a serious chronic disease with high associated burden and disproportionate costs to communities based on socioeconomic, gender, racial, and ethnic status. Addressing the complex challenges of global inequity in diabetes will require intentional efforts to focus on broader social contexts and systems that supersede individual-level interventions. We codify and highlight best practice approaches to achieve equity in diabetes care and outcomes on a global scale. We outline action plans to target diabetes equity on the basis of the recommendations established by The Lancet Commission on Diabetes, organising interventions by their effect on changing the ecosystem, building capacity, or improving the clinical practice environment. We present international examples of how to address diabetes inequity in the real world to show that approaches addressing the individual within a larger social context, in addition to addressing structural inequity, hold the greatest promise for creating sustainable and equitable change that curbs the global diabetes crisis.