Browsing by Subject "Social determinants of health"
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Item Open Access A housing mobility program's impacts on teen and young adult parenting.(SSM - population health, 2019-12) Fuller, Taleria R; Sciandra, Matt; Koumans, Emilia H; Boulet, Sheree L; Warner, Lee; Cox, Shanna; Gennetian, Lisa AObjective:To assess the impact of Moving to Opportunity for Fair Housing Demonstration Program (MTO) implemented in 1994 in five U.S. cities (Baltimore, Boston, Chicago, Los Angeles, and New York City) on teen births. Methods:We analyzed baseline and long-term evaluation data for youth (ages 13-20) and young adults (ages 21-30) (N = 7861) who were children or teens at baseline. We used regression analyses to estimate the impact of housing vouchers on having a teen birth. Results:Overall, MTO had no significant effect on teen births. However, among young adults whose parent had a child before age 20, the proportion with a teen birth themselves was 21% lower among those offered housing vouchers to low-poverty neighborhoods with no restrictions compared to those not offered housing vouchers (p < 0.05). Conclusion:MTO appeared to decrease intergenerational teen births among young adults. Further exploration of housing relocation may help untangle risks and protective factors for reducing intergenerational teen births. Public health implications:Reducing intergenerational teen births is important, especially among those facing economic, environmental, and health risks. Comprehensive programs addressing multiple social determinants of health are vital to reducing teen births.Item Open Access A Systems Thinking, Community-Based Exploration of Health Equity and Agency: Women’s Migraine as a Paradigmatic Case(2017) Befus, DeannaBackground. Creating health equity—“the attainment of the highest level of health for all people”— is a core tenet of public health (American Public Health Association, 2015; United States Department of Health and Human Services, 2011, p. 1). Achieving health equity requires the identification and amelioration of patterns of systemic disadvantage and the elimination of health disparities (Gostin & Powers, 2006; United States Department of Health and Human Services, 2011). To do this, health researchers must address social determinants of health (SDOH) and of equity. I have selected women with migraine as a paradigmatic case for this exploration of health equity and agency.
Migraine is a common and debilitating neurobiological disorder without a cure (Goadsby, 2012). It affects almost three times as many women as men, and disproportionately disables women occupying low social locations, that is, occupying a low position on the social hierarchy (Burch, Loder, Loder, & Smitherman, 2015b; Stewart, Roy, & Lipton, 2013). A dearth of effective and affordable treatment options has rendered non-pharmacological self-management a crucial part of living with migraine, yet clinical treatment guidelines consistently emphasize pharmacological intervention (Becker et al., 2015; Diamond et al., 2007; Raphael, 2012). Much of migraine research is epidemiological (Burch et al., 2015b; Buse et al., 2013; Lipton, Serrano, Holland, et al., 2013). The resulting gap in knowledge around the experiences and needs of women navigating the complexities of life with migraine is especially pronounced for those who are less likely or able to access systems that document and treat the condition.
Objective and Methods. The overall purpose of this dissertation is to develop knowledge on the effects of social and structural determinants on the experiences of women living with migraine, with attention to their strategies and priorities for self-management through a systems thinking lens. To do this in the context of this dissertation, I first explore the benefits of critical systems approaches for health equity research (Chapter 2), followed by a description of the development and use of two systems thinking tools for data collection in community focus groups of women with migraine (Chapter 3). Our study team used the system support map tool (SSM) to identify and describe migraine triggers and features, self-management strategies, and the needs and outcomes associated with self-management (Chapter 4). The connection circle (CC) tool explored the relationships between triggers and features, self-management strategies, and outcomes (Chapter 5).
We conducted seven focus groups with 19 women with migraine from diverse social locations and analyzed the data using qualitative content analysis, dimensional analysis, and measures of complexity. We examined variation by social location in the data from both tools.
Findings. The tools we developed allowed us to feasibly and effectively collect rich and nuanced data from community-based women with migraine. One of the tools—the CC— may be more effective when coupled with problem solving techniques when used with women in low social locations (Chapter 3).
The SSM data underscored the distinctions in migraine experience by social location (Chapter 4). While women from all social locations identified stress as a top migraine trigger, descriptions and definitions of stress varied. Women in low social locations were more likely to engage in isolating and avoidant self-management activities, and women in higher social locations were more likely to use proactive, complementary, and integrative approaches. Women in low social locations had lower expectations for self-management and were more interested in pain management than women in higher social locations, who were more interested in self-improvement.
The CC data revealed that ‘conceptualization of complexity,’ or the way and degree to which participants contemplated dynamic interrelationships, was a key dimension in understanding how women in diverse social locations identified relationships between different aspects of their migraine experiences. There were clear differences in the conceptualizations of and capacities for complexity by social location. Women in high social locations demonstrated greater depth, breadth, and structure of this key dimension than women in low social locations.
Discussion and Conclusions. As a non-fatal, but highly disabling, condition with limited and costly treatment options, migraine provides an excellent paradigmatic case for exploring health equity. Ability to have a high quality of life with migraine may be deeply entwined with one’s social location. Therefore, to improve the experiences of the group most affected by migraine—women in low social locations—we cannot limit our research and treatment to the biological and behavioral. We need to think in terms of the social and structural. Creating equitable outcomes, wherein everyone has an equal opportunity for a fulfilling and healthy life, requires that we intervene on multiple levels, engage with affected women, and explicitly commit to addressing social and structural determinants of health AND equity.
Item Open Access Addressing the Impact of COVID-19 on Immigrant and Refugee Children and Families at a Federally Qualified Health Center in Durham, North Carolina.(2021) Norton, Sarah EastmanBackground: The COVID-19 pandemic amplified disparities experienced by children in immigrant and refugee families (CIRF). The pandemic coincided with a recognition that proactively screening and addressing social risk drivers is an efficacious population health intervention. We used the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework to set up a program to screen for social risks drivers at a Federally Qualified Health Center (FQHC). The study sought to demonstrate to what extent the proactive outreach program would a) capture at-risk persons and b) facilitate linkage of identified persons to community resources. We sought to c) quantify social needs among CIRF and d) understand whether addressing social risk drivers would lead to caregivers perceiving an improvement in their child’s health. Lastly, we sought to e) elucidate the experiences with and preferences of families in regard to screening efforts. Methods: The study was conducted at the Lincoln Community Health Center in Durham, North Carolina. Eligible participants were ages 0-5, non-English speaking, and were seen at the clinic within the last 2 years. A care coordinator reached out to the guardians of eligible children for baseline screening. Participants with social needs received referral placement and navigation support. We looked at the number of baseline questionnaires completed, linkage rates and resolution of social needs as well as perceptions of SDOH screening and perceived changes in child’s health using descriptive and univariate statistics. Results: We attempted to contact 342 guardians; to date, we did not reach 85 (24.85%) participants and 21 (6.14%) have incomplete outreach. 212 (61.99%) participants were enrolled and completed baseline screening. Most participants had at least one social need. Of the 212 individuals enrolled, the 39 who completed the intervention (100%) indicated that the calls helped them to gain a better understanding of community resources. When asked who they would be most comfortable talking with about their social needs, the majority indicated a case manager in person (34, 89.5%) or over the phone (36, 94.74%). When asked about what characteristics were important to them when considering who they might speak with about their social needs, 36 (92.1%) selected language and 22 (57.9%) indicated that cultural affiliation was important. The impact of the intervention on the perception of child’s health was unable to be quantified due to a small sample size. Conclusion: Our findings illustrate the burden of social risk drivers experienced by CIRF and demonstrate the capacity of a proactive outreach SDOH screening program to meet the needs of CIRF served by a FQHC. It is our hope that this screening tool and proactive outreach program can be used as a model to better identify and address the social needs of CIRF and to thus enhance health outcomes and population health.
Item Open Access Associations between urbanicity and spinal cord astrocytoma management and outcomes.(Cancer epidemiology, 2023-10) Sykes, David AW; Waguia, Romaric; Abu-Bonsrah, Nancy; Price, Mackenzie; Dalton, Tara; Sperber, Jacob; Owolo, Edwin; Hockenberry, Harrison; Bishop, Brandon; Kruchko, Carol; Barnholtz-Sloan, Jill S; Erickson, Melissa; Ostrom, Quinn T; Goodwin, C RoryBackground
The management of spinal cord astrocytomas (SCAs) remains controversial and may include any combination of surgery, radiation, and chemotherapy. Factors such as urbanicity (metropolitan versus non-metropolitan residence) are shown to be associated with patterns of treatment and clinical outcomes in a variety of cancers, but the role urbanicity plays in SCA treatment remains unknown.Methods
The Central Brain Tumor Registry of the United States (CBTRUS) analytic dataset, which combines data from CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology, and End Results Programs, was used to identify individuals with SCAs between 2004 and 2019. Individuals' county of residence was classified as metropolitan or non-metropolitan. Multivariable logistic regression models were used to evaluate associations between urbanicity and SCA. Cox proportional hazard models were constructed to assess the effect of urbanicity on survival using the NPCR survival dataset (2004-2018).Results
1697 metropolitan and 268 non-metropolitan SCA cases were identified. The cohorts did not differ in age or gender composition. The populations had different racial/ethnic compositions, with a higher White non-Hispanic population in the non-metropolitan cohort (86 % vs 66 %, p < 0.001) and a greater Black non-Hispanic population in the metropolitan cohort (14 % vs 9.9 %, p < 0.001). There were no significant differences in likelihood of receiving comprehensive treatment (OR=0.99, 95 % CI [0.56, 1.65], p = >0.9), or survival (hazard ratio [HR]=0.92, p = 0.4) when non-metropolitan and metropolitan cases were compared. In the metropolitan cohort, there were statistically significant differences in SCA treatment patterns when stratified by race/ethnicity (p = 0.002).Conclusions
Urbanicity does not significantly impact SCA management or survival. Race/ethnicity may be associated with likelihood of receiving certain SCA treatments in metropolitan communities.Item Embargo Exposomic modeling approaches for social and environmental determinants of health(2023) McCormack, KaraStudies of human health have recently expanded to focus on the exposome paradigm, encompassing allexposures humans encounter from conception onward. The central theme of this work is to develop and test novel statistical methodologies that can address the challenges of the complex relationships between environmental exposures, socioeconomic distress, and health outcomes. However, source, measurement, and volume intricacies inherent to these data have constrained progression of statistical methods for key research questions.
In this work, we explore three approaches to characterizing community health and its potential impact on several types of disease outcomes. In the first approach, we implement a latent class model to socioeconomic and comorbidities data and explore these classifications as fixed effects in an ecological spatial model of COVID-19 cases and deaths in NYC during two time periods of the pandemic. In the second, we use a non-parametric Bayesian approach to form socio-economic and pollution cluster profiles across US counties. We then use these profiles to inform a Bayesian spatial model on breast cancer mortality for data from 2014. In the final approach, we utilize a latent network model traditionally used in psychometrics research to explore structural racism. Using information from five domains (employment, education, housing, health, and criminal justice), we identify new variable complexes to illustrate the complex the manifestations of structural racism at the census tract level in Pennsylvania.
Item Open Access Gender and Racial/Ethnic Disparities in Mental Health, Substance Use Disorders, and Behavioral Health Treatment Utilization in US Parolees and Probationers(2020) Curlee, VanessaBehavioral health (BH) refers to emotional well-being and actions that affect wellness, and includes mental health (MH) and substance use (SU) disorders. Although estimates vary, it is generally agreed that about 50% of all individuals held in jails and prisons suffer from a BH disorder. Justice-involved (JI) adults under supervision in the community (i.e. parolees, individuals exiting prison, and probationers, individuals that may be exiting jail, or under correctional supervision in the community for a specified amount of time instead of incarceration) often have untreated BH needs, particularly co-occurring MH and SU disorders. Untreated BH disorders are a barrier to community re-integration, and contribute to risk taking behaviors, SU relapse, and recidivism post-release. However, rehabilitative reentry efforts typically focus on SU treatment alone, resulting in unmet MH treatment needs. Research also indicates differential rates of BH disorders among justice-involved adults by self-reported gender and race/ethnicity, but national estimates are limited. Likewise, the post-release BH care experiences for these individuals are poorly delineated.
The overall purpose of this dissertation was to develop a deeper understanding of the BH needs and community-based BH treatment utilization in justice-involved adults. Chapter one provides an overview of the research problem, background, and significance; identifies gaps in knowledge related to this dissertation study as identified by the literature; and provides a summary of the conceptual and theoretical frameworks that guided the aims of this dissertation. Chapter two provides the results of a systematic review of the extant literature on the unmet BH needs and barriers and facilitators to community-based BH treatment utilization among justice-involved adults. Chapters three and four present the results of a secondary analysis of data from the 2016 National Survey on Drug Use and Health (NSDUH). Chapter five summarizes and synthesizes dissertation results, and provides recommendations for future research and implications for nursing practice.
Chapter three details the results of a cross-sectional, descriptive, and correlational study to describe and compare the past-year prevalence of depression, serious psychological distress, and/or SU disorders among JI adults compared to a group of adults not on parole or probation at any point during the past year, adjusting for individual characteristics informed by the social determinants of health (SDOH) framework. Chapter four describes the employment of a modified version of the Meleis’ Transitions Theory to highlight the increased vulnerability of JI adults with these BH needs during community reentry. This dissertation treated community reentry as a situational transition and the pattern of transition as multiple and simultaneous in JI adults, as they often face multiple challenges related to community reentry and integration. Specifically, this chapter focused on the describing the impact of self-reported gender, race/ethnicity, and their intersectionality (factors that influence the pattern of transition) on past-year BH needs and BH treatment utilization among JI adults with BH needs. Chapter four also details the individual-level and community/societal-level barriers to BH treatment utilization among JI adults with BH needs.
Results from our systematic review of the literature support high rates of BH needs and psychosocial stressors among justice-involved adults. Sociodemographic and geographical location were critical influences on disparities in BH needs and BH treatment utilization, and justice-involvement was a significant facilitator of BH treatment utilization among justice-involved adults. Further, although rates of health insurance have increased among justice-involved adults, rates of BH treatment utilization have not significantly improved and considerable unmet need for BH treatment persists. Dissertation study results (chapters three and four) revealed that almost half (46%) of the justice-involve group were affected by a BH disorder, and self-reported gender, race/ethnicity, and their intersectionality, significantly impact the probability of being affected by a past-year BH need and BH treatment utilization. Justice-involvement was a significant predictor of being affected by a BH need, with higher prevalence rates among the JI group. Age (18-49 years), an annual income less than $20 thousand, not married, and reporting fair/poor health were SDOH that were found to significantly increase the risk factors for BH needs in the JI group in this dissertation study.
Justice health is integral to public health, and efforts to address the national BH crisis must include and prioritize justice-involved individuals. Study results contribute to the limited literature on the impact of gender, race/ethnicity, and their intersectionality on BH and BH treatment utilization in justice-involved adults. Further, inability to access BH treatment utilization due to cost remains a persistent barrier to community-based BH treatment utilization among justice-involved adults. Dissertation findings provide further evidence of the disproportionately higher prevalence of BH needs among justice-involved adults compared to the non-justice-involved adults. It provides the first examination of co-occurring MH and SUDs in justice-involved adults in a nationally representative sample, and contributes to overcoming the paucity of literature differentiating substance misuse and dependency, which have significant implications for community-based BH treatment service planning and provision. Findings can inform a public health approach to identifying and treating BH disorders that is population-based, aid in the development of effective BH transitional and post-release reentry efforts, and contribute to improved BH equity and community integration in justice-involved adults.
Item Open Access "It's his cheerfulness that gives me hope:" A Qualitative Analysis of Access to Pediatric Cancer Care in Northern Tanzania(2023) Metcalf, MadelineBackground:Pediatric cancer is a significant and growing burden in low- and middle-income countries such as Tanzania. The objective of this project was to describe the barriers and facilitators to accessing pediatric cancer care in Northern Tanzania using the Three Delays Model
Methods:This was a cross-sectional qualitative study conducted between June and September 2023 at Kilimanjaro Christian Medical Center (KCMC). Parents and caregivers of children obtaining pediatric cancer care at KCMC were approached for participation in in-depth interviews (IDIs) and complimentary demographic surveys. This study is part of an ongoing collaboration between researchers from Duke Global Health Institute at Duke University and KCMC.
Results:Participants suggested significant financial barriers to accessing pediatric cancer care along the entire care continuum. Early delays were impacted by waiting for symptoms to resolve and the use of traditional medicine. Additional delays resulted from health infrastructure at mid-level health facilities, misdiagnoses, and delayed referral to KCMC for definitive treatment. Participants did not describe clinical delays after arrival to KCMC and rather offered perspective on their child’s cancer diagnosis, their concerns while obtaining care, and their hopes for the future.
Conclusions: The most significant clinical delays occurred within Delay 1 (the decision to seek care) and Delay 2 (reaching a medical facility). Advancements in clinical infrastructure and training at intermediary medical centers should be considered to support the prompt diagnosis and treatment for pediatric cancer. Lastly, financial and social schemes which limit out-of-pocket expenses should be considered.
Item Open Access Mind the Gap: A Comparative Analysis of Adolescent Mental Health, Social Determinants of Health, and Medicaid Policy in North Carolina(2023-12-11) Rory, SmithThis study examines the relationship between adolescent mental health care, social determinants of health, and the development of Medicaid across two North Carolina counties. Specifically, this thesis focuses on Durham County, a relatively urban area with several unincorporated suburbs, and Transylvania County, a rural community of approximately 30,000 inhabitants. Much research has been conducted on the relationship between social determinants of health, and access to and quality of adolescent mental health care. However, the multi-dimensional relationship between all three variables, as well as the influence of Medicaid policy and service innovations, remains unsettled. Through qualitative interviews and inductive analysis, this thesis investigates the differences between how adolescent mental health care is provided in each community. Additionally, it explores the extent to which adolescent mental health services address social determinants of health, and the role of Medicaid policy in the perceived effectiveness of those initiatives. Qualitative analysis of 15 interviews with healthcare providers, community leaders, and Medicaid care managers suggests that the mechanisms by which adolescent mental health and social determinants of health are addressed differ between the two counties, with clinical and nonprofit efforts emphasized in Durham and Transylvania Counties respectively. Yet in both communities, the efforts perceived as most successful rely on collaboration and community organization across various stakeholder groups. Across all interviews, challenges of healthcare access, fragmentation, and discontinuity of care emerged, highlighting a discrepancy between how behavioral health and SDOH innovations are proposed and how they truly affect North Carolinian adolescents.Item Open Access Postpartum Symptom Clusters in Birthing Individuals(2023) Scroggins, Jihye KimProblem: Many birthing individuals experience postpartum symptoms which are associated with adverse health conditions including long-term weight gain and depression. Postpartum symptoms often occur in clusters (i.e., three or more co-occurring symptoms that are related to each other) which makes it more difficult to manage. To date, research has been focused on individual symptoms which limits our understanding of how postpartum symptom clusters manifest and impact health. Therefore, the purpose of this dissertation was to develop knowledge on postpartum symptom clusters among birthing individuals. One systematic review (Chapter 2) and three quantitative studies (Chapters 3 to 5) were conducted to achieve this purpose.Methods: For the systematic review, five databases were searched to locate articles. Two reviewers performed title/abstract and full-text screening. Article qualities were examined using Standard Quality Assessment Criteria. Key information was extracted and synthesized using a narrative synthesis. For three quantitative studies, secondary data from the Community and Child Health Network study was used. First, latent profile analysis was performed in Chapter 3 to identify subgroups of postpartum women with different postpartum symptom profiles at 6 months postpartum using observed variables (i.e., general stress, posttraumatic stress, postpartum depression, and sleep disturbance-quality and -quantity). Next, in Chapters 3 to 5, associations between the identified symptom profiles and (a) clinical and social determinants of health (SDOH) characteristics and/or (b) maternal health outcomes (i.e., long-term depression, well-being, and allostatic load) were examined using bivariate and multivariate analysis. Findings: A total of 30 articles were included in the systematic review (Chapter 2). The majority were quantitative and cross-sectional. Factor analysis was the most frequently used. Stress, depression, somatic, and anxiety clusters were the most frequently identified. In Chapter 3, five distinct postpartum symptom profiles were identified which were labeled as Profile 1: Minimum, Profile 2: Highly disturbed sleep quantity, Profile 3: Mild-moderate, Profile 4: High, and Profile 5: High psychological symptoms. Postpartum women in high symptom severity profiles (Profiles 4 and 5) had significantly more early postpartum complications and a history of depression (Chapter 3). Experiences of different social-economic hardships (e.g., discrimination in healthcare settings or food insecurity) also had a significant impact on postpartum symptom profiles (Chapter 4). Furthermore, postpartum women in high symptom severity profiles had significantly higher depression at 18 and 24 months, lower well-being at 24 months, and higher overall allostatic load at 12 months (Chapters 3 and 5). Conclusion: This dissertation study found that birthing individuals do have complex and unique postpartum symptom cluster experiences and such experiences have a significant impact on their long-term health. Future research and practice should consider providing targeted interventions to optimally manage postpartum symptom clusters and prevent the development of adverse health outcomes. In doing so, it is critical to consider and address comprehensive SDOH from multiple layers of society.
Item Open Access Social Determinants of Health and Disparities in Spine Surgery: A Ten-Year Analysis of 8,565 Cases using Ensemble Machine Learning and Multilayer Perceptron.(The spine journal : official journal of the North American Spine Society, 2024-07) Shin, David; Razzouk, Jacob; Thomas, Jonathan; Nguyen, Kai; Cabrera, Andrew; Bohen, Daniel; Lipa, Shaina A; Bono, Christopher M; Shaffrey, Christopher I; Cheng, Wayne; Danisa, OlumideBackground context
The influence of SDOH on spine surgery is poorly understood. Historically, researchers commonly focused on the isolated influences of race, insurance status, or income on healthcare outcomes. However, analysis of SDOH is becoming increasingly more nuanced as viewing social factors in aggregate rather than individually may offer more precise estimates of the impact of SDOH on healthcare delivery.Purpose
The aim of this study was to evaluate the effects of patient social history on length of stay (LOS) and readmission within 90 days following spine surgery using ensemble machine learning and multilayer perceptron.Study design
Retrospective chart review PATIENT SAMPLE: 8,565 elective and emergency spine surgery cases performed from 2013-2023 using our institution's database of longitudinally collected electronic medical record information.Outcomes measures
Patient LOS, discharge disposition, and rate of 90-day readmission.Methods
Ensemble machine learning and multilayer perceptron were employed to predict LOS and readmission within 90 days following spine surgery. All other subsequent statistical analysis was performed using SPSS version 28. To further assess correlations among variables, Pearson's correlation tests and multivariate linear regression models were constructed. Independent sample t-tests, paired sample t-tests, one-way analysis of variance (ANOVA) with post-hoc Bonferroni and Tukey corrections, and Pearson's chi-squared test were applied where appropriate for analysis of continuous and categorical variables.Results
Black patients demonstrated a greater LOS compared to white patients, but race and ethnicity were not significantly associated with 90-day readmission rates. Insured patients had a shorter LOS and lower readmission rates compared to non-insured patients, as did privately insured patients compared to publicly insured patients. Patients discharged home had lower LOS and lower readmission rates, compared to patients discharged to other facilities. Marriage decreased both LOS and readmission rates, underweight patients showcased increased LOS and readmission rates, and religion was shown to impact LOS and readmission rates. When utilizing patient social history, lab values, and medical history, machine learning determined the top 5 most-important variables for prediction of LOS -along with their respective feature importances-to be insurance status (0.166), religion (0.100), ICU status (0.093), antibiotic use (0.061), and case status: elective or urgent (0.055). The top 5 most-important variables for prediction of 90-day readmission-along with their respective feature importances-were insurance status (0.177), religion (0.123), discharge location (0.096), emergency case status (0.064), and history of diabetes (0.041).Conclusions
This study highlights that SDOH is influential in determining patient length of stay, discharge disposition, and likelihood of readmission following spine surgery. Machine learning was utilized to accurately predict LOS and 90-day readmission with patient medical history, lab values, and social history, as well as social history alone.Item Open Access Structural, Biological, and Psychosocial Determinants of Frailty in Community-dwelling Older Adults in the U.S.(2023) Shakya, ShamatreeFrailty is a common geriatric syndrome in older adults associated with a host of adverse outcomes. Frailty disproportionately affects women, older adults who identify as Hispanic, non-Hispanic Black, and those with less income in the US. The underlying mechanism contributing to frailty disparities across structural social determinants of health (gender, race, ethnicity, and education) is poorly understood. This study aimed to elucidate whether these structural social determinants operate through intermediary biological factors (cardiometabolic) and psychosocial stressors and influence frailty in community-dwelling older adults in the US. The World Health Organization’s conceptual framework of action on social determinants of health (CSDH) underpins this study. The CSDH framework claims that structural social determinants of health shape social hierarchy contingent on individuals’ gender, race, ethnicity, and education, which may offer structural advantages and disadvantages. Individuals’ ranking in the social hierarchy may differentially expose them to intermediary health-promoting or damaging factors leading to disparate health outcomes. This study hypothesized that structural social determinants (gender, race, ethnicity, and education) are associated with disproportionate exposure to intermediary biological cardiometabolic factors and psychosocial stressors, which may be related to the differential frailty risk. This cross-sectional, descriptive, correlational study is the secondary analysis of the existing data from the Health and Retirement Study (HRS). This study involved approximately 8000 older adults (65 years and above) who met the eligibility criteria for the examination of physical, cardiometabolic biomarker measurements, and psychosocial information in 2006 or 2008. We used the Fried phenotype to classify frailty on the basis of the presence of at least three features, such as poor grip strength, slow gait speed, fatigue, weight loss, and low physical activity. We used clinical cutoffs to dichotomize the presence and absence of seven cardiometabolic factors (elevated blood pressure, sugar, C-reactive protein, total cholesterol; obesity, abdominal obesity, and low high-density lipoprotein). Based on empirical studies, we dichotomized six psychosocial factors (loneliness, financial strain, perceived everyday discrimination, subjective social status, poor neighborhood, and experience of traumatic life events) originating from multiple life domains into high and low psychosocial stressors. We used latent class analysis to identify subgroups of older adults with distinct combinations of cardiometabolic (typologies). Path analysis (a series of logistic regressions) was used to examine the structural determinants and cardiometabolic relationships with frailty and explore whether cardiometabolic typologies mediate the relationship between structural determinants and frailty. Our results further confirm that frailty disparities persist. Female, older adults who identify as Hispanic, non-Hispanic Black, and those with less education had a higher frailty risk relative to male, non-Hispanic White older adults, and those with high education. Structural social determinants were significantly related to latent subgroups of older adults with distinct cardiometabolic typologies. The members of the insulin resistance subgroup were more likely to be female, they were more likely identify as non-Hispanic Black, and were college non-graduates. The members of the hypertensive dyslipidemia were more likely to identify as non-Hispanic other minorities and were high school graduates, and the members in the hypertensive subgroup were more likely to be male and college graduates. The frailty risk differed among these latent subgroups of older adults, and the insulin resistance subgroup had a higher frailty risk than hypertensive dyslipidemia and hypertensive subgroups. In contrast, the frailty risk did not differ in the latter two subgroups. However, cardiometabolic typologies did not mediate the relationship between structural social determinants and frailty. Cumulative psychosocial stress was used to assess co-occurring psychosocial stress stemming from multiple life domains. We measured cumulative psychosocial stress by counting six dichotomized psychosocial stressors originating from multiple life domains. Path analysis (a series of multivariable regression models) was used to examine structural social determinants and cumulative psychosocial stress relationships with frailty and determine the mediating role of cumulative psychosocial stress between structural social determinants and frailty. Older adults who identified as Hispanic, non-Hispanic Black, non-Hispanic other ethnic minorities, and those with less education were more likely to experience greater cumulative psychosocial stress. Greater cumulative psychosocial stress was associated with higher frailty risk; however, it did not mediate the relationship between structural social determinants and frailty. Our results solidify the multifactorial nature of frailty. Structural social determinants, cardiometabolic typologies, and cumulative psychosocial stress independently contributed to frailty. Surprisingly, cardiometabolic typologies and cumulative psychosocial stress did not mediate the relationships between structural social determinants and frailty. Our study sets the foundation for exploring other biological and psychosocial stressors contributing to frailty and examining their mediating roles.
Item Open Access The Social Determinants of Health for African American Mothers Living with HIV(2015) Caiola, Courtney EllisProblem: The disparate health outcomes of African American mothers living with HIV functions at the intersection of gender-, race-, and class-inequality; HIV-related stigma; and motherhood, requiring multidimensional approaches to address the complex social and economic conditions of their lives, collectively known as the social determinants of health. African American women suffer significantly higher HIV infection rates and tend to die earlier from their infection than their White counterparts. Poverty is a significant precipitating factor for HIV infection and African American women are disproportionately poorer than other subpopulations in the United States. HIV-related stigma is linked to poorer mental and physical health outcomes across a broad range of demographic profiles. Being a mother adds an extra layer of social complexity to the lives of women living with HIV. This dissertation was designed to develop knowledge on the social determinants of health for African American mothers living with HIV by describing their social location at the intersection of gender-, race- and class – inequality; HIV-related stigma; and motherhood and exploring how their unique social identity influences their health-related experiences.
Methods: Using data from a literature review on intersectional approaches and other frameworks for examining vulnerable populations, an intersectional model for the study of the social determinants of health for African American mothers living with HIV was constructed. A pilot study exploring the methodological issues and ethical challenges of using photo elicitation with a highly stigmatized social group of women was conducted. The intersectional model and pilot study findings were then used to guide a qualitative descriptive study using storyline graphs, photo elicitation and in-depth qualitative interviewing as methods for exploring the intersection of the social determinants of health for eighteen (18) African American mothers living with HIV. Content, vector and frame analyses were used to describe the intersection of social determinants and identify potential process and structural level interventions.
Results: Findings from the pilot study include best practices for using visual methods with a highly stigmatized and potentially vulnerable group of women. Findings from the qualitative descriptive study include six additional social determinants of health - social support, religiosity, animal companions, physical environment, transportation and housing - not initially included in the conceptual model, a case for strength-based approaches, intersecting social determinants functioning as systems of oppression and the heterogeneous and fluid social locations as framed from the mother’s perspective. Three frames of social location for African American mothers living with HIV were proposed – emancipatory, situational, and internalized – as well as potential health implications and interventions. Each of the findings add to the literature on the configuration of intersecting social determinants health relevant to African American mothers living with HIV, expand the proposed intersectional model and help to generate hypotheses needed for intervention studies.