The Association Between Income and Life Expectancy in the United States, 2001-2014

Impact of Poverty on Stroke Recurrence: A Population-Based Study

BACKGROUND AND OBJECTIVES

Poverty is associated with greater stroke incidence. The relationship between poverty and stroke recurrence is less clear.

METHODS

In this population-based study, incident strokes within the Greater Cincinnati/Northern Kentucky region were ascertained during the 2015 study period and followed up for recurrence until December 31, 2018. The primary exposure was neighborhood socioeconomic status (nSES), defined by the percentage of households below the federal poverty line in each census tract in 4 categories (≤5%, >5%-10%, >10%-25%, >25%). Poisson regression models provided recurrence rate estimates per 100,000 residents using population data from the 2015 5-year American Community Survey, adjusting for age, sex, and race. In a secondary analysis, Cox models allowed for the inclusion of vascular risk factors in the assessment of recurrence risk by nSES among those with incident stroke.

RESULTS

Of 2,125 patients with incident stroke, 245 had a recurrent stroke during the study period. Poorer nSES was associated with increased stroke recurrence, with rates of 12.5, 17.5, 25.4, and 29.9 per 100,000 in census tracts with ≤5%, >5%-10%, >10%-25%, and >25% below the poverty line, respectively (p < 0.01). The relative risk (95% CI) for recurrent stroke among Black vs White individuals was 2.54 (1.91-3.37) before adjusting for nSES, and 2.00 (1.47-2.74) after adjusting for nSES, a 35.1% decrease. In the secondary analysis, poorer nSES (HR 1.74, 95% CI 1.10-2.76 for lowest vs highest category) and Black race (HR 1.31, 95% CI 1.01-1.70) were both independently associated with recurrence risk, though neither retained significance after full adjustment. Age, diabetes, and left ventricular hypertrophy were associated with increased recurrence risk in fully adjusted models.

DISCUSSION

Residents of poorer neighborhoods had a dose-dependent increase in stroke recurrence risk, and neighborhood poverty accounted for approximately one-third of the excess risk among Black individuals. These results highlight the importance of poverty, race, and the intersection of the 2 as potent drivers of stroke recurrence.

Trends and structural factors affecting health equity in the United States at the local level, 1990-2019

Health equity is fundamental to improving the health of populations, but in recent decades progress towards this goal has been mixed. To better support this mission, a deeper understanding of the local heterogeneity within population-level health equity is vital. This analysis presents trends in average health and health equity in the United States at the local level from 1990 to 2019 using three different health outcomes: mortality, self-reported health status, and healthy days. Furthermore, it examines the association between these measures of average health and health equity with several structural factors. Results indicate growing levels of geographic inequality disproportionately impacting less urbanized parts of the country, with rural counties experiencing the largest declines in health equity, followed by Medium and Small Metropolitan counties. Additionally, lower levels of health equity are associated with poorer local socioeconomic context, including several measures that are proxies for structural racism. Altogether, these findings strongly suggest social and economic factors play a pivotal role in explaining growing levels of geographic health inequality in the United States. Policymakers invested in improving health equity must adopt holistic and upstream approaches to improve and equalize economic opportunity as a means of fostering health equity.

Advancing Evidence-Based Public Health Policy: How Core Component Thinking Can Illuminate the Multilevel Nature of Public Health Policy

A growing body of literature uses the concept of core components to better understand small-scale programmatic interventions. Instead of interventions being viewed as unitary "black boxes," interventions are viewed as configurations of core components, which are the parts of interventions that carry their causal potential and therefore need to be reproduced with fidelity to produce the intended effect. To date, the concept of core components has not been as widely applied to public health policy interventions as it has to programmatic interventions. The purpose of this topical review is to familiarize public health practitioners and policy makers with the concept of core components as applied to public health policy interventions. Raising the profile of core component thinking can foster mindful adaptation and implementation of public health policy interventions while encouraging further research to enhance the supporting evidence base. We present 3 types of multilevel interactions in which the core components of a public health policy intervention produce effects at the population level by (1) seeking to directly affect individual behavior, (2) facilitating adoption of programmatic interventions by intermediaries, and (3) encouraging intermediaries to take action that can shape changes in upstream drivers of population health. Changing the unit of analysis from whole policies to core components can provide a basis for understanding how policies work and for facilitating novel evidence-generating strategies and rapid evidence reviews that can inform future adaptation efforts.

Disparities in Mortality by Sexual Orientation in a Large, Prospective Cohort of Female Nurses

Importance

Extensive evidence documents health disparities for lesbian, gay, and bisexual (LGB) women, including worse physical, mental, and behavioral health than heterosexual women. These factors have been linked to premature mortality, yet few studies have investigated premature mortality disparities among LGB women and whether they differ by lesbian or bisexual identity.

Objective

To examine differences in mortality by sexual orientation.

Design, Setting, and Participants

This prospective cohort study examined differences in time to mortality across sexual orientation, adjusting for birth cohort. Participants were female nurses born between 1945 and 1964, initially recruited in the US in 1989 for the Nurses' Health Study II, and followed up through April 2022.

Exposures

Sexual orientation (lesbian, bisexual, or heterosexual) assessed in 1995.

Main Outcome and Measure

Time to all-cause mortality from assessment of exposure analyzed using accelerated failure time models.

Results

Among 116 149 eligible participants, 90 833 (78%) had valid sexual orientation data. Of these 90 833 participants, 89 821 (98.9%) identified as heterosexual, 694 (0.8%) identified as lesbian, and 318 (0.4%) identified as bisexual. Of the 4227 deaths reported, the majority were among heterosexual participants (n = 4146; cumulative mortality of 4.6%), followed by lesbian participants (n = 49; cumulative mortality of 7.0%) and bisexual participants (n = 32; cumulative mortality of 10.1%). Compared with heterosexual participants, LGB participants had earlier mortality (adjusted acceleration factor, 0.74 [95% CI, 0.64-0.84]). These differences were greatest among bisexual participants (adjusted acceleration factor, 0.63 [95% CI, 0.51-0.78]) followed by lesbian participants (adjusted acceleration factor, 0.80 [95% CI, 0.68-0.95]).

Conclusions and Relevance

In an otherwise largely homogeneous sample of female nurses, participants identifying as lesbian or bisexual had markedly earlier mortality during the study period compared with heterosexual women. These differences in mortality timing highlight the urgency of addressing modifiable risks and upstream social forces that propagate and perpetuate disparities.

Learning interpretable causal networks from very large datasets, application to 400,000 medical records of breast cancer patients

Discovering causal effects is at the core of scientific investigation but remains challenging when only observational data are available. In practice, causal networks are difficult to learn and interpret, and limited to relatively small datasets. We report a more reliable and scalable causal discovery method (iMIIC), based on a general mutual information supremum principle, which greatly improves the precision of inferred causal relations while distinguishing genuine causes from putative and latent causal effects. We showcase iMIIC on synthetic and real-world healthcare data from 396,179 breast cancer patients from the US Surveillance, Epidemiology, and End Results program. More than 90% of predicted causal effects appear correct, while the remaining unexpected direct and indirect causal effects can be interpreted in terms of diagnostic procedures, therapeutic timing, patient preference or socio-economic disparity. iMIIC's unique capabilities open up new avenues to discover reliable and interpretable causal networks across a range of research fields.

Trends in California Cardiovascular Disease Mortality: Sex-Race/Ethnicity Disparity and Income Inequality

OBJECTIVE

To examine the cardiovascular disease (CVD)-related death trends and the relationship between CVD deaths and sex, race/ethnicity, and income in California from January 1, 1999, to December 31, 2021.

METHODS

The age-adjusted death rate (AADR) per 100,000 population attributable to ischemic heart disease (IHD), hypertensive heart disease (HHD) and heart failure (HF), stroke, and CVD combined were calculated using CDC WONDER (Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research) for California, 1999 to 2021. We used a joinpoint log-linear regression model to determine trends in CVD death. Income disparities were assessed using the slope index of inequality and health concentration index.

RESULTS

Between 1999 and 2021, overall death rates for CVD decreased significantly (average annual percent change, -2.2% [95% confidence interval: -2.6%, -1.7%]), IHD (-3.7% [-4.3%, -3.1%]), and stroke (-2.0% [-2.8%, -1.2%]) and increased for HHD (2.0% [0.6%, 3.5%]) and HF (2.0% [1.3%, 2.7%]). The AADR of combined CVD first decreased significantly (1999-2014; all P<.001), then increased significantly after COVID-19 (P=.02). The AADR of IHD decreased significantly (1999-2019; all P<.001) and then increased after the COVID-19 pandemic but was not statistically significant (P=.15). The AADR of HHD (2014-2021) and HF (2013-2021) increased significantly (all P<.001), and this increase accelerated after COVID-19. The AADR of stroke decreased (1999-2009), then increased after COVID-19 but was not statistically significant (P=.07). Our results revealed significant disparities with CVD death being disproportionately higher among male, non-Hispanic Black, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, Asian, and poorer populations.

CONCLUSION

All the death rates that were decreasing, stagnant, or increasing prior to the COVID-19 pandemic increased after the pandemic. We found increasingly adverse outcomes among the poor and racial/ethnic minority populations.

A "food insecurity poverty line" to replace the official threshold in Canadian rural and urban settings? A single-person household perspective

Household food insecurity is associated with both low income and high cost of living, it is a potentially better measure for consumption compared to income. We use data on food insecurity and income from 10 years of the Canadian Community Health Survey (2007-2017) of single-person households (n = 145,044) to estimate the probability of being food insecure at the Canadian poverty thresholds (Market Basket Measure thresholds, or MBMs), and determine the income required to reach that probability in each MBM region, aggregated by province and rural/urban status. A regression model shows the probability of being food insecure at the MBM is approximately 30% which we call the Food Insecurity Poverty Line (FIPL). The income required to meet the FIPL is substantially different from the MBM, sometimes 1.25 times the MBM. This implies that food insecurity is a potential sentinel measure for poverty.

Incomes to Outcomes: A Global Assessment of Disparities in Cleft and Craniofacial Treatment

OBJECTIVE

Recent investigations focused on health equity have enumerated widespread disparities in cleft and craniofacial care. This review introduces a structured framework to aggregate findings and direct future research.

DESIGN

Systematic review was performed to identify studies assessing health disparities based on race/ethnicity, payor type, income, geography, and education in cleft and craniofacial surgery in high-income countries (HICs) and low/middle-income countries (LMICs). Case reports and systematic reviews were excluded. Meta-analysis was conducted using fixed-effect models for disparities described in three or more studies.

SETTING

N/A.

PATIENTS

Patients with cleft lip/palate, craniosynostosis, craniofacial syndromes, and craniofacial trauma.

INTERVENTIONS

N/A.

RESULTS

One hundred forty-seven articles were included (80% cleft, 20% craniofacial; 48% HIC-based). Studies in HICs predominantly described disparities (77%,) and in LMICs focused on reducing disparities (42%). Level II-IV evidence replicated delays in cleft repair, alveolar bone grafting, and cranial vault remodeling for non-White and publicly insured patients in HICs (Grades A-B). Grade B-D evidence from LMICs suggested efficacy of community-based speech therapy and remote patient navigation programs. Meta-analysis demonstrated that Black patients underwent craniosynostosis surgery 2.8 months later than White patients (P < .001) and were less likely to undergo minimally-invasive surgery (OR 0.36, P = .002).

CONCLUSIONS

Delays in cleft and craniofacial surgical treatment are consistently identified with high-level evidence among non-White and publicly-insured families in HICs. Multiple tactics to facilitate patient access and adapt multi-disciplinary case in austere settings are reported from LMICs. Future efforts including those sharing tactics among HICs and LMICs hold promise to help mitigate barriers to care.

Where you live matters: Area deprivation predicts poor survival and liver transplant waitlisting

Social determinants of health (SDOH) are important predictors of poor clinical outcomes in chronic diseases, but their associations among the general cirrhosis population and liver transplantation (LT) are limited. We conducted a retrospective, multiinstitutional analysis of adult (≥18-years-old) patients with cirrhosis in metropolitan Chicago to determine the associations of poor neighborhood-level SDOH on decompensation complications, mortality, and LT waitlisting. Area deprivation index and covariates extracted from the American Census Survey were aspects of SDOH that were investigated. Among 15 101 patients with cirrhosis, the mean age was 57.2 years; 6414 (42.5%) were women, 6589 (43.6%) were non-Hispanic White, 3652 (24.2%) were non-Hispanic Black, and 2662 (17.6%) were Hispanic. Each quintile increase in area deprivation was associated with poor outcomes in decompensation (sHR [subdistribution hazard ratio] 1.07; 95% CI 1.05-1.10; P < .001), waitlisting (sHR 0.72; 95% CI 0.67-0.76; P < .001), and all-cause mortality (sHR 1.09; 95% CI 1.06-1.12; P < .001). Domains of SDOH associated with a lower likelihood of waitlisting and survival included low income, low education, poor household conditions, and social support (P < .001). Overall, patients with cirrhosis residing in poor neighborhood-level SDOH had higher decompensation, and mortality, and were less likely to be waitlisted for LT. Further exploration of structural barriers toward LT or optimizing health outcomes is warranted.

Impacts of social deprivation on mortality and protective effects of greenness exposure in Hong Kong, 1999-2018: A spatiotemporal perspective

Addressing health inequality is crucial for fostering healthy city development. However, there is a dearth of literature simultaneously investigating the effects of social deprivation and greenness exposure on mortality risks, as well as how greenness exposure may mitigate the adverse effect of social deprivation on mortality risks from a spatiotemporal perspective. Drawing on socioeconomic, remote sensing, and mortality record data, this study presents spatiotemporal patterns of social deprivation, population weighted greenness exposure, and all-cause and cause-specific mortality in Hong Kong. A Bayesian regression model was applied to investigate the impacts of social deprivation and greenness exposure on mortality and examine how socioeconomic inequalities in mortality may vary across areas with different greenness levels in Hong Kong from 1999 to 2018. We observed a decline in social deprivation (0.67-0.56), and an increase in greenness exposure (0.34-0.41) in Hong Kong during 1999-2018. Areas with high mortality gradually clustered in the Kowloon Peninsula and the northern regions of Hong Kong Island. Adverse impacts of social deprivation on all-cause mortality weakened in recent years (RR from 2009 to 2013: 1.103, 95%CI: 1.051-1.159, RR from 2014 to 2018: 1.041 95%CI: 0.950-1.139), while the protective impacts of greenness exposure consistently strengthened (RR from 1999 to 2003: 0.903, 95%CI: 0.827-0.984, RR from 2014 to 2018: 0.859, 95%CI: 0.763-0.965). Moreover, the adverse effects of social deprivation on mortality risks were found to be higher in areas with lower greenness exposure. These findings provide evidence of associations between social deprivation, greenness exposure, and mortality risks in Hong Kong over the past decades, and highlight the potential of greenness exposure to mitigate health inequalities. Our study provides valuable implications for policymakers to develop a healthy city.

Shortage of thoracic surgeons in the United States: Implications for treatment and survival for stage I lung cancer patients

OBJECTIVES

To evaluate whether there is a shortage of thoracic surgeons in the United States and whether any potential shortage is impacting lung cancer treatment and outcomes.

DESIGN

Using the US Area Health Resources File and Surveillance Epidemiology End Results database, we assessed the number of cardiothoracic surgeons per 100,000 people and the number of stage I non-small cell lung cancer (NSCLC) diagnoses in the US in 2010 versus 2018. Changes in the percentage of patients diagnosed with stage I NSCLC who underwent surgery and stereotactic body radiotherapy and changes in overall survival of patients with stage I NSCLC from 2010 to 2018 in the National Cancer Database were evaluated using multivariable logistic regression and Cox proportional hazards modeling.

RESULTS

From 2010 to 2018, the number of cardiothoracic surgeons per 100,000 people in the US decreased by 12% (P < .001), while the number of patients diagnosed with stage I NSCLC increased by 40% (P < .001). Over the same period, the percentage of patients who underwent surgery for stage I NSCLC decreased from 81.0% to 72.3% (adjusted odds ratio, 0.59; 95% confidence interval, 0.55-0.63); this decrease was similarly seen in a subgroup of young and otherwise healthy patients. Greater decreases in the percentage of patients who underwent surgery in nonmetropolitan and underserved regions corresponded with worse improvements in survival among patients in these regions from 2010 to 2018.

CONCLUSIONS

Recent declines in the US cardiothoracic surgery workforce may have led to significantly fewer patients undergoing surgery for stage I NSCLC and worsening disparities in survival between different patient populations.

The association between allostatic load and guaranteed annual income using the Canadian Longitudinal Study on Aging: A cross-sectional analysis of the benefits of guaranteed public pensions

BACKGROUND

Old Age Security (OAS) represents an public policy through which income-related inequalities in health may be improved. The goal of this cross-sectional study was to investigate the health benefits of receiving OAS in financially insecure older Canadians.

METHODS

Using data from the Canadian Longitudinal Study on Aging (CLSA) (n=15,691), ordered logistic regression was used to measure associations between financial insecurity and allostatic load.

RESULTS

Receiving OAS as highest personal income source appeared to remove the health penalty of being financially insecure. While financial insecurity was associated with worse allostatic load in both males and females not receiving OAS, those receiving OAS as highest personal income source had better allostatic load compared to other financially insecure older adults (ORM: 0.398, 95 % CI: 0.227, 0.696; ORF: 0.677, 95 % CI: 0.483, 0.949).

DISCUSSION

While longitudinal data would be needed to draw causal inferences, these results suggest OAS may play a role improving health outcomes and narrowing income-related health inequalities. Such findings may have important implications on older adults, other vulnerable populations, and future directions of Canadian health and public policy.

[Socioeconomic deprivation and premature mortality in Germany, 1998-2021 : An ecological study with what-if scenarios of inequality reduction]

BACKGROUND

Earlier mortality in socioeconomically disadvantaged population groups represents an extreme manifestation of health inequity. This study examines the extent, time trends, and mitigation potentials of area-level socioeconomic inequalities in premature mortality in Germany.

METHODS

Nationwide data from official cause-of-death statistics were linked at the district level with official population data and the German Index of Socioeconomic Deprivation (GISD). Age-standardized mortality rates before the age of 75 were calculated stratified by sex and deprivation quintile. A what-if analysis with counterfactual scenarios was applied to calculate how much lower premature mortality would be overall if socioeconomic mortality inequalities were reduced.

RESULTS

Men and women in the highest deprivation quintile had a 43% and 33% higher risk of premature death, respectively, than those in the lowest deprivation quintile of the same age. Higher mortality rates with increasing deprivation were found for cardiovascular and cancer mortality, but also for other causes of death. Socioeconomic mortality inequalities had started to increase before the COVID-19 pandemic and further exacerbated in the first years of the pandemic. If all regions had the same mortality rate as those in the lowest deprivation quintile, premature mortality would be 13% lower overall.

DISCUSSION

The widening gap in premature mortality between deprived and affluent regions emphasizes that creating equivalent living conditions across Germany is also an important field of action for reducing health inequity.

Perception of uncontrollable mortality risk is associated with food insecurity and reduced economic effort among resource-insecure college students during COVID-19

In the framework of the uncontrollable mortality risk hypothesis, resource scarcity intersects with mortality risk, shaping resource allocation strategies with enduring impacts on human health and wellbeing. Despite rising economic and food insecurity among US college students, little is known about how these insecurities relate to mortality risk, or how scarcity and mortality risk interact to shape college students' resource allocation strategies. We examine perceptions of resource scarcity and mortality risk and their associations with food insecurity and resource allocation strategies among economically insecure college students during COVID-19 lockdowns. Participants were recruited through an economic crisis response center at a major public university in the United States. A total of 118 participants completed an online Qualtrics survey assessing sociodemographic characteristics, perceptions of mortality risk and resource availability, food security, economic effort, and time perspective; a subset (n = 51) also participated in a telephone interview assessing psychological distress. In general, participants reported more environmental adversity and economic effort during COVID-19 lockdowns compared to before. Students experiencing higher levels of uncontrollable (and not controllable) mortality risk report lower levels of economic effort, and the association was strongest among students perceiving the fewest resources. We also found significant associations between uncontrollable mortality risk and food insecurity. Our results highlight uncontrollable mortality risk's influence on human well-being. Public health efforts should target the experiences and root structural causes of uncontrollable mortality risk, which among economically insecure college students increasingly involves food insecurity.

Screening for social determinants of health among populations at risk for MASLD: a scoping review

Background

Social determinants of health (SDoH) have been associated with disparate outcomes among those with metabolic dysfunction-associated steatotic liver disease (MASLD) and its risk factors. To address SDoH among this population, real-time SDoH screening in clinical settings is required, yet optimal screening methods are unclear. We performed a scoping review to describe the current literature on SDoH screening conducted in the clinical setting among individuals with MASLD and MASLD risk factors.

Methods

Through a systematic literature search of MEDLINE, Embase, and CINAHL Complete databases through 7/2023, we identified studies with clinic-based SDoH screening among individuals with or at risk for MASLD that reported pertinent clinical outcomes including change in MASLD risk factors like diabetes and hypertension.

Results

Ten studies (8 manuscripts, 2 abstracts) met inclusion criteria involving 148,151 patients: 89,408 with diabetes and 25,539 with hypertension. Screening was primarily completed in primary care clinics, and a variety of screening tools were used. The most commonly collected SDoH were financial stability, healthcare access, food insecurity and transportation. Associations between clinical outcomes and SDoH varied; overall, higher SDoH burden was associated with poorer outcomes including elevated blood pressure and hemoglobin A1c.

Conclusion

Despite numerous epidemiologic studies showing associations between clinical outcomes and SDoH, and guidelines recommending SDoH screening, few studies describe in-clinic SDoH screening among individuals with MASLD risk factors and none among patients with MASLD. Future research should prioritize real-time, comprehensive assessments of SDoH, particularly among patients at risk for and with MASLD, to mitigate disease progression and reduce MASLD health disparities.

Healthcare on the brink: navigating the challenges of an aging society in the United States

The US healthcare system is at a crossroads. With an aging population requiring more care and a strained system facing workforce shortages, capacity issues, and fragmentation, innovative solutions and policy reforms are needed. This paper aims to spark dialogue and collaboration among healthcare stakeholders and inspire action to meet the needs of the aging population. Through a comprehensive analysis of the impact of an aging society, this work highlights the urgency of addressing this issue and the importance of restructuring the healthcare system to be more efficient, equitable, and responsive.

The fortunes and misfortunes of social life across the life course: A new era of research from field, laboratory and comparative studies

Social gradients in health and aging have been reported in studies across many human populations, and - as the papers included in this special collection highlight - also occur across species. This paper serves as a general introduction to the special collection of Neuroscience and Biobehavioral Reviews entitled "Social dimensions of health and aging: population studies, preclinical research, and comparative research using animal models". Authors of the fourteen reviews are primarily members of a National Institute of Aging-supported High Priority Research Network on "Animal Models for the Social Dimensions of Health and Aging". The collection is introduced by a foreword, commentaries, and opinion pieces by leading experts in related fields. The fourteen reviews are divided into four sections: Section 1: Biodemography and life course studies; Section 2: Social behavior and healthy aging in nonhuman primates; Section 3: Social factors, stress, and hallmarks of aging; Section 4: Neuroscience and social behavior.

The Impact of Social Determinants of Health on Transition From Pediatric to Adult Cardiology Care

Social determinants of health (SDoH) are the economic, social, environmental, and psychosocial factors that influence health. Adolescents and young adults with congenital heart disease (CHD) require lifelong cardiology follow-up and therefore coordinated transition from pediatric to adult healthcare systems. However, gaps in care are common during transition, and they are driven in part by pervasive disparities in SDoH, including race, ethnicity, socioeconomic status, access to insurance, and remote location of residence. These disparities often coexist and compound the challenges faced by patients and families. For example, Black and Indigenous individuals are more likely to be subject to systemic racism and implicit bias within healthcare and other settings, to be unemployed and poor, to have limited access to insurance, and to have a lower likelihood of transfer of care to adult CHD specialists. SDoH also are associated with acquired cardiovascular disease, a comorbidity that adults with CHD face. This review summarizes existing evidence regarding the impact of SDoH on the transition to adult care and proposes strategies at the individual, institutional, and population and/or system levels. to reduce inequities faced by transition-age youth. These strategies include routinely screening for SDoH in clinical settings with referral to appropriate services, providing formal transition education for all transition-age youth, including training on navigating complex medical systems, creating satellite cardiology clinics to facilitate access to care for those who live remote from tertiary centres, advocating for lifelong insurance coverage where applicable, mandating cultural-sensitivity training for providers, and increasing the diversity of healthcare providers in pediatric and adult CHD care.

Motivation, inclusivity, and realism should drive data science education

Data science education provides tremendous opportunities but remains inaccessible to many communities. Increasing the accessibility of data science to these communities not only benefits the individuals entering data science, but also increases the field's innovation and potential impact as a whole. Education is the most scalable solution to meet these needs, but many data science educators lack formal training in education. Our group has led education efforts for a variety of audiences: from professional scientists to high school students to lay audiences. These experiences have helped form our teaching philosophy which we have summarized into three main ideals: 1) motivation, 2) inclusivity, and 3) realism. 20 we also aim to iteratively update our teaching approaches and curriculum as we find ways to better reach these ideals. In this manuscript we discuss these ideals as well practical ideas for how to implement these philosophies in the classroom.

Causal Mediation of Neighborhood-Level Pediatric Hospitalization Inequities

BACKGROUND AND OBJECTIVES

Population-wide racial inequities in child health outcomes are well documented. Less is known about causal pathways linking inequities and social, economic, and environmental exposures. Here, we sought to estimate the total inequities in population-level hospitalization rates and determine how much is mediated by place-based exposures and community characteristics.

METHODS

We employed a population-wide, neighborhood-level study that included youth <18 years hospitalized between July 1, 2016 and June 30, 2022. We defined a causal directed acyclic graph a priori to estimate the mediating pathways by which marginalized population composition causes census tract-level hospitalization rates. We used negative binomial regression models to estimate hospitalization rate inequities and how much of these inequities were mediated indirectly through place-based social, economic, and environmental exposures.

RESULTS

We analyzed 50 719 hospitalizations experienced by 28 390 patients. We calculated census tract-level hospitalization rates per 1000 children, which ranged from 10.9 to 143.0 (median 45.1; interquartile range 34.5 to 60.1) across included tracts. For every 10% increase in the marginalized population, the tract-level hospitalization rate increased by 6.2% (95% confidence interval: 4.5 to 8.0). After adjustment for tract-level community material deprivation, crime risk, English usage, housing tenure, family composition, hospital access, greenspace, traffic-related air pollution, and housing conditions, no inequity remained (0.2%, 95% confidence interval: -2.2 to 2.7). Results differed when considering subsets of asthma, type 1 diabetes, sickle cell anemia, and psychiatric disorders.

CONCLUSIONS

Our findings provide additional evidence supporting structural racism as a significant root cause of inequities in child health outcomes, including outcomes at the population level.

Association of plant-based diets with total and cause-specific mortality across socioeconomic deprivation level: a large prospective cohort

PURPOSE

Current evidence on the association between plant-based diet indices (PDIs) and mortality is inconsistent. We aimed to investigate the association of PDIs with all-cause and cause-specific mortality and to examine whether such associations were modified by socioeconomic deprivation level.

METHODS

A total of 189,003 UK Biobank participants with at least one 24-h dietary assessment were included. All food items were categorised into three groups, including healthy plant foods, less healthy plant foods, and animal foods. Three PDIs, including the overall PDI (positive scores for all plant-based food intake and inverse scores for animal-based foods), the healthful PDI (hPDI) (positive scores only for healthy plant food intake and inverse scores for others), and the unhealthful PDI (uPDI) (positive scores only for less healthy plant food intake and inverse scores for others), were calculated according to the quantities of each food subgroup in three categories. The Townsend deprivation index was used as the indicator of socioeconomic deprivation level. Cox proportional hazard models were used to estimate the hazard ratios (HRs) of PDIs for all-cause and cause-specific mortality. The modification effects of socioeconomic deprivation levels on these associations were evaluated.

RESULTS

During a median follow-up of 9.6 years, 9335 deaths were documented. Compared with the lowest quintile, the highest quintile of overall PDI was associated with adjusted HRs of 0.87 (95% CI 0.81-0.93) for all-cause mortality and 0.77 (0.66-0.91) for cardiovascular mortality. Compared with the lowest quintile, the highest quintile of hPDI was associated with lower risks of all-cause mortality (0.92, 0.86-0.98), and death caused by respiratory disease (0.63, 0.47-0.86), neurological disease (0.65, 0.48-0.88), and cancer (0.90, 0.82-0.99). Compared with the lowest quintile, the highest quintile of uPDI was associated with an HR of 1.29 (1.20-1.38) for all-cause mortality, 1.95 (1.40-2.73) for neurological mortality, 1.54 (1.13-2.09) for respiratory mortality, and 1.16 (1.06-1.27) for cancer mortality. The magnitudes of associations of hPDI and uPDI with mortality were larger in the most socioeconomically deprived participants (the highest tertile) than in the less deprived ones (p-values for interaction were 0.039 and 0.001, respectively).

CONCLUSIONS

This study showed that having a high overall PDI and hPDI were related to a reduced risk of death, while the uPDI was linked to a higher risk of death. Sticking to a healthy plant-based diet may help decrease mortality risks across socioeconomic deprivation levels, especially for those who are the most socioeconomically deprived.

Long-term variations of urban-Rural disparities in infectious disease burden of over 8.44 million children, adolescents, and youth in China from 2013 to 2021: An observational study

BACKGROUND

An accelerated epidemiological transition, spurred by economic development and urbanization, has led to a rapid transformation of the disease spectrum. However, this transition has resulted in a divergent change in the burden of infectious diseases between urban and rural areas. The objective of our study was to evaluate the long-term urban-rural disparities in infectious diseases among children, adolescents, and youths in China, while also examining the specific diseases driving these disparities.

METHODS AND FINDINGS

This observational study examined data on 43 notifiable infectious diseases from 8,442,956 cases from individuals aged 4 to 24 years, with 4,487,043 cases in urban areas and 3,955,913 in rural areas. The data from 2013 to 2021 were obtained from China's Notifiable Infectious Disease Surveillance System. The 43 infectious diseases were categorized into 7 categories: vaccine-preventable, bacterial, gastrointestinal and enterovirus, sexually transmitted and bloodborne, vectorborne, zoonotic, and quarantinable diseases. The calculation of infectious disease incidence was stratified by urban and rural areas. We used the index of incidence rate ratio (IRR), calculated by dividing the urban incidence rate by the rural incidence rate for each disease category, to assess the urban-rural disparity. During the nine-year study period, most notifiable infectious diseases in both urban and rural areas exhibited either a decreased or stable pattern. However, a significant and progressively widening urban-rural disparity in notifiable infectious diseases was observed. Children, adolescents, and youths in urban areas experienced a higher average yearly incidence compared to their rural counterparts, with rates of 439 per 100,000 compared to 211 per 100,000, respectively (IRR: 2.078, 95% CI [2.075, 2.081]; p < 0.001). From 2013 to 2021, this disparity was primarily driven by higher incidences of pertussis (IRR: 1.782, 95% CI [1.705, 1.862]; p < 0.001) and seasonal influenza (IRR: 3.213, 95% CI [3.205, 3.220]; p < 0.001) among vaccine-preventable diseases, tuberculosis (IRR: 1.011, 95% CI [1.006, 1.015]; p < 0.001), and scarlet fever (IRR: 2.942, 95% CI [2.918, 2.966]; p < 0.001) among bacterial diseases, infectious diarrhea (IRR: 1.932, 95% CI [1.924, 1.939]; p < 0.001), and hand, foot, and mouth disease (IRR: 2.501, 95% CI [2.491, 2.510]; p < 0.001) among gastrointestinal and enterovirus diseases, dengue (IRR: 11.952, 95% CI [11.313, 12.628]; p < 0.001) among vectorborne diseases, and 4 sexually transmitted and bloodborne diseases (syphilis: IRR 1.743, 95% CI [1.731, 1.755], p < 0.001; gonorrhea: IRR 2.658, 95% CI [2.635, 2.682], p < 0.001; HIV/AIDS: IRR 2.269, 95% CI [2.239, 2.299], p < 0.001; hepatitis C: IRR 1.540, 95% CI [1.506, 1.575], p < 0.001), but was partially offset by lower incidences of most zoonotic and quarantinable diseases in urban areas (for example, brucellosis among zoonotic: IRR 0.516, 95% CI [0.498, 0.534], p < 0.001; hemorrhagic fever among quarantinable: IRR 0.930, 95% CI [0.881, 0.981], p = 0.008). Additionally, the overall urban-rural disparity was particularly pronounced in the middle (IRR: 1.704, 95% CI [1.699, 1.708]; p < 0.001) and northeastern regions (IRR: 1.713, 95% CI [1.700, 1.726]; p < 0.001) of China. A primary limitation of our study is that the incidence was calculated based on annual average population data without accounting for population mobility.

CONCLUSIONS

A significant urban-rural disparity in notifiable infectious diseases among children, adolescents, and youths was evident from our study. The burden in urban areas exceeded that in rural areas by more than 2-fold, and this gap appears to be widening, particularly influenced by tuberculosis, scarlet fever, infectious diarrhea, and typhus. These findings underscore the urgent need for interventions to mitigate infectious diseases and address the growing urban-rural disparity.

Assessing the impact of socio-demographics and farming activity on ward-level mortality patterns using farm and population decennial censuses

INTRODUCTION AND OBJECTIVE

Farmers experience a specific set of unique dangers, which increases their risk of mortality compared with any other occupation. This study hypothesised that Northern Ireland's (NIs) agriculturally saturated Wards have a higher risk of mortality compared against non-agriculturally based Wards.

DESIGN

The Population Census and Farm Census information were downloaded from the Northern Ireland Neighbourhood Service (NINIS) online depository to compile three mortality-based data sets (2001, 2011, pooled data sets). Assessing the impact of socio-demographics and farming activity on Ward-level mortality patterns using farm and population decennial censuses. This study analysed all 582 Ward areas of NI, which enclosed the entire populace of the country in 2001 and 2011.

FINDINGS

Path analysis was utilised to examine direct and indirect paths linked with mortality within two census years (2001; 2011), alongside testing pathways for invariance between census years (pooled data set). Ward-level results provided evidence for exogenous variables to mortality operating through three/four endogenous variables via: (i) direct effects (age), (ii) summed indirect effects (age; males; living alone; farming profit; and deprivation) and (iii) total effects (age; males; living alone; and deprivation). Multi-group results cross-validated these cause-and-effect relationships relating to mortality.

DISCUSSION AND CONCLUSION

This study demonstrated that farming intensity scores, farming profits and socio-demographics' influence on mortality risk in a Ward were dependent on the specific social-environmental characteristics within that area. In line with earlier area level research, results support the aggregated interpretation that higher levels of farming activity within a Ward increase the risk of mortality within those Wards of NI. This was an essential study to enable future tailoring of new strategies and upgrading of current policies to bring about significant mortality risk change at local level.

Do social determinants influence post-stroke aphasia outcomes? A scoping review

PURPOSE

To conduct a scoping review on five individual social determinants of health (SDOHs): gender, education, ethnicity, socioeconomic status, and social support, in relation to post-stroke aphasia outcomes.

MATERIALS AND METHODS

A comprehensive search across five databases was conducted in 2020 and updated in 2022. Twenty-five studies (3363 participants) met the inclusion criteria. Data on SDOHs and aphasia outcomes were extracted and analysed descriptively.

RESULTS

Twenty studies provide information on SDOH and aphasia recovery outcomes. Five studies provide insights on SDOH and response to aphasia intervention. Research on SDOH and aphasia recovery has predominantly focussed solely on language outcomes (14 studies), with less research on the role of SDOH on activity, participation, and quality of life outcomes (6 studies). There is no evidence to support a role for gender or education on language outcomes in the first 3 months post stroke. SDOHs may influence aphasia outcomes at or beyond 12 months post onset.

CONCLUSIONS

Research on SDOHs and aphasia outcomes is in its infancy. Given SDOHs are modifiable and operate over a lifetime, and aphasia is a chronic condition, there is a pressing need to understand the role of SDOHs on aphasia outcomes in the long term.

Work status among middle-aged and older individuals in China: the effects on physical and mental health

Objective

China's middle-aged and older population is a rich source of human capital. Therefore, considering the health of this group is important when creating and using human resources.

Methods

Using data from the nationwide China Health and Retirement Longitudinal Study (CHARLS) 2018 baseline survey of 19,000 adults ages 45 years and older, this study was an objective investigation of the effects of work on the physical and mental health of middle-aged and older adults. We conducted several types of analyses using details of participants' lifestyles and demographic characteristics (living environment, education, financial level, and access to medical services) with work (i.e., employment or volunteer work) as a primary input component of health production to examine their effects on the health status of middle-aged and older individuals.

Results

Six primary outcomes were identified: (1) Employment positively affects both the physical and mental health of middle-aged and older people; (2) Employment can influence the physical and mental health of middle-aged and older people through income, cognitive level, and social support networks; (3) Compared to non-self-employment, self-employment dramatically worsens physical health but has no apparent detrimental effects on mental health. Compared to non-agricultural employment, agricultural labor affects both physical and mental health. (4) Employment has more positive physical and mental health effects in Individuals with higher rather than lower levels of education. (5) Employment opportunities in the eastern region are more likely to promote better physical health than those in the central and western regions of China, although the effects on mental health are negative. (6) When considering groups at different ages of the lifespan, the 60-65-year-old group, who are just entering retirement probably benefit more from continuing work.

Conclusion

We provide some recommendations to encourage middle-aged and older people to work and utilize their experience, which will enhance their physical and mental well-being and help them in realize their own value and social integration.

Epigenetic signatures of social status in wild female spotted hyenas (Crocuta crocuta)

In mammalian societies, dominance hierarchies translate into inequalities in health, reproductive performance and survival. DNA methylation is thought to mediate the effects of social status on gene expression and phenotypic outcomes, yet a study of social status-specific DNA methylation profiles in different age classes in a wild social mammal is missing. We tested for social status signatures in DNA methylation profiles in wild female spotted hyenas (Crocuta crocuta), cubs and adults, using non-invasively collected gut epithelium samples. In spotted hyena clans, female social status influences access to resources, foraging behavior, health, reproductive performance and survival. We identified 149 differentially methylated regions between 42 high- and low-ranking female spotted hyenas (cubs and adults). Differentially methylated genes were associated with energy conversion, immune function, glutamate receptor signalling and ion transport. Our results provide evidence that socio-environmental inequalities are reflected at the molecular level in cubs and adults in a wild social mammal.

Association of socioeconomic status and overactive bladder in US adults: a cross-sectional analysis of nationally representative data

Background

Socioeconomic status inequality is an important variable in the emergence of urological diseases in humans. This study set out to investigate the association between the prevalence of overactive bladder (OAB) and the poverty income ratio (PIR) that served as a more influential indicator of socioeconomic status compared to education and occupation.

Method

Data from the National Health and Nutrition Examination Survey (NHANES) conducted from 2007 to 2020 were used in this cross-sectional study. The association between the PIR and OAB was examined using weighted multivariate logistic regression and weighted restricted cubic splines (RCS). Additionally, interaction analysis was used for investigation to the connections between PIR and OAB in various covariate groups in order to confirm the stability of the results.

Results

We observed a noteworthy inverse association between PIR and OAB after adjusting for potential confounding variables (OR = 0.87, 95% CI, 0.84-0.90, p < 0.0001). PIR was transformed into categorical variables, and the association held steady after that (1.0 < PIR <4.0 vs. PIR ≤ 1.0, OR = 0.70, 95% CI =0.63-0.77, p < 0.0001; PIR ≥ 4.0 vs. PIR ≤ 1.0, OR = 0.56, 95% CI =0.48-0.65, p < 0.0001). Additionally, RCS analysis showed that PIR and OAB had a negative nonlinear response relationship. Subgroup analyses showed that the inverse association between PIR and prevalence of OAB was stronger in obese than in nonobese individuals (P for interaction < 0.05).

Conclusion

In our study, we observed a significant negative association between the PIR and the prevalence of OAB. In the future, PIR could be used as a reference standard to develop strategies to prevent and treat OAB.

Reduction in all-cause medical and caregiving costs through innovative health awareness projects in a rural area in Japan: a retrospective cohort study

BACKGROUND

This study evaluates cost reduction in participants of a health awareness program (the Center of Healthy Aging Program, CHAP) in a Japanese rural area, characterized by an annual check-up and personalized interview on health issues and related risks immediately after the check-up.

METHODS

This is a cross-sectional study using medical and caregiving costs and Japan-specific health check-up results in Hirosaki residents stored by the local government, which were individually-based linked to the CHAP information collected by Hirosaki University. This is the first study that used anonymized data with individually-based linkages to both a research institute and a local government in Japan under a strict limitation regarding linking to third-party data. We included residents who had been continuously enrolled for > 6 months as of 1 July 2015. We compared 5-year all-cause costs between three groups (with CHAP, with Japan-specific health check-up, and no check-up) using a multivariate negative binomial regression model considering risk factors including lifestyle habits and an inverse probability weight to adjust for baseline characteristics: age, sex, Charlson comorbidity index, baseline care level, and risk score of coronary heart diseases.

RESULTS

A total of 384, 9805, and 32,630 residents aged 40-74 years were included for the CHAP, Japan-specific health check-up, and no check-up groups, respectively. The Japan-specific health check-up group showed older and higher Charlson comorbidity index than the others. After inverse probability weight adjusting, the amount of all-cause medical costs was significantly lower only in the CHAP group. Faster walking speed and exercise habits were independently associated with lower all-cause medical and caregiving costs.

CONCLUSIONS

We demonstrated a 5-year all-cause cost reduction in residents who participated in the CHAP and also suggested the effect of exercise habits in Hirosaki, which indicated the significance of individually-based data linkages to external third-party data for all local governments to improve the health condition of residents.

Low Household Income Increases Hospital Length of Stay and Decreases Home Discharge Rates in Lumbar Fusion

STUDY DESIGN

Retrospective Matched Cohort Study.

OBJECTIVES

Low median household income (MHI) has been correlated with worsened surgical outcomes, but few studies have rigorously controlled for demographic and medical factors at the patient level. This study isolates the relationship between MHI and surgical outcomes in a lumbar fusion cohort using coarsened exact matching.

METHODS

Patients undergoing single-level, posterior lumbar fusion at a single institution were consecutively enrolled and retrospectively analyzed (n = 4263). Zip code was cross-referenced to census data to derive MHI. Univariate regression correlated MHI to outcomes. Patients with low MHI were matched to those with high MHI based on demographic and medical factors. Outcomes evaluated included complications, length of stay, discharge disposition, 30- and 90 day readmissions, emergency department (ED) visits, reoperations, and mortality.

RESULTS

By univariate analysis, MHI was significantly associated with 30- and 90 day readmission, ED visits, reoperation, and non-home discharge, but not mortality. After exact matching (n = 270), low-income patients had higher odds of non-home discharge (OR = 2.5, P = .016) and higher length of stay (mean 100.2 vs 92.6, P = .02). There were no differences in surgical complications, ED visits, readmissions, or reoperations between matched groups.

CONCLUSIONS

Low MHI was significantly associated with adverse short-term outcomes from lumbar fusion. A matched analysis controlling for confounding variables uncovered longer lengths of stay and higher rates of discharge to post-acute care (vs home) in lower MHI patients. Socioeconomic disparities affect health beyond access to care, worsen surgical outcomes, and impose costs on healthcare systems. Targeted interventions must be implemented to mitigate these disparities.

Does unequal economic development contribute to the inequitable distribution of healthcare resources? Evidence from China spanning 2001-2020

BACKGROUND

There is a dearth of research combining geographical big data on medical resource allocation and growth with various statistical data. Given the recent achievements of China in economic development and healthcare, this study takes China as an example to investigate the dynamic geographical distribution patterns of medical resources, utilizing data on healthcare resources from 290 cities in China, as well as economic and population-related data. The study aims to examine the correlation between economic growth and spatial distribution of medical resources, with the ultimate goal of providing evidence for promoting global health equity.

METHODS

The data used in this study was sourced from the China City Statistical Yearbook from 2001 to 2020. Two indicators were employed to measure medical resources: the number of doctors per million population and the number of hospital and clinic beds per million population. We employed dynamic convergence model and fixed-effects model to examine the correlation between economic growth and the spatial distribution of medical resources. Ordinary least squares (OLS) were used to estimate the β values of the samples.

RESULTS

The average GDP for all city samples across all years was 36,019.31 ± 32,029.36, with an average of 2016.31 ± 1104.16 doctors per million people, and an average of 5986.2 ± 6801.67 hospital beds per million people. In the eastern cities, the average GDP for all city samples was 47,672.71 ± 37,850.77, with an average of 2264.58 ± 1288.89 doctors per million people, and an average of 3998.92 ± 1896.49 hospital beds per million people. Cities with initially low medical resources experienced faster growth (all β < 0, P < 0.001). The long-term convergence rate of the geographic distribution of medical resources in China was higher than the short-term convergence rate (|βi + 1| > |βi|, i = 1, 2, 3, …, 9, all β < 0, P < 0.001), and the convergence speed of doctor density exceeded that of bed density (bed: |βi| >doc: |βi|, i = 3, 4, 5, …, 10, P < 0.001). Economic growth significantly affected the convergence speed of medical resources, and this effect was nonlinear (doc: βi < 0, i = 1, 2, 3, …, 9, P < 0.05; bed: βi < 0, i = 1, 2, 3, …, 10, P < 0.01). The heterogeneity between provinces had a notable impact on the convergence of medical resources.

CONCLUSIONS

The experiences of China have provided significant insights for nations worldwide. Governments and institutions in all countries worldwide, should actively undertake measures to actively reduce health inequalities. This includes enhancing healthcare standards in impoverished regions, addressing issues of unequal distribution, and emphasizing the examination of social determinants of health within the domain of public health research.

What drives low-income older adults' intention to use mobility applications?

AIM

Mobility applications have the potential to support low-income older adults in facing mobility challenges. However, there is a generally lower uptake of technology in this segment. To understand factors affecting the intention to use a mobility app, we drew upon the Protection Motivation Theory, and tested a model of low-income older adults' technology adoption.

METHODS

A cross-sectional survey was conducted across seven states in Malaysia among community-dwelling low-income older adults aged ≥60 years old (n = 282). Measurement items were adapted from pre-validated scales and 7-point Likert Scales were used. Partial least squares structural equation modeling was utilized to assess the hypothesized model.

RESULTS

Mobility technology awareness was found to shape an individual's threat and coping appraisals associated with their intention to use a mobility app. The decision of a low-income older adult to adopt a mobility app as a protective action is not a direct function of threat and coping appraisals but is indirect, and mediated by the underlying cost-benefit perceptions of non-adoption and adoption of the mobility app. In terms of technology perceptions, perceived usefulness is a significant predictor, but not perceived ease of use.

CONCLUSIONS

This study entails a new model by uncovering the psychological factors encompassing mobility technology awareness, threat-coping appraisals, and cost-benefit perceptions on Technology Acceptance Model studies. These insights have important implications for the development and implementation of a mobility app among low-income older adults. Geriatr Gerontol Int 2024; 24: 342-350.

How Socio-economic Inequalities Cluster People with Diabetes in Malaysia: Geographic Evaluation of Area Disparities Using a Non-parameterized Unsupervised Learning Method

Accurate assessments of epidemiological associations between health outcomes and routinely observed proximal and distal determinants of health are fundamental for the execution of effective public health interventions and policies. Methods to couple big public health data with modern statistical techniques offer greater granularity for describing and understanding data quality, disease distributions, and potential predictive connections between population-level indicators with areal-based health outcomes. This study applied clustering techniques to explore patterns of diabetes burden correlated with local socio-economic inequalities in Malaysia, with a goal of better understanding the factors influencing the collation of these clusters. Through multi-modal secondary data sources, district-wise diabetes crude rates from 271,553 individuals with diabetes sampled from 914 primary care clinics throughout Malaysia were computed. Unsupervised machine learning methods using hierarchical clustering to a set of 144 administrative districts was applied. Differences in characteristics of the areas were evaluated using multivariate non-parametric test statistics. Five statistically significant clusters were identified, each reflecting different levels of diabetes burden at the local level, each with contrasting patterns observed under the influence of population-level characteristics. The hierarchical clustering analysis that grouped local diabetes areas with varying socio-economic, demographic, and geographic characteristics offer opportunities to local public health to implement targeted interventions in an attempt to control the local diabetes burden.

Wealth Redistribution to Extend Longevity in the US

Importance

The US is unique among wealthy countries in its degree of wealth inequality and its poor health outcomes. Wealth is known to be positively associated with longevity, but little is known about whether wealth redistribution might extend longevity.

Objective

To examine the association between wealth and longevity and estimate the changes in longevity that could occur with simulated wealth distributions that were perfectly equal, similar to that observed in Japan (among the most equitable of Organisation for Economic Co-operation and Development [OECD] countries), generated by minimum inheritance proposals, and produced by baby bonds proposals.

Design, Setting, and Participants

This longitudinal cohort study analyzed the association between wealth and survival among participants in the Health and Retirement Study (1992-2018), a nationally representative panel study of middle-aged and older (≥50 years) community-dwelling, noninstitutionalized US adults. The data analysis was performed between November 15, 2022, and September 24, 2023.

Exposure

Household wealth on study entry, calculated as the sum of all assets minus the value of debts and classified into deciles.

Main Outcomes and Measures

Weibull survival models were used to estimate the association between per-person wealth decile and survival, adjusting for age, sex, marital status, household size, and race and ethnicity. Changes in longevity that might occur under alternative wealth distributions were then estimated.

Results

The sample included 35 164 participants (mean [SE] age at study entry, 59.1 [0.1] years; 50.1% female and 49.9% male [weighted]). The hazard of death generally decreased with increasing wealth, wherein participants in the highest wealth decile had a hazard ratio of 0.59 for death (95% CI, 0.53-0.66) compared with those in the lowest decile, corresponding to a 13.5-year difference in survival. A simulated wealth distribution of perfect equality would increase populationwide median longevity by 2.2 years (95% CI, 2.2-2.3 years), fully closing the mortality gap between the US and the OECD average. A simulated minimum inheritance proposal would increase populationwide median longevity by 1.7 years; a simulated wealth distribution similar to Japan's would increase populationwide median longevity by 1.2 years; and a simulated baby bonds proposal would increase populationwide median longevity by 1.0 year.

Conclusions and Relevance

These findings suggest that wealth inequality in the US is associated with significant inequities in survival. Wealth redistribution policies may substantially reduce those inequities and increase population longevity.

When money and mental health problems pile up: The reciprocal relationship between income and psychological distress

Background

Longitudinal studies suggest that socioeconomic status (SES) and mental health have a bidirectional relationship such that SES declines lead to a deterioration of mental health (social causation), while worsening mental health leads to SES declines (social drift). However, the dynamic relationship between income and psychological distress has not been sufficiently studied.

Methods

We use cross-lagged panel models with unit fixed effects (FE-CLPM) and data from a five-wave representative panel (n = 3103) of working-age (18-64) New York City adults. Yearly measures include individual earnings, family income (income-to-needs), and psychological distress. We also examine effects by age, gender, education, and racial/ethnic identification.

Results

We find significant bidirectional effects between earnings and distress. Increases in past-year individual earnings decrease past-month psychological distress (social causation effect [SCE], standardized β= -0.07) and increases in psychological distress reduce next-year individual earnings (social drift effect [SDE], β= -0.03). Family income and distress only have a unidirectional relationship from past-year family income to distress (SCE, β= -.03). Strongest evidence of bidirectional effects between earnings and distress is for prime working-age individuals (SCE, β= -0.1; SDE, β= -0.03), those with less than bachelor's degrees (SCE, β= -0.08; SDE, β= -0.05), and Hispanics (SCE, β= -0.06; SDE, β= -0.08). We also find evidence of reciprocal effects between family income and distress for women (SCE, β= -0.03; SDE, β= -0.05), and Hispanics (SDE, β= -0.04; SDE, β= -0.08).

Conclusions

Individual earnings, which are labor market indicators, may be stronger social determinants of mental health than family income. However, important differences in social causation and social drift effects exist across groups by age, education, gender, and racial/ethnic identities. Future research should examine the types of policies that may buffer the mental health impact of negative income shocks and the declines in income associated with worsening mental health, especially among the most vulnerable.

Social Determinants of Health and Disparities in Hypertension and Cardiovascular Diseases

High blood pressure causes over 10 million preventable deaths annually globally. Populations in low- and middle-income countries suffer the most, experiencing increased uncontrolled blood pressure and cardiovascular disease (CVD) deaths. Despite improvements in high-income countries, disparities persist, notably in the United States, where Black individuals face up to 4× higher CVD mortality than White individuals. Social determinants of health encompass complex, multidimensional factors linked to an individual's birthplace, upbringing, activities, residence, workplaces, socioeconomic and environmental structures, and significantly affect health outcomes, including hypertension and CVD. This review explored how social determinants of health drive disparities in hypertension and related CVD morbidity from a socioecological and life course perspective. We present evidence-based strategies, emphasizing interventions tailored to specific community needs and cross-sector collaboration to address health inequalities rooted in social factors, which are key elements toward achieving the United Nations' Sustainable Development Goal 3.4 for reducing premature CVD mortality by 30% by 2030.

Impacts of Poverty and Lifestyles on Mortality: A Cohort Study in Predominantly Low-Income Americans

INTRODUCTION

Low socioeconomic status has been linked to increased mortality. However, the impacts of poverty, alone or combined with health behaviors, on mortality and life expectancy have not been adequately investigated.

METHODS

Data from the Southern Community Cohort Study was used, including nearly 86,000 participants recruited during 2002-2009 across 12 US southeastern states. Analysis was conducted from February 2022 to January 2023.

RESULTS

During a median follow-up of 12.1 years, 19,749 deaths were identified. A strong dose-response relationship was found between household incomes and mortality, with a 3.3-fold (95%CI=3.1-3.6) increased all-cause mortality observed for individuals in the lowest income group (<$15,000/year) compared with those in the highest group (≥$50,000/year). Within each income group, mortality monotonically increased with declining healthy lifestyle score. Risk was significantly lower among those in the lowest income but healthiest lifestyle group, compared to those with the highest income but unhealthiest lifestyle (HR=0.82, 95%CI=0.69-0.97). Poor White participants appeared to experience higher all-cause mortality than poor Black participants. Life expectancy was more than 10.0 years shorter for those in the lowest income group compared with those in the highest income group.

CONCLUSIONS

Poverty is strongly associated with increased risk of death, but the risks could be modestly abated by a healthier lifestyle. These findings call for a comprehensive strategy for enhancing a healthy lifestyle and improving income equality to reduce death risks, particularly among those experiencing health disparities due to poverty.

Access to Care for Adolescents and Young Adults With Cancer in the United States: State of the Literature

Access to care remains a persistent challenge for adolescents and young adults (AYAs) with cancer. We review key findings in the science to date. (1) Location of care matters. There is survival benefit for AYAs treated either at a pediatric center or site with special status (eg, Children's Oncology Group, National Cancer Institute [NCI]-designated Comprehensive Cancer Center). (2) Socioeconomic status and insurance require further investigation. Medicaid expansion has had a moderate effect on AYA outcomes. The dependent care expansion benefit has come largely from improvements in coverage for younger populations whose parents have insurance, while some subgroups likely still face insurance gaps. (3) Clinical trial enrollment remains poor, but access may be improving. Numerous barriers and facilitators of clinical trial enrollment include those that are system level and patient level. NCI has established several initiatives over the past decade to improve enrollment, and newer collaboratives have recently brought together multidisciplinary US teams to increase clinical trial enrollment. (4) Effective AYA programs require provider and system flexibility and program reflection. With flexibility comes a need for metrics to assess program effectiveness in the context of the program model. Centers treating AYAs with cancer could submit a subset of metrics (appropriate to their program and/or services) to maintain their status; persistence would require an entity with staying power committed to overseeing the metrics and the system. Substantial clinical and biological advances are anticipated over the next 20 years that will benefit all patients with cancer. In parallel, it is crucial to prioritize research regarding access to health care and cancer care delivery; only with equitable access to care for AYAs can they, too, benefit from these advances.

Stacked Up Against Us: Using Photovoice and Participatory Methods to Explore Structural Racism's Impact on Adolescent Sexual and Reproductive Health Inequities

While structural racism has profound impacts on adolescent health, little is known about how youth synthesize racialized experiences and work to dismantle systems of oppression. This article provides an overview of a Youth Participatory Action Research study that used Photovoice and community mapping to explore how structural violence, like racism, impacts the sexual and reproductive health of historically excluded youth as they navigate unjust socio-political landscapes. Youth participants used photography and community maps to identify how the experience of bias, profiling, and tokenism impacted their ability to navigate complex social systems. With youth voices prioritized, participants explored ways to address structural racism in their lives. The importance of co-creating opportunities with and for youth in critical reflection of their lived experience is emphasized. Through an Arts and Cultural in Public Health framework, we provide an analysis of the ways structural racism functions as a gendered racial project and fundamental cause of adolescent sexual and reproductive health inequities, while identifying pathways toward liberation in pursuit of health and well-being.

Trends in socioeconomic inequalities in cause-specific premature mortality in Belgium, 1998-2019

BACKGROUND

Higher levels of socioeconomic deprivation have been consistently associated with increased risk of premature mortality, but a detailed analysis by causes of death is lacking in Belgium. We aim to investigate the association between area deprivation and all-cause and cause-specific premature mortality in Belgium over the period 1998-2019.

METHODS

We used the 2001 and 2011 Belgian Indices of Multiple Deprivation to assign statistical sectors, the smallest geographical units in the country, into deprivation deciles. All-cause and cause-specific premature mortality rates, population attributable fraction, and potential years of life lost due to inequality were estimated by period, sex, and deprivation deciles.

RESULTS

Men and women living in the most deprived areas were 1.96 and 1.78 times more likely to die prematurely compared to those living in the least deprived areas over the period under study (1998-2019). About 28% of all premature deaths could be attributed to socioeconomic inequality and about 30% of potential years of life lost would be averted if the whole population of Belgium faced the premature mortality rates of the least deprived areas.

CONCLUSION

Premature mortality rates have declined over time, but inequality has increased due to a faster pace of decrease in the least deprived areas compared to the most deprived areas. As the causes of death related to poor lifestyle choices contribute the most to the inequality gap, more effective, country-level interventions should be put in place to target segments of the population living in the most deprived areas as they are facing disproportionately high risks of dying.

Social frailty as a predictor of all-cause mortality and functional disability: a systematic review and meta-analysis

The association between social frailty and adverse health outcomes, especially mortality and functional disability, which are essential health outcomes, has not been systematically summarized or meta-analyzed. In this study, we conducted a systematic review and meta-analysis of the impact of social frailty on all-cause mortality and functional disability, while addressing the components of social frailty. In this study, social frailty was operationally defined in alignment with the previous literature, as follows: "a state of increased vulnerability to the interactive back-and-forth of the community, including general resources, social resources, social behaviors, and needs." Hazard ratios or odds ratios described in each selected literature were used as the meta-analytic results. Considering the impact of social frailty on all-cause mortality, the hazard ratio was 1.96 (95% CI 1.20-3.19), indicating a significant association between the two but high heterogeneity. The hazard and odds ratios for the impact of social frailty on functional disability were 1.43 (95% CI 1.20-1.69) and 2.06 (95% CI 1.55-2.74), respectively. A significant association was found between social frailty and functional disability; both hazard and odds ratios were found, and low heterogeneity between these articles was observed. These results highlight the importance of assessing social frailty using more standardized methods and examining its effects on various health outcomes.

Exploring the future adult vaccine landscape-crowded schedules and new dynamics

Amidst the backdrop of the COVID-19 pandemic, vaccine innovation has garnered significant attention, but this field was already on the cusp of a groundbreaking renaissance. Propelling these advancements are scientific and technological breakthroughs, alongside a growing understanding of the societal and economic boons vaccines offer, particularly for non-pediatric populations like adults and the immunocompromised. In a departure from previous decades where vaccine launches could be seamlessly integrated into existing processes, we anticipate potentially than 100 novel, risk-adjusted product launches over the next 10 years in the adult vaccine market, primarily addressing new indications. However, this segment is infamous for its challenges: low uptake, funding shortfalls, and operational hurdles linked to delivery and administration. To unlock the societal benefits of this burgeoning expansion, we need to adopt a fresh perspective to steer through the dynamics sparked by the rapid growth of the global adult vaccine market. This article aims to provide that fresh perspective, offering a detailed analysis of the anticipated number of adult vaccine approvals by category and exploring how our understanding of barriers to adult vaccine uptake might evolve. We incorporated pertinent insights from external stakeholder interviews, spotlighting shifting preferences, perceptions, priorities, and decision-making criteria. Consequently, this article aspires to serve as a pivotal starting point for industry participants, equipping them with the knowledge to skillfully navigate the anticipated surge in both volume and complexity.

Identifying Factors That Influence Physical Activity and Healthy Aging Among Older Latino Adults

BACKGROUND

For older Latinos, some benefits of leisure-time physical activity (LTPA) include enhanced cognitive functioning, decreased loneliness, and reduced premature mortality. Despite LTPA benefits, adults ≥50 years are one of the most inactive age groups in the United States.

METHODS

This qualitative study aimed to add to the limited evidence of LTPA in older Latino adults by exploring the barriers and facilitators for fitness class uptake and park use. Guided by a Social-Ecological Model of Health and Social Determinants of Health theoretical and a phenomenological research design, qualitative research data were collected via 27 personal interviews with Latino adults using a semistructured interview guide. Participants were recruited using purposive sampling strategies in collaboration with community partners. Bicultural data collectors conducted the semistructured interviews over Zoom. Thematic analysis was performed using Dedoose, following an inductive and deductive approach.

RESULTS

The main barriers to fitness class attendance and park use were family and/or work commitments, perceived safety, and perceived discrimination. Conversely, the critical facilitators for participation were socialization into a group, social connectedness with group members, fitness instructor characteristics, and exercise history.

CONCLUSIONS

Findings from this study hold important implications for the design of fitness programming and park-based recreation, including the need to increase the cultural diversity of recreation staff and culturally relevant programming. Future research is needed on time poverty related to family/work commitments and whether discriminatory practices at fitness centers, like ageism and race/ethnicity, influence physical activity behavior.

The impact of COVID-19 on life expectancy across socioeconomic groups in Denmark

BACKGROUND

Denmark was one of the few countries that experienced an increase in life expectancy in 2020, and one of the few to see a decrease in 2021. Because COVID-19 mortality is associated with socioeconomic status (SES), we hypothesize that certain subgroups of the Danish population experienced changes in life expectancy in 2020 and 2021 that differed from the country overall. We aim to quantify life expectancy in Denmark in 2020 and 2021 by SES and compare this to recent trends in life expectancy (2014-2019).

METHODS

We used Danish registry data from 2014 to 2021 for all individuals aged 30+. We classified the study population into SES groups using income quartiles and calculated life expectancy at age 30 by year, sex, and SES, and the differences in life expectancy from 2019 to 2020 and 2020 to 2021. We compared these changes to the average 1-year changes from 2014 to 2019 with 95% confidence intervals. Lastly, we decomposed these changes by age and cause of death distinguishing seven causes, including COVID-19, and a residual category.

RESULTS

We observed a mortality gradient in life expectancy changes across SES groups in both pandemic years. Among women, those of higher SES experienced a larger increase in life expectancy in 2020 and a smaller decrease in 2021 compared to those of lower SES. Among men, those of higher SES experienced an increase in life expectancy in both 2020 and 2021, while those of lower SES experienced a decrease in 2021. The impact of COVID-19 mortality on changes in life expectancy in 2020 was counterbalanced by improvements in non-COVID-19 mortality, especially driven by cancer and cardiovascular mortality. However, in 2021, non-COVID-19 mortality contributed negatively even for causes as cardiovascular mortality that has generally a positive impact on life expectancy changes, resulting in declines for most SES groups.

CONCLUSIONS

COVID-19 mortality disproportionally affected those of lower SES and exacerbated existing social inequalities in Denmark. We conclude that in health emergencies, particular attention should be paid to those who are least socially advantaged to avoid widening the already existing mortality gap with those of higher SES. This research contributes to the discussion on social inequalities in mortality in high-income countries.

The current state of complex systems research on socioeconomic inequalities in health and health behavior-a systematic scoping review

BACKGROUND

Interest in applying a complex systems approach to understanding socioeconomic inequalities in health is growing, but an overview of existing research on this topic is lacking. In this systematic scoping review, we summarize the current state of the literature, identify shared drivers of multiple health and health behavior outcomes, and highlight areas ripe for future research.

METHODS

SCOPUS, Web of Science, and PubMed databases were searched in April 2023 for peer-reviewed, English-language studies in high-income OECD countries containing a conceptual systems model or simulation model of socioeconomic inequalities in health or health behavior in the adult general population. Two independent reviewers screened abstracts and full texts. Data on study aim, type of model, all model elements, and all relationships were extracted. Model elements were categorized based on the Commission on Social Determinants of Health framework, and relationships between grouped elements were visualized in a summary conceptual systems map.

RESULTS

A total of 42 publications were included; 18 only contained a simulation model, 20 only contained a conceptual model, and 4 contained both types of models. General health outcomes (e.g., health status, well-being) were modeled more often than specific outcomes like obesity. Dietary behavior and physical activity were by far the most commonly modeled health behaviors. Intermediary determinants of health (e.g., material circumstances, social cohesion) were included in nearly all models, whereas structural determinants (e.g., policies, societal values) were included in about a third of models. Using the summary conceptual systems map, we identified 15 shared drivers of socioeconomic inequalities in multiple health and health behavior outcomes.

CONCLUSIONS

The interconnectedness of socioeconomic position, multiple health and health behavior outcomes, and determinants of socioeconomic inequalities in health is clear from this review. Factors central to the complex system as it is currently understood in the literature (e.g., financial strain) may be both efficient and effective policy levers, and factors less well represented in the literature (e.g., sleep, structural determinants) may warrant more research. Our systematic, comprehensive synthesis of the literature may serve as a basis for, among other things, a complex systems framework for socioeconomic inequalities in health.

The potential role of social care in reducing childhood obesity

PURPOSE OF REVIEW

This review evaluates the current evidence for relationships of social factors with childhood obesity and for a role of social care in reduction of childhood obesity.

RECENT FINDINGS

Most literature on the relationship between social factors and childhood obesity has examined food insecurity as a risk factor for obesity. Associations between food insecurity and excess weight in children are most consistent during infancy and among those with food insecurity at more than one time point. A few pilot food security interventions that link patients with produce or groceries show feasibility and potential promise for reducing childhood obesity risk factors. However, full-scale, randomized studies to examine interventions that reduce social needs and their effects on childhood obesity are lacking. Future research is needed to examine holistic social care approaches to effectively reduce childhood obesity risk factors.

SUMMARY

Food insecurity acts as a barrier to childhood obesity prevention and treatment. Patient-centered, validated measures of social needs and effective interventions to address social needs are needed to equitably prevent and treat childhood obesity.

Precision Population Cancer Medicine in Cancer of the Uterine Cervix: A Potential Roadmap to Eradicate Cervical Cancer

With the success of the Human Genome Project, the era of genomic medicine (GM) was born. Later on, as GM made progress, there was a feeling of exhilaration that GM could help resolve many disease processes. It also led to the conviction that personalized medicine was possible, and a relatively synonymous word, precision medicine (PM), was coined. However, the influence of environmental factors and social determinants of diseases was only partially given their due importance in the definition of PM, although more recently, this has been recognized. With the rapid advances in GM, big data, data mining, wearable devices for health monitoring, telemedicine, etc., PM can be more easily extended to population-level health care in disease management, prevention, early screening, and so on.and the term precision population medicine (PPM) more aptly describes it. PPM's potential in cancer care was posited earlier,and the current authors planned a series of cancer disease-specific follow-up articles. These papers are mainly aimed at helping emerging students in health sciences (medicine, pharmacy, nursing, dentistry, public health, population health), healthcare management (health-focused business administration, nonprofit administration, public institutional administration, etc.), and policy-making (e.g., political science), although not exclusively. This first disease-specific report focuses on the cancer of the uterine cervix (CC). It describes how recent breakthroughs can be leveraged as force multipliers to improve outcomes in CC - by improving early detection, better screening for CC, potential GM-based interventions during the stage of persistent Human papillomavirus (HPV) infection and treatment interventions - especially among the disadvantaged and resource-scarce populations. This work is a tiny step in our attempts to improve outcomes in CC and ultimately eradicate CC from the face of the earth.

The impact of integrated care on health care utilization and costs in a socially deprived urban area in Germany: A difference-in-differences approach within an event-study framework

We investigated the impact of an integrated care initiative in a socially deprived urban area in Germany. Using administrative data, we empirically assessed the causal effect of its two sub-interventions, which differed by the extent to which their instruments targeted the supply and demand side of healthcare provision. We addressed confounding using propensity score matching via the Super Learner machine learning algorithm. For our baseline model, we used a two-way fixed-effects difference-in-differences approach to identify causal effects. We then employed difference-in-differences analyses within an event-study framework to explore the heterogeneity of treatment effects over time, allowing us to disentangle the effects of the sub-interventions and improve causal interpretation and generalizability. The initiative led to a significant increase in hospital and emergency admissions and non-hospital outpatient visits, as well as inpatient, non-hospital outpatient, and total costs. Increased utilization may indicate that the intervention improved access to care or identified unmet need.

Perceptions of Falling Behind "Most White People": Within-Group Status Comparisons Predict Fewer Positive Emotions and Worse Health Over Time Among White (but Not Black) Americans

Despite the persistence of anti-Black racism, White Americans report feeling worse off than Black Americans. We suggest that some White Americans may report low well-being despite high group-level status because of perceptions that they are falling behind their in-group. Using census-based quota sampling, we measured status comparisons and health among Black (N = 452, Wave 1) and White (N = 439, Wave 1) American adults over a period of 6 to 7 weeks. We found that Black and White Americans tended to make status comparisons within their own racial groups and that most Black participants felt better off than their racial group, whereas most White participants felt worse off than their racial group. Moreover, we found that White Americans' perceptions of falling behind "most White people" predicted fewer positive emotions at a subsequent time, which predicted worse sleep quality and depressive symptoms in the future. Subjective within-group status did not have the same consequences among Black participants.