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McNeill E, Lindenfeld Z, Mostafa L, Zein D, Silver D, Pagán J, Weeks WB, Aerts A, Des Rosiers S, Boch J, Chang JE. Uses of Social Determinants of Health Data to Address Cardiovascular Disease and Health Equity: A Scoping Review. J Am Heart Assoc 2023; 12:e030571. [PMID: 37929716 PMCID: PMC10727404 DOI: 10.1161/jaha.123.030571] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/06/2023] [Indexed: 11/07/2023]
Abstract
Background Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Prior research suggests that social determinants of health have a compounding effect on health and are associated with cardiovascular disease. This scoping review explores what and how social determinants of health data are being used to address cardiovascular disease and improve health equity. Methods and Results After removing duplicate citations, the initial search yielded 4110 articles for screening, and 50 studies were identified for data extraction. Most studies relied on similar data sources for social determinants of health, including geocoded electronic health record data, national survey responses, and census data, and largely focused on health care access and quality, and the neighborhood and built environment. Most focused on developing interventions to improve health care access and quality or characterizing neighborhood risk and individual risk. Conclusions Given that few interventions addressed economic stability, education access and quality, or community context and social risk, the potential for harnessing social determinants of health data to reduce the burden of cardiovascular disease remains unrealized.
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Affiliation(s)
- Elizabeth McNeill
- Department of Public Health Policy and ManagementNew York University School of Global Public HealthNew YorkNYUSA
| | - Zoe Lindenfeld
- Department of Public Health Policy and ManagementNew York University School of Global Public HealthNew YorkNYUSA
| | - Logina Mostafa
- Department of Public Health Policy and ManagementNew York University School of Global Public HealthNew YorkNYUSA
| | - Dina Zein
- Department of Public Health Policy and ManagementNew York University School of Global Public HealthNew YorkNYUSA
| | - Diana Silver
- Department of Public Health Policy and ManagementNew York University School of Global Public HealthNew YorkNYUSA
| | - José Pagán
- Department of Public Health Policy and ManagementNew York University School of Global Public HealthNew YorkNYUSA
| | - William B. Weeks
- Microsoft Corporation, Precision Population Health, Microsoft ResearchRedmondWAUSA
| | - Ann Aerts
- The Novartis FoundationBaselSwitzerland
| | | | | | - Ji Eun Chang
- Department of Public Health Policy and ManagementNew York University School of Global Public HealthNew YorkNYUSA
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Liu C, Ma Y, Hofman A, Waziry R, Koton S, Pike JR, Windham BG, Power MC, Sharrett AR, Gottesman RF. Educational Attainment and Dementia: Mediation by Mid-Life Vascular Risk Factors. Ann Neurol 2023; 94:13-26. [PMID: 36966451 DOI: 10.1002/ana.26647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/27/2023]
Abstract
INTRODUCTION Lower education is associated with higher burden of vascular risk factors in mid-life and higher risk of dementia in late life. We aim to understand the causal mechanism through which vascular risk factors potentially mediate the relationship between education and dementia. METHODS In a cohort of 13,368 Black and White older adults in the Atherosclerosis Risk in Communities Study, we assessed the relationship between education (grade school, high school without graduation, high school graduate or equivalent, college, graduate/professional school) and dementia among all participants and among those with incident stroke. Cox models were adjusted for age, race-center (a variable stratified by race and field center), sex, apolipoprotein E (APOE) ε4 genotype, and family history of cardiovascular disease. Causal mediation models assessed mediation by mid-life systolic blood pressure, fasting blood glucose, body mass index, and smoking. RESULTS More education was associated with 8 to 44% lower risk of dementia compared to grade school-level education in a dose-response pattern, while the relationship between education and post-stroke dementia was not statistically significant. Up to 25% of the association between education and dementia was mediated through mid-life vascular risk factors, with a smaller percentage mediated for lower levels of education. INTERPRETATION A substantial proportion of the relationship between education and dementia was mediated through mid-life vascular risk factors. However, risk factor modification is unlikely to fully address the large educational disparities in dementia risk. Prevention efforts must also address disparities in socioeconomic resources leading to divergent early-life education and other structural determinants of mid-life vascular risk factors. ANN NEUROL 2023;94:13-26.
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Affiliation(s)
- Chelsea Liu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Yuan Ma
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Albert Hofman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Reem Waziry
- Department of Neurology, Columbia University Irving Medical Center, Columbia University, New York, NY, USA
| | - Silvia Koton
- Stanley Steyer School of Health Professions, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - James R Pike
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - B Gwen Windham
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Melinda C Power
- Department of Epidemiology, George Washington University Milken Institute School of Public Health, Washington, DC, USA
| | - A Richey Sharrett
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Rebecca F Gottesman
- National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, MD, USA
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Kim MH, Schwartz GL, White JS, Glymour MM, Reardon SF, Kershaw KN, Gomez SL, Collin DF, Inamdar PP, Wang G, Hamad R. School racial segregation and long-term cardiovascular health among Black adults in the US: A quasi-experimental study. PLoS Med 2022; 19:e1004031. [PMID: 35727819 PMCID: PMC9258802 DOI: 10.1371/journal.pmed.1004031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 07/06/2022] [Accepted: 05/26/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) disproportionately affects Black adults in the United States. This is increasingly acknowledged to be due to inequitable distribution of health-promoting resources. One potential contributor is inequities in educational opportunities, although it is unclear what aspects of education are most salient. School racial segregation may affect cardiovascular health by increasing stress, constraining socioeconomic opportunities, and altering health behaviors. We investigated the association between school segregation and Black adults' CVD risk. METHODS AND FINDINGS We leveraged a natural experiment created by quasi-random (i.e., arbitrary) timing of local court decisions since 1991 that released school districts from court-ordered desegregation. We used the Panel Study of Income Dynamics (PSID) (1991 to 2017), linked with district-level school segregation measures and desegregation court order status. The sample included 1,053 Black participants who ever resided in school districts that were under a court desegregation order in 1991. The exposure was mean school segregation during observed schooling years. Outcomes included several adult CVD risk factors and outcomes. We fitted standard ordinary least squares (OLS) multivariable linear regression models, then conducted instrumental variables (IV) analysis, using the proportion of schooling years spent in districts that had been released from court-ordered desegregation as an instrument. We adjusted for individual- and district-level preexposure confounders, birth year, and state fixed effects. In standard linear models, school segregation was associated with a lower probability of good self-rated health (-0.05 percentage points per SD of the segregation index; 95% CI: -0.08, -0.03; p < 0.001) and a higher probability of binge drinking (0.04 percentage points; 95% CI: 0.002, 0.07; p = 0.04) and heart disease (0.01 percentage points; 95% CI: 0.002, 0.15; p = 0.007). IV analyses also found that school segregation was associated with a lower probability of good self-rated health (-0.09 percentage points; 95% CI: -0.17, -0.02, p = 0.02) and a higher probability of binge drinking (0.17 percentage points; 95% CI: 0.04, 0.30, p = 0.008). For IV estimates, only binge drinking was robust to adjustments for multiple hypothesis testing. Limitations included self-reported outcomes and potential residual confounding and exposure misclassification. CONCLUSIONS School segregation exposure in childhood may have longstanding impacts on Black adults' cardiovascular health. Future research should replicate these analyses in larger samples and explore potential mechanisms. Given the recent rise in school segregation, this study has implications for policies and programs to address racial inequities in CVD.
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Affiliation(s)
- Min Hee Kim
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Gabriel L. Schwartz
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Justin S. White
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco (UCSF), San Francisco, California, United States of America
- Department of Epidemiology & Biostatistics, UCSF, San Francisco, California, United States of America
| | - M. Maria Glymour
- Department of Epidemiology & Biostatistics, UCSF, San Francisco, California, United States of America
| | - Sean F. Reardon
- Stanford University, Stanford, California, United States of America
| | - Kiarri N. Kershaw
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Scarlett Lin Gomez
- Department of Epidemiology & Biostatistics, UCSF, San Francisco, California, United States of America
| | - Daniel F. Collin
- Department of Family & Community Medicine, UCSF, San Francisco, California, United States of America
| | - Pushkar P. Inamdar
- Department of Epidemiology & Biostatistics, UCSF, San Francisco, California, United States of America
| | - Guangyi Wang
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco (UCSF), San Francisco, California, United States of America
| | - Rita Hamad
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco (UCSF), San Francisco, California, United States of America
- Department of Family & Community Medicine, UCSF, San Francisco, California, United States of America
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Baah FO, Chittams J, Carlson B, Sethares KA, Daus M, Moser DK, Riegel B. Sociodemographic Indicators of Social Position and Self-care Maintenance in Adults with Heart Failure. Clin Nurs Res 2021; 30:847-854. [PMID: 33605154 DOI: 10.1177/1054773821995593] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Social determinants of health (SDH) are known to influence health. Adequate self-care maintenance improves heart failure (HF) outcomes. However, the relationship between self-care maintenance and SDH remains unclear. Explore the relationship between sociodemographic indicators of social position and self-care maintenance in adults with HF. This was a secondary analysis of data from a cross-sectional descriptive study of 543 adults with HF. Participants completed the Self-Care of HF Index and a sociodemographic survey. We used multiple regression with backward elimination to determine which SDH variables were determinants of self-care maintenance. Marital status (p = .02) and race (p = .02) were significant determinants of self-care maintenance. Education (p = .06) was highest in Whites (35.6%). These variables explained only 3.8% of the variance in self-care maintenance. Race, education, and marital status were associated with HF self-care maintenance. SDH is complex and cannot be explained with simple sociodemographic characteristics.
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Frakt AB, Jha AK, Glied S. Pivoting from decomposing correlates to developing solutions: An evidence-based agenda to address drivers of health. Health Serv Res 2020; 55 Suppl 2:781-786. [PMID: 32776528 PMCID: PMC7518812 DOI: 10.1111/1475-6773.13539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Health is influenced by many factors outside the health system. This is often expressed by decomposing contributors to health into factors that sum to 100 percent. In this commentary, we assess the (few) strengths and (many) limitations of such decompositions. We conclude that they fail to be useful for policy guidance. We conclude by proposing an alternative approach to assessing how various factors affect health: evaluations of interventions.
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Affiliation(s)
- Austin B. Frakt
- VA Boston Healthcare SystemBoston University School of Public HealthHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Ashish K. Jha
- Brown University School of Public HealthProvidenceRhode IslandUSA
| | - Sherry Glied
- New York University's Robert F. Wagner Graduate School of Public ServiceNew York CityNew YorkUSA
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Harrati A, Glymour MM. Lifecourse epidemiology matures: Commentary on Zhang et al. "Early-life socioeconomic status, adolescent cognitive ability, and cognition in late midlife". Soc Sci Med 2019; 244:112645. [PMID: 31722818 DOI: 10.1016/j.socscimed.2019.112645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 10/26/2019] [Indexed: 01/23/2023]
Abstract
The effect of education on late life cognition has attracted substantial attention in lifecourse epidemiology, in part because of its relevance for understanding the effect of education on dementia. Although numerous studies document an association between education and later life cognition, these studies are potentially confounded by early life socioeconomic position and cognition. Good measures of these early life constructs are rarely available in data sets assessing cognition in late life. A further body of evidence has taken advantage of compulsory schooling law (CSL) instrumental variables (IV), although these estimates have been criticized based on questions about the validity of CSL IVs. In this issue of the Journal, Zhang et al. took advantage of the Wisconsin Longitudinal Study to control for both prospectively measured adolescent IQ and early life socioeconomic status in an analysis evaluating the effect of education on cognitive scores in late middle age (Zhang et al., 2019; IN THIS ISSUE). Their results indicate a moderate effect of each additional year of education on later life cognition, of approximately 0.1-0.15 standard deviations per year of schooling. These estimates are remarkably aligned with findings from prior observational designs and from the CSL IV studies. Although criticisms of any individual study are plausible, this new study complements the body of prior evidence to provide compelling evidence for the benefits of education on late life cognition.
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Affiliation(s)
- Amal Harrati
- Division of Primary Care and Population Health, Department of Medicine, Stanford University, Stanford, 94305, USA
| | - M Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco, 94158, USA.
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Hamad R, Nguyen TT, Glymour MM, Vable A, Manly JJ, Rehkopf DH. Quality and quantity: The association of state-level educational policies with later life cardiovascular disease. Prev Med 2019; 126:105750. [PMID: 31195021 PMCID: PMC6697595 DOI: 10.1016/j.ypmed.2019.06.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/02/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
Education is a powerful predictor of cardiovascular morbidity and mortality. While the majority of the literature has focused on years of educational attainment or degree attainment, fewer studies examine the role of educational quality in the prevention of cardiovascular disease (CVD). We tested the hypothesis that average state-level educational quality was associated with CVD, linking state-level data on educational quality with individual demographic and health data from multiple waves of the National Health and Nutrition Examination Survey (N = 34,770). We examined thirteen CVD-related outcomes-including blood pressure, cholesterol, and heart attack-to understand the multiple pathways through which educational quality may influence CVD. The primary predictor was a composite index of educational quality, combining state-level measures of student-teacher ratios, per-pupil expenditures, and school term length. We fit multivariable models, regressing each outcome on the educational quality composite index and adjusting for individual- and state-level covariates. We also assessed whether the association between state educational quality and CVD differed for less educated individuals. Overall, higher educational quality was associated with less smoking (OR = 0.86, 95%CI: 0.77, 0.97), but there was no statistically significant association for the other 12 outcomes. Interaction tests indicated that less educated individuals benefited less from higher educational quality relative to those with more education for several outcomes. Our study suggests that state-level educational quality is not strongly associated with CVD, and that this null association overall may mask heterogeneous benefits that accrue disproportionately to those with higher levels of education.
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Affiliation(s)
- Rita Hamad
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA; Department of Family & Community Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Thu T Nguyen
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - M Maria Glymour
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Anusha Vable
- Department of Family & Community Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer J Manly
- Taub Institute for Research on Alzheimer's Disease and the Aging Brain and the Department of Neurology, Columbia University Medical Center, New York City, New York, USA
| | - David H Rehkopf
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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