Invited Commentary: Is the Polysocial Score Approach Valuable for Advancing Social Determinants of Health Research?

Social determinants of health (SDOH) encompass the social environmental factors and lived experiences that collectively shape an individual's health. Recently, the polysocial score approach has been introduced as an innovative method for capturing the cumulative impact of a broad spectrum of social factors. This approach offers a promising opportunity to complement and enhance conventional methodologies in the advancement of SDOH research. In this issue of the Journal, Jawadekar et al. (Am J Epidemiol. XXXX;XXX(XX):XX-X-XXXX) evaluated the value of the polysocial score for predicting cognitive performance and mortality among middle-aged and older adults. Models built on a smaller set of social determinants, including race, gender, and education, performed comparably to the polysocial score models where a more complex set of social factors were included. In this invited commentary, I welcome the evaluation of the predictive ability of the polysocial score and the discussion of its merits and limitations. I also summarize the practical utility of the polysocial score in predicting health outcomes and its mechanistic significance in unveiling the relationship between genetics, social environment, and lifestyles in shaping an individual's health and elucidate health disparities. Lastly, I propose several avenues for future research.

A social profile of deaths related to sickle cell disease in India: a case for an ethical policy response

India accounts for 14.5 percent of the global SCD newborns, roughly over 42,000 a year, second to sub-Saharan Africa. Despite the availability of cheap diagnostic and treatment options, SCD remains a largely neglected disease within healthcare policy and practice. Epidemiological modeling based on small, often dated, regional studies (largely from sub-Saharan Africa) estimate that between 50 and 90 percent of affected children will/die before the age of 5 years. This premise, coupled with targets of reducing under 5 mortality (SDG 4), privileges public health interventions for screening and prevention of new births, undermining investments in long-term health and social care. This paper presents a retrospective, descriptive analysis of the socio-demographic profile of 447 patients diagnosed with sickle cell or sickle-beta thalassemia, who died following admission at a tertiary care entre in India. We used anonymized hospital records of 3,778 sickle cell patients, admitted in pediatric and adult/medical wards between January 2016 and February 2021. A majority of hospital deaths occurred in the second and third decades of life, following a hospital admission for a week. The overall mortality during 2016-2019 was 14% with little gender difference over time. Contrary to our expectations, the number of hospital deaths did not increase during the first year of the COVID-19 pandemic, between 2020 and 2021. The conclusion highlights the importance of longitudinal, socio-demo-graphic data on deaths as providing important insights for identifying ethical policy interventions focused on improving SCD outcomes over time, reducing inequities in access to care, and preventing what might be considered "excess" deaths.

Overcoming Marginalization by Creating a Sense of Belonging

Marginalization encompasses structural, interpersonal, and intergroup dynamics that perpetuate inequality and exclusion. This manuscript advocates that the solution to marginalization lies in fostering a sense of belonging. Belonging is a fundamental human need, critical for mental well-being, academic success, and personal growth. It significantly impacts engagement, retention, and overall development, especially in health professional education settings like nursing schools. When individuals feel they belong, they are more likely to seek support, engage actively in learning, and perform better academically. However, achieving a sense of belonging is not straightforward, and many challenges at both individual and institutional levels hinder its realization. Individual challenges include resistance to change, implicit biases, and lack of awareness of the disparities caused by marginalization. Institutional challenges include insufficient commitment, inadequate resource allocation, and lack of representation from marginalized groups. In the United States, recent legislation obstructing initiatives toward diversity, equity, and inclusion poses additional obstacles. To overcome these challenges and promote belonging, this manuscript offers strategies that highlight the importance of aligning institutional values with policies and practices, recognizing and rewarding inclusive efforts, and actively seeking diverse perspectives.

Public perspectives on inequality and mental health: A peer research study

INTRODUCTION

Associations between structural inequalities and health are well established. However, there is limited work examining this link in relation to mental health, or that centres public perspectives. This study explores people's experience and sense-making of inequality in their daily lives, with particular consideration of impacts on mental health.

METHODS

We conducted a peer research study. Participants had to live in one of two London Boroughs and have an interest in inequalities and mental health. Using social media, newsletters, local organisations and our peer researchers' contacts, we recruited 30 participants who took photos representing their experience of inequality and discussed them during semi-structured interviews. Data were analysed using reflexive thematic analysis.

RESULTS

Three themes were identified in this study: (1) inequalities are unjust, multilayered and intertwined with mental health. Accounts demonstrated a deep understanding of inequalities and their link to mental health outcomes, describing inequalities as 'suffering' and 'not good for anyone'. Financial, housing, immigration and healthcare problems exacerbated poor mental health, with racism, gender-based violence and job loss also contributing factors for both poor mental health and experiences of inequality; (2) inequalities exclude and have far-reaching mental health consequences, impacting personal sense of belonging and perceived societal value and (3) moving forwards-addressing long-standing inequality and poor public mental health necessitated coping and resilience strategies that are often unacknowledged and undervalued by support systems.

CONCLUSION

Lived experience expertise was central in this study, creating an innovative methodological approach. To improve public mental health, we must address the everyday, painful structural inequalities experienced by many as commonplace and unfair. New policies and strategies must be found that involve communities, redistributing resources and power, building on a collective knowledge base, to coproduce actions combatting inequalities and improving population mental health.

PATIENT OR PUBLIC CONTRIBUTION

This study was peer-led, designed and carried out by researchers who had experiences of poor mental health. Six authors of the paper worked as peer researchers on this study.

Service delivery inaccessibility as a predictor of teenage pregnancy in South Africa

Background

With the onset of the South African democracy in 1994 it was hoped that many social inequalities would be addressed urgently. However, studies have shown that service delivery inaccessibility remains a challenge and investigating the social implications of such injustices remains important.

Objective

This study determined to establish the association between service delivery inaccessibility and adolescent pregnancy in South Africa.

Methods

Using data from 2019 and 2021 general household surveys, 7 737 teenage females were included. The study applied descriptive statistics, chi-squared testing as well as multilevel binary logistic regression.

Results

Random-intercept multilevel binary logistic regression revealed that the risk of adolescent pregnancy independently increased as the level of service inaccessibility increased at household level (no services: OR=1.73, 1 service: OR=1.40, 2 services: OR=1.28) and community level (medium: OR=1.22, high: OR=1.38) at a P-value of 0.05.

Conclusion

Findings highlight the need to guarantee universal service delivery urgently not only for development, but also to prevent adolescent pregnancy. Furthermore, the findings present evidence of structural factors driving adolescent pregnancy in South Africa, which renders continued cycles of poverty, injustice and early pregnancy amongst the majority of Blacks.

Diversity Wanted! Utilizing Transdisciplinary Scholarship on Structural Inequality to Educate Psychology Graduate Students

INTRODUCTION

The scholarship of teaching and learning (SoTL) should promote diversity, equity, inclusion, and social justice for the next generation of psychologists.

STATEMENT OF THE PROBLEM

I worry that the SoTL propagates an exclusionary field that becomes increasingly irrelevant in our diverse society given that graduate curricula largely exclude scholarship on structural inequality.

LITERATURE REVIEW

I detail the process of graduate curricular changes in my current department, with a focus on my new required graduate course, Diversity, Systems, and Inequality. I utilize scholarship from law, sociology, philosophy, women and gender studies, education, and psychology.

TEACHING IMPLICATIONS

I provide the structure and content of the course-including syllabi and lecture slides-as well as modes of assessment that promote inclusivity and critical thinking. I detail how current faculty can learn to incorporate the content of this work into their own teaching and scholarship through weekly journal clubs.

CONCLUSION

SoTL outlets can publish transdisciplinary, inclusive course materials regarding structural inequality, thus mainstreaming and amplifying such work for the benefit of the field and our world.

Deepening and widening the gap: The impacts of the COVID-19 pandemic on gender and racial inequalities in Brazil

Shaped by inconsistent policy decisions, the COVID-19 pandemic in Brazil has made structural gender and racial inequalities more acute. Black and low-income women are overburdened with unpaid domestic work, increased domestic violence, and more vulnerable due to informal and exploitative working regimes. These structural aspects are intensifying, since the pandemic has broadened inequalities at the intersection of gender, race, labor market, and social class. We examine pre- and during pandemic inequalities on three dimensions: (a) unpaid domestic and care work, (b) women's labor market participation, and (c) domestic violence. We link the care diamond model and racial stratification forwarding a feminist perspective by examining how the interlocking of race and gender in Brazil renders different socioeconomic dynamics to the detriment of Black and low-income women. Based on this evidence, we stress that a more equal future requires a better social protection and policies targeting the articulation of gender, race, and class.

Identifying Challenges, Enabling Practices, and Reviewing Existing Policies Regarding Digital Equity and Digital Divide Toward Smart and Healthy Cities: Protocol for an Integrative Review

BACKGROUND

Digital equity denotes that all individuals and communities have equitable access to the information technology required to participate in digital life and can fully capitalize on this technology for their individual and community gain and benefits. Recent research highlighted that COVID-19 heightened the existing structural inequities and further exacerbated the technology-related social divide, especially for racialized communities, including new immigrants, refugees, and ethnic minorities. The intersection of challenges associated with racial identity (eg, racial discrimination and cultural differences), socioeconomic marginalization, and age- and gender-related barriers affects their access to health and social services, education, economic activity, and social life owing to digital inequity.

OBJECTIVE

Our aim is to understand the current state of knowledge on digital equity and the digital divide (which is often considered a complex social-political challenge) among racialized communities in urban cities of high-income countries and how they impact the social interactions, economic activities, and mental well-being of racialized city dwellers.

METHODS

We will conduct an integrative review adapting the Whittemore and Knafl methodology to summarize past empirical or theoretical literature describing digital equity issues pertaining to urban racialized communities. The context will be limited to studies on multicultural cities in high-income countries (eg, Calgary, Alberta) in the last 10 years. We will use a comprehensive search of 8 major databases across multiple disciplines and gray literature (eg, Google Scholar), using appropriate search terms related to digital "in/equity" and "divide." A 2-stage screening will be conducted, including single citation tracking and a hand search of reference lists. Results will be synthesized using thematic analysis guidelines.

RESULTS

As of August 25, 2022, we have completed a systematic search of 8 major academic databases from multiple disciplines, gray literature, and citation or hand searching. After duplicate removal, we identified 8647 articles from all sources. Two independent reviewers are expected to complete the 2-step screening (title, abstract, and full-text screening) using Covidence followed by data extraction and analysis in 4 months (by December 2022). Data will be extracted regarding digital equity-related initiatives, programs, activities, research findings, issues, barriers, policies, recommendations, etc. Thematic analysis will reveal how barriers and facilitators of digital equity affect or benefit racialized population groups and what social, material, and systemic issues need to be addressed to establish digital equity for racialized communities in the context of a multicultural city.

CONCLUSIONS

This project will inform public policy about digital inequity alongside conventional systemic inequities (eg, education and income levels); promote digital equity by exploring and examining the pattern, extent, and determinants and barriers of digital inequity across sociodemographic variables and groups; and analyze its interconnectedness with spatial dimensions and variations of the urban sphere (geographic differences).

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40068.

Social Equality in an Alternate World

Genes have long been used to validate social inequality. The Genetic Lottery: Why DNA Matters for Social Equality, by Kathryn Paige Harden, attempts not only to reclaim genetic research on human behavior from its eugenic past but also to argue that genetic research can be used to understand and enhance social equality. This review essay illustrates why embracing a political agenda in which genetics matter for social equality will not in practice advance efforts to reduce social inequality. It argues that the points raised in The Genetic Lottery would be important in an alternate world in which structural inequalities have ceased to exist, but not in the world we live in today.

How Microaggressions Reinforce and Perpetuate Systemic Racism in the United States

The consequences of racial microaggressions are most often discussed at an interpersonal level. In this article, we contend that microaggressions play an important role in maintaining systems of racial oppression beyond the interpersonal context. Specifically, we illustrate how microaggressions establish White superiority in the United States by othering people of color (e.g., treating people of color as if they are not true citizens) and communicating that they are inferior (e.g., environmental exclusions and attacks, treating people of color as second-class citizens). We also present evidence that microaggressions play a role in protecting and reinforcing systemic racism. By obscuring systemic racism (e.g., false color blindness, denial of individual racism) and promoting ideas that maintain existing systemic inequalities (e.g., the myth of meritocracy, reverse-racism hostility), microaggressions provide cover and support for established systems of oppression. Overall, we find considerable evidence-from both empirical studies and real-world examples-that microaggressions contribute to the maintenance of systems of racial oppression in the United States. We conclude with a discussion of how we might begin to challenge this cycle by increasing awareness of systemic racism and the microaggressions that aid in its perpetuation.

Food Insecurity and Eating Pathology in Adolescents

Adolescence is a critical period for the emergence of eating disorders, and food insecurity may be related to eating pathology and weight, as evidenced in adults. However, little is known about food insecurity and eating pathology during this developmental period, and associations between food insecurity and body mass index (BMI) are mixed. Therefore, we examined associations between food insecurity and BMI percentile, self-reported eating-related pathology and binge eating, and subgroup differences by race/ethnicity. In a subset, we examined the relationship between food insecurity and real-world hunger, food craving, and loss-of-control eating using ecological momentary assessment (EMA). Fifty-eight adolescents at two sites (clinical sample, n = 38, BMI percentile ≥ 70th; community sample, n = 20, all BMI strata) completed self-report questionnaires. Adolescents were 15.2 ± 2.1 years old, 62% female, 50% Black, 34.5% Hispanic, with BMI percentile = 80.5 ± 25.8 (range 4-99). In the full sample, food insecurity was associated with greater BMI (p < 0.01), higher shape/weight overvaluation (p = 0.04), and greater number of binge eating episodes among those reporting at least one binge episode (p < 0.01), with significant relationships for BMI percentile, shape/weight overvaluation, body dissatisfaction, and binge episode frequency among Hispanic adolescents only (each p < 0.01). As in adults, food insecurity may be a risk factor for eating pathology, particularly for Hispanic teens.

Annual Research Review: Youth firearm violence disparities in the United States and implications for prevention

OBJECTIVE

Research has identified the United States (U.S.) as a global outlier in its firearm ownership rates, with a correspondingly higher risk of youth firearm violence compared to other countries. The relative extent of disparities in youth firearm violence within the U.S. has been less clear. Little is known about factors in the social ecology driving these disparities and whether current firearm violence prevention approaches sufficiently address them.

METHOD

Applying a health disparities framework, we synthesized epidemiological, sociological, and prevention science literatures, emphasizing structural inequalities in youth sociocultural positionality in life course developmental context. We also highlighted findings from national injury data and other studies regarding the magnitude and impacts of youth firearm violence disparities.

RESULTS

The burden of firearm violence varied markedly at intersections of gender, race, place, developmental stage, and homicidal or suicidal intent. Firearm homicide among Black boys and young men (ages 15-24) was at outlier levels - many times greater than the rates of any other demographic group, developmental stage, or violence intent, particularly in urban settings. Recent research has operationalized structural racism and implicated historically racialized spaces as a root cause of this disparity. In contrast, elevated firearm suicide rates were found among Native and White boys and young men in rural settings; firearm-related cultural attitudes and gender socialization were points of consideration to explain these disparities. We highlighted research-based youth firearm violence preventive interventions, and emphasized gaps in efforts focused on structural and sociocultural factors.

CONCLUSIONS

More explicit attention to reducing firearm homicide among Black boys and young men and firearm suicide among Native and rural White boys and young men is urgently needed and has potential to substantially lower overall rates of firearm violence in the U.S.

The Covid-19 Pandemics: why Intersectionality Matters

Covid-19 has been a disrupting event in contemporary social life but is far from being a great equaliser. Preliminary studies have put in evidence how different social groups faced a differentiated risk of contagion and coped differently with the various consequences of the emergency. Evidence shows how minorities and migrants face disproportionally higher risks of contagion than the white upper and middle class, and how vulnerable communities are more exposed to deaths and the rapid spread of the virus. At the same time, societies are coping with social distancing measures and their disruptive social and economic consequences, which have a more significant impact on the most vulnerable segments of societies: women, children, low-income classes and ethnic minorities. This article argues that an intersectional framework allows an understanding of what is occurring in the current pandemic, both in terms of its social determinants and social consequences. To open the black box of inequality, intersectional scholars analyze the intersections of multiple structures of inequalities (such as gender, age, class, ethnicity), which have a multiplying effect when disadvantaged positions intersect in the same individual. Covid-19 is a clear example of an intersectional phenomenon: the impact of individual and community exposure to Covid-19 is the results of multiple and interrelating structures of inequality. Up to now, research in social sciences has underestimated the role of intersectionality in analyzing the social and economic consequences of this pandemic.

Racial residential segregation and economic disparity jointly exacerbate COVID-19 fatality in large American cities

The disproportionately high rates of both infections and deaths among racial and ethnic minorities (especially Blacks and Hispanics) in the United States during the COVID-19 pandemic are consistent with the conclusion that structural inequality can produce lethal consequences. However, the nature of this structural inequality in relation to COVID-19 is poorly understood. Here, we hypothesized that two structural features, racial residential segregation and income inequality, of metropolitan areas in the United States have contributed to health-compromising conditions, which, in turn, have increased COVID-19 fatalities; moreover, that these two features, when combined, may be particularly lethal. To test this hypothesis, we examined the growth rate of confirmed COVID-19 cases and deaths in an early 30-day period of the outbreak in the counties located in each of the 100 largest metropolitan areas in the United States. The growth curves for cases and deaths were steeper in counties located in metropolitan areas where Blacks and Hispanics are residentially segregated from Whites. Moreover, the effect of racial residential segregation was augmented by income inequality within each county. These data strongly suggest that racial and economic disparities have caused a greater death toll during the current pandemic. We draw policy implications for making virus-resilient cities free from such consequences.

Children's evaluations of individually and structurally based inequalities: The role of status

Social inequalities limit important opportunities and resources for members of marginalized and disadvantaged groups. Understanding the origins of how children construct their understanding of social inequalities in the context of their everyday peer interactions has the potential to yield novel insights into when-and how-individuals respond to different types of social inequalities. The present study examined whether children (N = 176; 3- to 8-years-old; 52% female, 48% male; 70% European American, 16% African American, 10% Latinx, and 4% Asian American; middle-income backgrounds) differentiate between structurally based inequalities (e.g., based on gender) and individually based inequalities (e.g., based on merit). Children were randomly assigned to a group that received more (advantaged) or fewer (disadvantaged) resources than another group due to either their groups' meritorious performance on a task or the gender biases of the peer in charge of allocating resources. Overall, children evaluated structurally based inequalities to be more unfair and worthy of rectification than individually based inequalities, and disadvantaged children were more likely to view inequalities to be wrong and act to rectify them compared to advantaged children. With age, advantaged children became more likely to rectify the inequalities and judge perpetuating allocations to be unfair. Yet, the majority of children allocated equally in response to both types of inequality. The findings generated novel evidence regarding how children evaluate and respond to individually and structurally based inequalities, and how children's own status within the inequality informs these responses. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Differential Impacts during COVID-19 in Canada: A Look at Diverse Individuals and Their Businesses

The coronavirus disease 2019 (COVID-19) pandemic is affecting all segments of society. This study investigates the pandemic's economic and social impacts on diverse groups in Canada, including women, immigrants, Indigenous peoples, persons with disabilities, and racialized people. Using two large online Statistics Canada surveys, which are neither random nor weighted to represent the Canadian population, we consider quantitative differences in the pandemic challenges and concerns reported by women and men, immigrants and those born in Canada, and intersectional groups, both as individuals and as the businesses they own or represent. Within the samples, individuals from diverse groups and their businesses are more negatively affected by COVID-19.

Chronic Disease, the Built Environment, and Unequal Health Risks in the 500 Largest U.S. Cities

Health is increasingly subject to the complex interplay between the built environment, population composition, and the structured inequity in access to health-related resources across communities. The primary objective of this paper was to examine cardiometabolic disease (diabetes, cardiovascular diseases, stroke) markers and their prevalence across relatively small geographic units in the 500 largest cities in the United States. Using data from the American Community Survey and the 500 Cities Project, the current study examined cardiometabolic diseases across 27,000+ census tracts in the 500 largest cities in the United States. Earlier works clearly show cardiometabolic diseases are not randomly distributed across the geography of the U.S., but rather concentrated primarily in Southern and Eastern regions of the U.S. Our results confirm that chronic disease is correlated with social and built environment factors. Specifically, racial concentration (%, Black), age concentration (% 65+), housing stock age, median home value, structural inequality (Gini index), and weight status (% overweight/obese) were consistent correlates (p < 0.01) of cardiometabolic diseases in the sample of census tracts. The paper examines policy-related features of the built and social environment and how they might play a role in shaping the health and well-being of America’s metropolises.

Inequities in Access: The Impact of a Segmented Health Insurance System on Physician Visits and Hospital Admissions Among Older Adults in the 2014 China Family Panel Studies

The fragmentation of job-based and community-based insurance plans inevitably undermines health care accessibility in China’s market-oriented health system, especially for uninsured and rural residents. Based on the 2014 China Family Panel Studies, this secondary data analysis examined whether socioeconomic indicators, health-related determinants, and particularly social health insurance status affect physician visits in the past 2 weeks and hospital admissions in the past 12 months among a representative sample of older adults (n = 6,570). Grounded in Andersen’s behavioral framework, 2 series of logistic regression analyses were performed: one was built in a hierarchical manner, assessing blocks of predisposing, enabling, health-need, and lifestyle-behavioral factors; the other was conducted in a cross-referencing manner, comparing uninsured populations with job-based and community-based insurance enrollees. Results show that, after full adjustment, the odds of physician visits were lower among urban insurance enrollees (OR = 0.67, 95% CI: 0.47–0.97) than rural residents. For hospital admissions, both uninsured elders (OR = 0.65, 95% CI: 0.48–0.87) and community-based insurance enrollees (OR = 0.67, 95% CI: 0.47–0.97) had lower use of inpatient care than job-based insurance enrollees, demonstrating inequitable access. This study suggests that policy efforts should unify the social health insurance system to combat existing insurance-related inequities in health care use for underserved aging populations.

Power matters: The role of power and morality needs in competitive victimhood among advantaged and disadvantaged groups

Competitive victimhood denotes group members' efforts to establish that their ingroup has suffered greater injustice than an adversarial outgroup. Previous research in contexts of structural inequality has stressed the role of the need to defend the ingroup's moral identity, rather than the need for power, in leading advantaged and disadvantaged group members to engage in competitive victimhood. Focusing on the structural inequality between Jewish and Arab citizens of Israel (Study 1) and Israeli women and men (Study 2), we found that across all groups and contexts, power needs predicted competitive victimhood. Also, the need to protect the ingroup's moral reputation (i.e., defensive moral needs) positively predicted competitive victimhood, whereas among advantaged group members, the need to protect the ingroup's moral essence negatively predicted competitive victimhood. Finally, exploratory analyses revealed that competitive victimhood correlated, positively for advantaged and negatively for disadvantaged group members, with support for policies securing realistic and symbolic resources for the disadvantaged group. Theoretical and practical implications of these results, which are consistent with the logic of the needs-based model of reconciliation, are discussed.

Profound barriers to basic cancer care most notably experienced by uninsured women: Historical note on the present policy considerations

America is considering the replacement of Obamacare with Trumpcare. This historical cohort revisited pre-Obamacare colon cancer care among people living in poverty in California (N = 5,776). It affirmed a gender by health insurance hypothesis on nonreceipt of surgery such that uninsured women were at greater risk than uninsured men. Uninsured women were three times as likely as insured women to be denied access to such basic care. Similar men were two times as likely. America is bound to repeat such profound health care inequities if Obamacare is repealed. Instead, Obamacare ought to be retained and strengthened in all states, red and blue.