No abstract

This review article addresses the concept of the social determinants of health (SDH), selected theories, and its application in studies of chronic disease. Once ignored or regarded only as distant or secondary influences on health and disease, social determinants have been increasingly acknowledged as fundamental causes of health afflictions. For the purposes of this discussion, SDH refers to SDH variables directly relevant to chronic diseases and, in some circumstances, obesity, in the research agenda of the Mid-South Transdisciplinary Collaborative Center for Health Disparities Research. The health effects of SDH are initially discussed with respect to smoking and the social gradient in mortality. Next, four leading SDH theories—life course, fundamental cause, social capital, and health lifestyle theory—are reviewed with supporting studies. The article concludes with an examination of neighborhood disadvantage, social networks, and perceived discrimination in SDH research.

Introduction This study examined how perceived racial privilege and perceived racial discrimination in health care varied with race and socioeconomic status (SES). Methods The sample consisted of white, black, and Native American respondents to the Behavioral Risk Factor Surveillance System (2005–2013) who had sought health care in the past 12 months. Multiple logistic regression models of perceived racial privilege and perceived discrimination were estimated. Analyses were performed in 2016. Results Perceptions of racial privilege were less common among blacks and Native Americans compared with whites, while perceptions of racial discrimination were more common among these minorities. In whites, higher income and education contributed to increased perceptions of privileged treatment and decreased perceptions of discrimination. The pattern was reversed in blacks, who reported more discrimination and less privilege at higher income and education levels. Across racial groups, respondents who reported foregone medical care due to cost had higher risk of perceived racial discrimination. Health insurance contributed to less perceived racial discrimination and more perceived privilege only among whites. Conclusions SES is an important social determinant of perceived privilege and perceived discrimination in health care, but its role varies by indicator and racial group. Whites with low education or no health insurance, well-educated blacks, and individuals who face cost-related barriers to care are at increased risk of perceived discrimination. Policies and interventions to reduce these perceptions should target structural and systemic factors, including society-wide inequalities in income, education, and healthcare access, and should be tailored to account for racially specific healthcare experiences.

Purpose Less than 10% of patients enrolled in clinical trials are minorities. The patient navigation model has been used to improve access to medical care but has not been evaluated as a tool to increase the participation of minorities in clinical trials. The Increasing Minority Participation in Clinical Trials project used patient navigators (PNs) to enhance the recruitment of African Americans for and their retention in therapeutic cancer clinical trials in a National Cancer Institute–designated comprehensive cancer center. Methods Lay individuals were hired and trained to serve as PNs for clinical trials. African American patients potentially eligible for clinical trials were identified through chart review or referrals by clinic nurses, physicians, and social workers. PNs provided two levels of services: education about clinical trials and tailored support for patients who enrolled in clinical trials. Results Between 2007 and 2014, 424 African American patients with cancer were referred to the Increasing Minority Participation in Clinical Trials project. Of those eligible for a clinical trial (N = 378), 304 (80.4%) enrolled in a trial and 272 (72%) consented to receive patient navigation support. Of those receiving patient navigation support, 74.5% completed the trial, compared with 37.5% of those not receiving patient navigation support. The difference in retention rates between the two groups was statistically significant (P < .001). Participation of African Americans in therapeutic cancer clinical trials increased from 9% to 16%. Conclusion Patient navigation for clinical trials successfully retained African Americans in therapeutic trials compared with non–patient navigation trial participation. The model holds promise as a strategy to reduce disparities in cancer clinical trial participation. Future studies should evaluate it with racial/ethnic minorities across cancer centers.

Introduction This study investigates social determinants of systemic inflammation, focusing on race, SES, and perceived discrimination. Methods Data on 884 white and 170 black participants were obtained from the Survey of Midlife in the U.S., a cross-sectional observational study combining survey measures, anthropometry, and biomarker assay. Data, collected in 2004–2009, were analyzed in 2016. Main outcome measures were fasting blood concentrations of C-reactive protein, interleukin 6, fibrinogen, and E-selectin. For each biomarker, series of multivariate linear regression models were estimated for the pooled sample and separately for blacks and whites. Full models included social determinants; psychological, lifestyle, and health factors; and demographic covariates. Results Bivariate analyses indicated higher concentrations of all inflammation markers among blacks compared with whites (p<0.001). In fully adjusted models using the pooled sample, racial differences persisted for interleukin 6 (p<0.001) and fibrinogen (p<0.01). For E-selectin and C-reactive protein, racial differences were explained after adjusting for covariates. Education was linked to lower fibrinogen concentration (p<0.05) in the fully adjusted model and C-reactive protein concentration (p<0.01) after adjusting for demographic factors and income. Lifetime perceived discrimination was related to higher concentrations of fibrinogen (p<0.05) in the fully adjusted model, and higher concentrations of E-selectin and interleukin 6 (p<0.05) after adjusting for socioeconomic status (SES) and demographic factors. Conclusions This study clarifies the contributions of race, SES, and perceived discrimination to inflammation. It suggests that inflammation-reducing interventions should focus on blacks and individuals facing socioeconomic disadvantages, especially low education.

Introduction States in the Mid-South region are among the least healthy in the nation. This descriptive study examines sociodemographic differences in the distribution of chronic diseases and health-related behaviors in the Mid-South versus the rest of the U.S., identifying subgroups at increased risk of chronic disease. Methods Data were obtained from the 2013 Behavioral Risk Factor Surveillance System; analyses were completed in January 2016. Twelve chronic health conditions were assessed: obesity, diabetes, high blood pressure, coronary heart disease, myocardial infarction, stroke, chronic kidney disease, cancer, arthritis, asthma, chronic obstructive pulmonary disease, and depression. Evaluated health-related behaviors included smoking, physical activity, and fruit and vegetable consumption. Age-standardized percentages were reported using complex survey design parameters to enhance generalizability. Results The Mid-South population had increased rates of chronic disease and worse health-related behaviors than the rest of the U.S. population. Mid-South blacks had the highest percentages of obesity, diabetes, high blood pressure, and stroke of all subgroups, along with lower physical activity and fruit and vegetable consumption. In both races and regions, individuals with lower income and education had higher rates of chronic disease and unhealthy behaviors than those with higher income and education. However, black men in both regions had higher obesity and cancer rates in the higher education category. In general, education-level disparities were more pronounced in health-related behaviors, whereas income-level disparities were more pronounced in chronic health conditions. Conclusions Future studies should test tailored interventions to address the specific needs of population subgroups in order to improve their health.

CF disease progression and outcomes are influenced by a number of nongenetic factors, such as material well-being, educational attainment, living and working conditions, physical environment and exposures, family environment, social support, health behaviors, and health care. This review discusses pathways by which financial, educational, and social resources are translated into health advantages in CF. Expert commentary: To achieve equitable CF outcomes, the contribution of nongenetic factors must be emphasized, highlighting the mechanisms through which the social and physical environments influence disease variability.

No abstract