Social determinants of health theoretical frameworks identify health insurance coverage as a determinant of older adults’ osteoporosis diagnoses, which results in health inequities. In this research, we used the longitudinal Health and Retirement Study dataset of older United States adults, sampled biennially from 2012 to 2016. Logistic regressions estimated odds of osteoporosis diagnosis with and without a bone scan and/or hip fracture, holding insurance type, and health and demographic factors constant. Results were validated using the National Health and Nutrition Examination Survey. Probable underdiagnosing is present in older adults identifying as Black/African American and as males without a bone scan, regardless of fracture status, potentially as products of structural racism and sexism. Models including a bone scan show a reduction in disparities. These findings suggest having a bone scan is still crucial for addressing health inequities in older adults, and remedying barriers to accessing a scan is paramount.
Socioeconomic status (SES) is an important social determinant of health inequities that has been linked to chronic conditions, including osteoporosis, but research tends to focus on socioeconomic disadvantage rather than how socioeconomic advantage may facilitate these inequities. This study accounts for structural inequities and assesses the relationship between early-life and later-life SES, and risk of osteoporosis diagnosis. Data come from the nationally representative, population-based cohort Health and Retirement Study and include individuals ages 50 to 90. The outcome variable is osteoporosis diagnosis. Logistic regression models of the relationship between SES and osteoporosis diagnosis are estimated, accounting for demographic, health, and childhood variables. Higher levels of childhood and adult SES link to lower odds of osteoporosis diagnosis. Structural inequities in income and underdiagnosis of osteoporosis among persons identifying as Black/African American were detected. Accounting for bone density scan access, inequities in osteoporosis diagnosis appear to stem from barriers to accessing health care due to financial constraints. The important role of SES and evidence of structural inequities leading to underdiagnosis suggest the critical importance of clinicians receiving Diversity, Equity, and Inclusion training to reduce health inequities.
Demographic and early‐life socioeconomic and parental investment factors may influence later‐life health and development of chronic and progressive diseases, including osteoporosis, a costly condition common among women. The “long arm of childhood” literature links negative early‐life exposures to lower socioeconomic attainment and worse adult health. We build on a small literature linking childhood socioeconomic status (SES) and bone health, providing evidence of whether associations exist between lower childhood SES and maternal investment and higher risk of osteoporosis diagnosis. We further examine whether persons identifying with non‐White racial/ethnic groups experience underdiagnosis. Data from the nationally representative, population‐based cohort Health and Retirement Study (N = 5,490–11,819) were analyzed for participants ages 50–90 to assess these relationships. Using a machine learning algorithm, we estimated seven survey‐weighted logit models. Greater maternal investment was linked to lower odds of osteoporosis diagnosis (odds ratio [OR] = 0.80, 95% confidence interval [CI] = 0.69, 0.92), but childhood SES was not (OR = 1.03, 95% CI = 0.94, 1.13). Identifying as Black/African American (OR = 0.56, 95% CI = 0.40, 0.80) was associated with lower odds, and identifying as female (OR = 7.22, 95% CI = 5.54, 9.40) produced higher odds of diagnosis. There were differences in diagnosis across intersectional racial/ethnic and sex identities, after accounting for having a bone density scan, and a model predicting bone density scan receipt demonstrated unequal screening across groups. Greater maternal investment was linked to lower odds of osteoporosis diagnosis, likely reflecting links to life‐course accumulation of human capital and childhood nutrition. There is some evidence of underdiagnosis related to bone density scan access. Yet results demonstrated a limited role for the long arm of childhood in later‐life osteoporosis diagnosis. Findings suggest that (1) clinicians should consider life‐course context when assessing osteoporosis risk and (2) diversity, equity, and inclusivity training for clinicians could improve health equity. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
Social epidemiology posits that chronic stress from social determinants will lead to a prolonged inflammatory response that may induce accelerated aging as measured, for example, through telomere length (TL). In this paper, we hypothesize variables across demographic, health-related, and contextual/environmental domains influence the body’s stress response, increase inflammation (as measured through high-sensitivity C-reactive protein (hs-CRP)), and thereby lead to shortening of telomeres. This population-based research uses data from the 2008 Health and Retirement Study on participants ages ≤ 54–95 + years, estimating logistic regression and Cox proportional hazards models of variables (with and without confounders) across the domains on shortened TL. A mediation analysis is also conducted. Contrary to expectations, hs-CRP is not associated with risk of shortened TL. Rather, factors related to accessing health care, underlying conditions of frailty, and social inequality appear to predict risk of shorter TL, and models demonstrate considerable confounding. Further, hs-CRP is not a mediator for TL. Therefore, the social determinants of health examined do not appear to follow an inflammatory pathway for shortened TL. The finding of a relationship to social determinants affecting access to health care and medical conditions underscores the need to address social determinants alongside primary care when examining health inequities.
Psychosocial disorders can stem from or have profound effects on one’s health, having been linked to many negative health outcomes. In this study, we hypothesize psychological disorders are associated with a higher risk osteoporosis diagnosis. Self-reported information from years 2012-2016 of the public-use, longitudinal cohort-based Health and Retirement Study, was evaluated from 11,716 American respondents aged 50-90 years old. The odds of scores on the Center for Epidemiological Studies Depression (CESD) scale, and broader psychological disorders (emotional, nervous, psychiatric) on osteoporosis diagnosis (outcome), were estimated with a logistic regression using survey weights, while controlling for sex, logged age, education level, race/ethnicity, family structure during childhood (number of adults), having thyroid disease, allostatic load, and body weight. A McFadden’s R2 (0.18) shows the model fits relatively well. The results demonstrate that as CESD score goes up, there is a 10% increase in odds (OR = 1.1, P < 0.001) of an osteoporosis diagnosis. Similarly, if a respondent reported a doctor told them they had other psychological disorders, the odds of an osteoporosis diagnosis increased by 52% (OR = 1.52, P < 0.001). It is unknown whether the components of broader psychological disorders are caused by decreased quality of life and/or other limitations from osteoporosis or if they contribute to bone health changes in this sample, or both. However, as CESD is a short-term measure (reflecting on the week prior) it is deduced to be as a result of a decreased quality of life associated with some cases of osteoporosis.
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