Objective To examine whether overall lifestyles mediate associations of socioeconomic status (SES) with mortality and incident cardiovascular disease (CVD) and the extent of interaction or joint relations of lifestyles and SES with health outcomes. Design Population based cohort study. Setting US National Health and Nutrition Examination Survey (US NHANES, 1988-94 and 1999-2014) and UK Biobank. Participants 44 462 US adults aged 20 years or older and 399 537 UK adults aged 37-73 years. Exposures SES was derived by latent class analysis using family income, occupation or employment status, education level, and health insurance (US NHANES only), and three levels (low, medium, and high) were defined according to item response probabilities. A healthy lifestyle score was constructed using information on never smoking, no heavy alcohol consumption (women ≤1 drink/day; men ≤2 drinks/day; one drink contains 14 g of ethanol in the US and 8 g in the UK), top third of physical activity, and higher dietary quality. Main outcome measures All cause mortality was the primary outcome in both studies, and CVD mortality and morbidity in UK Biobank, which were obtained through linkage to registries. Results US NHANES documented 8906 deaths over a mean follow-up of 11.2 years, and UK Biobank documented 22 309 deaths and 6903 incident CVD cases over a mean follow-up of 8.8-11.0 years. Among adults of low SES, age adjusted risk of death was 22.5 (95% confidence interval 21.7 to 23.3) and 7.4 (7.3 to 7.6) per 1000 person years in US NHANES and UK Biobank, respectively, and age adjusted risk of CVD was 2.5 (2.4 to 2.6) per 1000 person years in UK Biobank. The corresponding risks among adults of high SES were 11.4 (10.6 to 12.1), 3.3 (3.1 to 3.5), and 1.4 (1.3 to 1.5) per 1000 person years. Compared with adults of high SES, those of low SES had higher risks of all cause mortality (hazard ratio 2.13, 95% confidence interval 1.90 to 2.38 in US NHANES; 1.96, 1.87 to 2.06 in UK Biobank), CVD mortality (2.25, 2.00 to 2.53), and incident CVD (1.65, 1.52 to 1.79) in UK Biobank, and the proportions mediated by lifestyle were 12.3% (10.7% to 13.9%), 4.0% (3.5% to 4.4%), 3.0% (2.5% to 3.6%), and 3.7% (3.1% to 4.5%), respectively. No significant interaction was observed between lifestyle and SES in US NHANES, whereas associations between lifestyle and outcomes were stronger among those of low SES in UK Biobank. Compared with adults of high SES and three or four healthy lifestyle factors, those with low SES and no or one healthy lifestyle factor had higher risks of all cause mortality (3.53, 3.01 to 4.14 in US NHANES; 2.65, 2.39 to 2.94 in UK Biobank), CVD mortality (2.65, 2.09 to 3.38), and incident CVD (2.09, 1.78 to 2.46) in UK Biobank. Conclusions Unhealthy lifestyles mediated a small proportion of the socioeconomic inequity in health in both US and UK adults; therefore, healthy lifestyle promotion alone might not substantially reduce the socioeconomic inequity in health, and other measures tackling social determinants of health are warranted. Nevertheless, healthy lifestyles were associated with lower mortality and CVD risk in different SES subgroups, supporting an important role of healthy lifestyles in reducing disease burden.

https://www.bmj.com/content/bmj/373/bmj.n604.full.pdf

Associations of healthy lifestyle and socioeconomic status with mortality and incident cardiovascular disease: two prospective cohort studies.

Social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are the non-medical factors that influence health outcomes. Evidence indicates that health behaviours, comorbidities and disease-modifying therapies all contribute to multiple sclerosis (MS) outcomes; however, our knowledge of the effects of social determinants — that is, the ‘risks of risks’ — on health has not yet changed our approach to MS. Assessing and addressing social determinants of health could fundamentally improve health and health care in MS; this approach has already been successful in improving outcomes in other chronic diseases. In this narrative Review, we identify and discuss the body of evidence supporting an effect of many social determinants of health, including racial background, employment and social support, on MS outcomes. It must be noted that many of the published studies were subject to bias, and screening tools and/or practical interventions that address these social determinants are, for the most part, lacking. The existing work does not fully explore the potential bidirectional and complex relationships between social determinants of health and MS, and the interpretation of findings is complicated by the interactions and intersections among many of the identified determinants. On the basis of the reviewed literature, we consider that, if effective interventions targeting social determinants of health were available, they could have substantial effects on MS outcomes. Therefore, funding for and focused design of studies to evaluate and address social determinants of health are urgently needed. Here, the authors discuss the potential effects of social determinants of health on multiple sclerosis risk and outcomes. They suggest that addressing these determinants of health could substantially improve the lives of individuals with multiple sclerosis and call for more research. 

/pdf/social-determinants-of-health-in-multiple-sclerosis-5b5h4yx0.pdf

Social determinants of health in multiple sclerosis

Reducing disparities in adverse pregnancy outcomes in the United States.

Background: Although the poor health of people experiencing homelessness is increasingly recognised in health discourse, there is a dearth of research that has quantified the nature and magnitude of chronic health issues and morbidity among people experiencing homelessness, particularly in the Australian context. Methods: Analysis of the medical records of 2068 “active” patients registered with a specialist homeless health service in Perth, Western Australia as of 31 December 2019. Results: Overall, 67.8% of patients had at least one chronic physical health condition, 67.5% had at least one mental health condition, and 61.6% had at least one alcohol or other drug (AOD) use disorder. Nearly half (47.8%) had a dual diagnosis of mental health and AOD use issues, and over a third (38.1%) were tri-morbid (mental health, AOD and physical health condition). Three-quarters (74.9%) were multimorbid or had at least two long-term conditions (LTCs), and on average, each patient had 3.3 LTCs. Conclusions: The study findings have substantial implications from both a health risk and healthcare treatment perspective for people experiencing homeless. The pervasiveness of preventable health conditions among people experiencing homelessness also highlights the imperative to improve the accessibility of public health programs and screening to reduce their morbidity and premature mortality.

Multimorbidity among People Experiencing Homelessness-Insights from Primary Care Data.

People living in more deprived areas of high-income countries have lower cancer survival than those in less deprived areas. However, associations between individual-level socio-economic circumstances and cancer survival are relatively poorly understood. Moreover, few studies have addressed contextual effects, where associations between individual-level socio-economic status and cancer survival vary depending on area-based deprivation.Using 9276 individual-level observations from a longitudinal study in England and Wales, we examined the association with cancer survival of area-level deprivation and individual-level occupation, education, and income, for colorectal, prostate and breast cancer patients aged 20-99 at diagnosis. With flexible parametric excess hazard models, we estimated excess mortality across individual-level and area-level socio-economic variables and investigated contextual effects.For colorectal cancers, we found evidence of an association between education and cancer survival in men with Excess Hazard Ratio (EHR) = 0.80, 95% Confidence Interval (CI) = 0.60;1.08 comparing "degree-level qualification and higher" to "no qualification" and EHR = 0.74 [0.56;0.97] comparing "apprenticeships and vocational qualification" to "no qualification", adjusted on occupation and income; and between occupation and cancer survival for women with EHR = 0.77 [0.54;1.10] comparing "managerial/professional occupations" to "manual/technical," and EHR = 0.81 [0.63;1.06] comparing "intermediate" to "manual/technical", adjusted on education and income. For breast cancer in women, we found evidence of an association with income (EHR = 0.52 [0.29;0.95] for the highest income quintile compared to the lowest, adjusted on education and occupation), while for prostate cancer, all three individual-level socio-economic variables were associated to some extent with cancer survival. We found contextual effects of area-level deprivation on survival inequalities between occupation types for breast and prostate cancers, suggesting wider individual-level inequalities in more deprived areas compared to least deprived areas. Individual-level income inequalities for breast cancer were more evident than an area-level differential, suggesting that area-level deprivation might not be the most effective measure of inequality for this cancer. For colorectal cancer in both sexes, we found evidence suggesting area- and individual-level inequalities, but no evidence of contextual effects.Findings highlight that both individual and contextual effects contribute to inequalities in cancer outcomes. These insights provide potential avenues for more effective policy and practice. 

https://bmcpublichealth.biomedcentral.com/counter/pdf/10.1186/s12889-022-12525-1

An investigation of cancer survival inequalities associated with individual-level socio-economic status, area-level deprivation, and contextual effects, in a cancer patient cohort in England and Wales

Patients’ socioeconomic circumstances should be routinely documented in their healthcare record, say Andrew Moscrop and colleagues

https://www.bmj.com/content/bmj/371/bmj.m4150.full.pdf

If social determinants of health are so important, shouldn't we ask patients about them?

Objective To guide family physicians working in a range of primary care clinical settings on how to provide care and support for patients who are vulnerably housed or experiencing homelessness. Sources of information The approach integrates recommendations from evidence-based clinical guidelines, the views of persons with lived experience of homelessness, the theoretical tenets of the Patient’s Medical Home framework, and practical lessons learned from family physicians working in a variety of clinical practice settings. Main message Family physicians can use simple and effective approaches to identify patients who are homeless or vulnerably housed; take initial steps to initiate access to housing, income assistance, case management, and treatment for substance use; and work collaboratively using trauma-informed and anti-oppressive approaches to better assist individuals with health and social needs. Family physicians also have a powerful advocacy voice and can partner with local community organizations and people with lived experience of homelessness to advocate for policy changes to address social inequities. Conclusion Family physicians can directly address the physical health, mental health, and social needs of patients who are homeless or vulnerably housed. Moreover, they can champion outreach and onboarding programs that assist individuals who have experienced homelessness in accessing patient medical homes and can advocate for broader action on the underlying structural causes of homelessness.

https://www.cfp.ca/content/cfp/66/8/563.full.pdf

Caring for patients with lived experience of homelessness

Resume Objectif Guider les medecins de famille de divers types de pratique familiale quant a la facon de dispenser des soins et du soutien aux patients loges precairement ou qui vivent l’itinerance. Sources d’information L’approche integre les recommandations tirees des lignes directrices cliniques fondees sur les donnees probantes, l’opinion des personnes avec une experience vecue de l’itinerance, les principes theoriques du cadre de travail du Centre de medecine de famille et des lecons pratiques provenant de medecins de famille qui travaillent dans des contextes cliniques varies. Message principal Les medecins de famille peuvent utiliser des approches simples et efficaces pour identifier les patients itinerants ou loges precairement; franchir les premieres etapes pour faciliter l’acces au logement, a l’aide financiere, a la gestion de cas et au traitement de la toxicomanie; et collaborer en faisant appel a des approches anti-oppressives et qui tiennent compte des traumatismes pour mieux venir en aide aux personnes qui ont des besoins sur les plans social et sanitaire. Les medecins de famille ont un solide pouvoir de plaidoyer et peuvent s’associer aux organisations communautaires locales et aux personnes ayant vecu l’itinerance pour revendiquer des reformes politiques qui tiennent compte des iniquites sociales. Conclusion Les medecins de famille ont la capacite de repondre directement aux besoins sociaux et aux besoins en matiere de sante physique et de sante mentale des patients itinerants ou loges precairement. En outre, ils peuvent promouvoir les programmes d’approche et d’integration qui aident les personnes avec une experience vecue de l’itinerance a acceder aux centres de medecine de famille et peuvent militer pour l’adoption de mesures generales visant a contrer les causes structurelles sous-jacentes de l’itinerance.

https://www.cfp.ca/content/cfp/66/8/e204.full.pdf

Soigner les patients ayant connu l’itinérance.

We are grateful for the interest shown in our paper and for the responses on The BMJ website and on social media.1

Soljak emphasises the importance of occupation, both as a marker of social class and as a determinant of occupational hazards.2 He points to workers at higher risk in the current context of covid-19. The lack of socioeconomic data …

https://www.bmj.com/content/bmj/372/bmj.n177.full.pdf

Authors' reply to Soljak, Robson and colleagues, and Kelly.

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If social determinants of health are so important, shouldn't we ask patients about them?

Caring for patients with lived experience of homelessness

Soigner les patients ayant connu l’itinérance.

Authors' reply to Soljak, Robson and colleagues, and Kelly.