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Responding to the need for qualitative research that reveals the lived reality of how forced migrants endured the COVID-19 pandemic this paper presents findings from eleven interviews with asylum seekers residing in Ireland's Direct Provision (DP) accommodation system that detail care deficits before, during and after COVID-19 along with analysis of how care is discussed within Irish policy documents concerned with the health and wellbeing of asylum seekers. The research contributes personal testimony and documentary evidence of the inability of DP to properly adapt to the pandemic and its failure to protect the health and wellbeing of asylum seekers given pre-existing care deficits. The paper argues that an ethic of care practiced for and with asylum seekers must ensure they are not re-traumatised, and their health disparities are not exacerbated during public health crises and beyond. The findings are relevant to efforts to reform how international protection responsibilities are enacted in Ireland and other destinations of forced migrants, including EU member states.

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The objective of this study was to evaluate the racial and ethnic disparities in delivery hospitalizations involving severe maternal morbidity (SMM) by location of residence and community income. We used the 2016 to 2019 Healthcare Cost and Utilization Project National Inpatient Sample. International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify delivery hospitalizations with SMM. Using logistic regression models, we examined the association between race and ethnicity and delivery hospitalizations involving SMM. In adjusted analyses, the models were stratified by location of residence and community income and adjusted for patient and hospital characteristics. In rural areas, non-Hispanic Black women (AOR 1.50; 95% CI 1.25-1.79) and women of other races (AOR 1.32; 95% CI 1.03-1.69) had an increased odds of experiencing a delivery hospitalization involving SMM when compared to non-Hispanic White women. In micropolitan areas, non-Hispanic Black women (AOR 1.88; 95% CI 1.79-1.97), non-Hispanic Asian/Pacific Islander women (AOR 1.54; 95% CI 1.16-2.05), and women of other races (AOR 1.31; 95% CI 1.03-1.67) had an increased odds of experiencing a delivery hospitalization involving SMM when compared to non-Hispanic White women. Non-Hispanic Black women also had increased odds of experiencing a delivery hospitalization involving SMM in communities with the lowest income (quartile 1) (AOR 1.59; 95% CI 1.49-1.66), middle income (quartiles 2 and 3) (AOR 1.81; 95% CI 1.72-1.91), and highest income (AOR 2.09; 95% CI 1.90-2.29) when compared to non-Hispanic White women. We found that location of residence and community income are associated with racial and ethnic differences in SMM in the United States. These factors, outside of individual factors assessed in previous studies, provide a better understanding of some of the structural and systemic factors that may contribute to SMM.

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The purpose of this perspective is to discuss the imperative for curricular change that focuses on the utilization of structural competency to promote excellence in physical therapist professional education, transform society, and achieve health equity. Pedagogy centered around biomedical and social determinants of health (SDOH) models are limited in that they lack self-reflexivity, encode social identities like race and gender as risk factors for poor health, fail to examine structural causes of health inequity, conflate SDOH and the structural forces that shape their unequal distribution, and overlook instances of injustice. Promoting health equity will require structural competency, an approach that considers drivers of health beyond the individual and their conditions of daily living (ie, SDOH). Utilizing this approach in physical therapist professional education will help learners understand the evolving needs of society in a deeper, more holistic way: one that considers structural determinants of health as the primary drivers of health equity and inequity. IMPACT STATEMENT: This paper provides a perspective on how physical therapist professional education can promote health equity for all by embracing an equity-focused, structurally competent pedagogy/approach.

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INTRODUCTION: In 2021, the structural determinants of health (SDOH) were added to the Accreditation Council of Graduate Medical Education common program requirements for all accredited residency programs, including general surgery. In this study, we sought to explore the current scope of, and concepts used in, health disparities curricula for general surgery residents, specifically investigating how general surgery residents learn about health disparities and the SDOH. METHODS: We searched PubMed, EMBASE, Education Research Complete (EBSCOhost), and Web of Science Core Collection using keywords related to health disparities and the SDOH. Inclusion criteria consisted of all studies published after 2005 that discussed health disparities curricula for Accreditation Council of Graduate Medical Education-accredited general surgery residency programs. Five thousand three hundred seventeen articles were screened using a two-phase process. Data extraction and analysis was performed using critical review methods. RESULTS: Seventeen articles were identified. Within these articles, seven unique health disparities curricula were found. All seven of the identified curricula employed cultural frameworks as methods to mitigate health disparities. Three curricula, all published after 2011, included education on the SDOH. A wide variety of educational methods were utilized; in-person didactics was the most common. CONCLUSIONS: In the current literature, culture continues to play a large role in health disparities training for general surgery residents. Though further efforts are needed to understand the methods used in programs that have not published scholarly work, it is imperative to ensure that residents are provided with the sociopolitical perspective needed to understand the SDOH and serve all patients, including those affected by health disparities.

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PURPOSE OF REVIEW: To analyze how social and structural determinants of health and social injustice impact the risk of obesity, its treatment and treatment outcomes, and to explore the implications for prevention and future treatment interventions. RECENT FINDINGS: Racial and ethnic minorities, such as non-Hispanic Black adults and Hispanic adults, and adults with a low socioeconomic status have a greater risk of obesity than non-Hispanic white adults and adults with a high socioeconomic status. The underlying causes of obesity disparities include obesogenic neighborhood environments, inequities in access to obesity treatment, and lack of access to affordable nutrient-dense foods. Experts have called for interventions that address the social and structural determinants of obesity disparities. Population-based interventions that focus on improving neighborhood conditions, discouraging the consumption of unhealthy foods and beverages, expanding access to obesity treatment, and ensuring equitable access to fruits and vegetables have been proven to be effective. There is a growing body of evidence that shows the relationship between social and structural determinants of health and injustice on disparities in obesity among racial and ethnic minorities and individuals with a low SES. Population-based, equity-focused interventions that address the underlying causes of obesity disparities are needed to reduce obesity disparities and improve the health outcomes of minoritized and marginalized groups.

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INTRODUCTION: Social determinants of health (SDH) are nonbiologic influencers of disease and health care disparities. This study focused on understanding the association between SDH and urology clinic "no-show" visits within a diverse urban population. METHODS: We retrospectively identified patients scheduled for urology clinic visits from October 2015 to June 2022 who completed a 10-question social needs screener. For each patient, demographic variables, and number of missed clinic appointments were abstracted. Multivariable logistic regression was performed to determine the association of unmet social needs and no-shows. RESULTS: Of 5761 unique patients seen in clinic, 5293 completed a social needs screener. Respondents were most commonly male (62.8%), Hispanic (50.3%), English-speaking (75.5%), and insured by Medicare (46.0%). Overall, 8.2%, 4.6%, and 6.1% reported 1, 2, and 3+ unmet social needs, respectively. Most patients (61.7%) had 0 no-shows; 38.3% had 1+ no-shows. Between the 0 and 1+ no-show groups, we found significant differences with respect to gender (P =.05), race/ethnicity (P = .002), preferred language (P = .006), insurance payer (P < .001), SDH status (P = .003), and total number of unmet social needs (P = .006). On multivariable analysis, patients concerned about housing quality (odds ratio [OR] = 1.50, P = .002), legal help (OR = 1.53, P = .009), and with 3+ unmet social needs (OR = 1.39, P = .006) were more likely to have 1+ no-shows. CONCLUSIONS: Unmet social needs were associated with increased no-show urology clinic visits. Routine social needs screening could identify at-risk patients who would benefit from services. This may be particularly pertinent for patients with urgent diagnoses or those requiring frequent office visits where missing appointments could impact morbidity and mortality.

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Effective nutrition training is fundamental to medical education. Current training is inadequate and can cause harm to students and patients alike; it leaves physicians unprepared to counsel on nutrition, places undue focus on weight and body mass index (BMI), can exacerbate anti-obesity bias, and increase risk for development of eating disorders, while neglecting social determinants of health and communication skills. Physicians and educators hold positions of influence in society; what we say and how we say it matters. We propose actionable approaches to improve nutrition education to minimize harm and pursue evidence-based, effective, and equitable healthcare.

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BACKGROUND: A challenge facing many Academic Health Centers (AHCs) attempting to revise health professions education to include the impact of racism as a social and structural determinant of health (SSDoH) is a lack of broad faculty expertise to reinforce and avoid undermining learning modules addressing this topic. To encourage an institutional culture that is in line with new anti-racism instruction, we developed a six-part educational series on the history of racism in America and its impact on contemporary health inequities for teaching structural competency to health professions academicians. METHODS: We developed a six-hour elective continuing education (CE) series for faculty and staff with the following objectives: (1) describe and discuss race as a social construct; (2) describe and discuss the decolonization of the health sciences and health care; (3) describe and discuss the history of systemic racism and structural violence from a socio-ecological perspective; and (4) describe and discuss reconciliation and repair in biomedicine. The series was spread over a six-month period and each monthly lecture was followed one week later by an open discussion debriefing session. Attendees were assessed on their understanding of each objective before and after each series segment. RESULTS: We found significant increases in knowledge and understanding of each objective as the series progressed. Attendees reported that the series helped them grapple with their discomfort in a constructive manner. Self-selected attendees were overwhelmingly women (81.8%), indicating a greater willingness to engage with this material than men. CONCLUSIONS: The series provides a model for AHCs looking to promote anti-racism and structural competency among their faculty and staff.

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BACKGROUND: While justice is promised to all U.S. citizens, the truth is that the pathway to equity and justice in health is riddled with obstacles for many marginalized and minoritized groups. The United States ranks lower on crucial health measures than its high-income peer countries, reflecting differences in health outcomes for marginalized and minoritized populations. PURPOSE: Promoting equity and justice in health is vital as health shapes the daily experiences of individuals and communities, specifically those from marginalized and minoritized backgrounds. METHOD: This paper highlights the health care system and sociopolitical factors contributing to the longstanding structural barriers that impede health and the need for structural competence, advocacy, and activism in the nursing workforce. DISCUSSION: Understanding systemic issues underlying health inequities provides an opportunity to develop targeted strategies to eliminate practices perpetuating inequities and pave the way for everyone to have a fair and just opportunity to be as healthy as possible. CONCLUSION: Specific education, practice, research, and policy recommendations can advance equity and justice in health.

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INTRODUCTION: Type 2 diabetes impacts millions and poor maintenance of diabetes can lead to preventable complications, which is why achieving and maintaining target A1C levels is critical. Thus, we aimed to examine inequities in A1C over time, place, and individual characteristics, given known inequities across these indicators and the need to provide continued surveillance. METHODS: Secondary de-identified data from medical claims from a single payer in Texas was merged with population health data. Generalized Estimating Equations were utilized to assess multiple years of data examining the likelihood of having non-target (>7% and ≥7%, two slightly different cut points based on different sources) and separately uncontrolled (>9%) A1C. Adults in Texas, with a Type 2 Diabetes (T2D) flag and with A1C reported in first quarter of the year using data from 2016 and 2019 were included in analyses. RESULTS: Approximately 50% had A1Cs within target ranges (<7% and ≤7%), with 50% considered having non-target (>7% and ≥7%) A1Cs; with 83% within the controlled ranges (≤9%) as compared to approximately 17% having uncontrolled (>9%) A1Cs. The likelihood of non-target A1C was higher among those individuals residing in rural (vs urban) areas (P < .0001); similar for the likelihood of reporting uncontrolled A1C, where those in rural areas were more likely to report uncontrolled A1C (P < .0001). In adjusted analysis, ACA enrollees in 2016 were approx. 5% more likely (OR = 1.049, 95% CI = 1.002-1.099) to have non-target A1C (≥7%) compared to 2019; in contrast non-ACA enrollees were approx. 4% more likely to have non-target A1C (≥7%) in 2019 compared to 2016 (OR = 1.039, 95% CI = 1.001-1.079). In adjusted analysis, ACA enrollees in 2016 were 9% more likely (OR = 1.093, 95% CI = 1.025-1.164) to have uncontrolled A1C compared to 2019; whereas there was no significant change among non-ACA enrollees. CONCLUSIONS: This study can inform health care interactions in diabetes care settings and help health policy makers explore strategies to reduce health inequities among patients with diabetes. Key partners should consider interventions to aid those enrolled in ACA plans, those in rural and border areas, and who may have coexisting health inequities.

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State-level COVID-19 vaccination rates among older adults have been uneven in the United States. Due to the immunocompromised nature of older adults, vaccine hesitancy increases the risk of morbidity and mortality. This study aims to determine the association between the social determinants of health, the structural determinants of health, and COVID-19 vaccine hesitancy among older adults in the United States. Secondary data from the Health and Retirement Study (HRS) dataset were used. A descriptive analysis and multinomial multivariable logistic regression were performed to examine the association of the independent variables-gender, age, race, immigration status, marital status, broadband internet access, social security income, Medicare coverage, education, and frequency of religious service-with the dependent variable, vaccine hesitancy. Compared to the respondents with no vaccine hesitancy and without the specific predictor, the respondents who reported religious attendance at least once/week were more likely to be "somewhat hesitant", divorced respondents had higher odds of being "somewhat hesitant", and older adults aged 65-74 years were more likely to be "very hesitant" or "somewhat hesitant" about the COVID-19 vaccine. Compared to the respondents with no vaccine hesitancy and without the specific predictor, females had higher odds of being "very hesitant", "somewhat hesitant", or a "little hesitant", and African Americans were more likely to be "very hesitant", "somewhat hesitant", or a "little hesitant" about the COVID-19 vaccine. Addressing these factors may limit the barriers to vaccine uptake reported among older adults and improve herd immunity among the immunocompromised population.

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PURPOSE OF REVIEW: Cardiovascular disease (CVD) is the leading cause of mortality in people who have diabetes. Racial and ethnic minorities with diabetes have suboptimal management of cardiovascular risk factors, leading to higher mortality. Social and structural determinants of health are external factors that influence an individual's ability to choose positive health behaviors. In this review, we will discuss cardiovascular complications in people who have diabetes and their relationship to social determinants of health (SDOH). RECENT FINDINGS: Recent innovations in diabetes treatment, including new devices and medications, have improved care and survival. However, disparities in the availability of these treatments to racial and ethnic minorities may contribute to continued inequities in CVD outcomes. Racial/ethnic disparities in CVD relate to inequities in economic opportunity, education and health literacy, neighborhoods and social cohesion, and health care access and quality driven by structural racism.

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Background: Few studies have investigated associations between perceived social determinants of health (SDOH) and Alzheimer's disease and related dementia (ADRD) biomarkers or between SDOH and resilience against ADRD. Objective: To examine associations between perceived and objective SDOH and ADRD-related outcomes. Methods: We used cross-sectional data on≥50-year-olds without dementia in the Healthy Brain Initiative (n = 162). Questionnaires captured trust in neighbors and indices of perceived neighborhood greenspace access, time spent in neighborhood greenspaces, and interpersonal discrimination. Residential addresses were linked to 2021 Area Deprivation Index scores. The Vulnerability Index (VI) is based on 12 dementia risk factors (e.g., age, race/ethnicity, diabetes) and Resilience Index (RI) is based on 6 protective factors (e.g., diet, mindfulness, physical activity). Cognitive measured included number symbol coding task and Montreal Cognitive Assessment. Biomarkers included Aß42/40 and pTau-217/npTau-217, hippocampal and white matter hyperintensity volume, lipoprotein A, and high-sensitivity c-reactive protein. Results: Perceived greater access to greenspaces (estimate = 2.83, 95% CI = 1.40-4.26) and greater time in neighborhood greenspaces were associated with greater RI scores (estimate = 2.30, 95% CI = 1.24-3.35). Reporting greater discrimination (estimate = 0.10, 95% CI = 0.04-0.16) and living in higher deprivation neighborhoods were associated with greater VI scores (estimate = 0.017, 95% CI = 0.003-0.032). Greater discrimination was associated with greater white matter hyperintensity volume (estimate = 0.27, 95% CI = 0.04-0.51). Conclusions: Perceived greenspace access and time spent in greenspaces were associated with resilience against ADRD, and interpersonal discrimination was associated with vulnerability to ADRD. Future work needs to validate perceived SDOH measures, examine associations in racially/ethnic diverse populations, and investigate longitudinal associations between SDOH and ADRD-related biomarkers.

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Background: Food insecurity is a major public health concern in the United States, particularly for pregnant and postpartum individuals. In 2020, ∼13.8 million (10.5%) U.S. households experienced food insecurity. However, the association between food security and pregnancy outcomes in the United States is poorly understood. Purpose: The purpose of this review was to critically appraise the state of the evidence related to food insecurity as a determinant of health within the context of pregnancy in the United States. We also explored the relationship between food insecurity and pregnancy outcomes. Methods: PubMed, CINAHL, Web of Science, and Food and Nutrition Science databases were used. The inclusion criteria were peer-reviewed studies about food (in)security, position articles from professional organizations, and policy articles about pregnancy outcomes and breastfeeding practices. Studies conducted outside of the United States and those without an adequate definition of food (in)security were excluded. Neonatal health outcomes were also excluded. Included articles were critically appraised with the STROBE and Critical Appraisal Skills Program checklists. Results: Nineteen studies met the inclusion criteria. Inconsistencies exist in defining and measuring household food (in)security. Pregnant and postpartum people experienced several adverse physiological and psychological outcomes that impact pregnancy compared with those who do not. Intersections between neighborhood conditions and other economic hardships were identified. Findings regarding the impact of food insecurity on breastfeeding behaviors were mixed, but generally food insecurity was not associated with poor breastfeeding outcomes in adjusted models. Conclusion: Inconsistencies in definitions and measures of food security limit definitive conclusions. There is a need for standardizing definitions and measures of food insecurity, as well as a heightened awareness and policy change to alleviate experiences of food insecurity.

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This study explores the influence of mental health and structural determinants of health on motivational readiness for health behaviour change in 1462 Spanish primary healthcare users. Chi-square test and structural equation modelling were performed. Results showed that depression and anxiety were negatively associated with being in the action stages of motivational readiness for a healthy diet and physical activity. This association was statistically significant only for motivational readiness for a healthy diet and depression (ß=-0.076;p=0.046). Furthermore, women and workers were more likely to be in the action stages of motivational readiness for a healthy diet while older adults and adults with higher health-related quality of life were more likely to be in the action stages of motivational readiness for physical activity. The present study suggests that structural (being older, being a woman and being employed) and intermediary (suffering from depression and higher health-related quality of life) determinants of health influence motivational readiness for health behaviour changes.

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Background: Black birthing people have significantly higher risks of maternal mortality and morbidity compared with White people. Preconception chronic conditions increase the risk of adverse pregnancy outcomes, yet little is known about disparities in preconception health. This study applies an intersectional framework to examine the simultaneous contributions of racial marginalization and economic deprivation in determining disparities in preconception risk factors and access to care. Methods: Using data from the Pregnancy Risk Assessment Monitoring System, 2016-2020 (N = 123,697), we evaluated disparities by race and income in self-reported preconception hypertension, diabetes, obesity, depression, and smoking, as well as preconception insurance coverage and utilization of health care. We estimated linear regression models and calculated predicted probabilities. Results: Black respondents experienced higher probabilities of preconception obesity and high blood pressure at every income level compared with White respondents. Higher income did not attenuate the probability of obesity for Black respondents (linear trend p = 0.21), as it did for White respondents (p < 0.001). Conversely, while White respondents with low income were at higher risk of preconception depression and smoking than their Black counterparts, higher income was strongly associated with reduced risk, with significantly steeper reductions for White compared with Black respondents (difference in trends p < 0.001 for both risk factors). White respondents had higher probabilities of utilizing preconception care across all income levels, despite similar probabilities of insurance coverage. Conclusions: Higher income does not protect against the risk of preconception obesity and other preconception risk factors for Black birthing people as it does for White birthing people. Results point to the need to consider multiple forms of intersecting structural factors in policy and intervention research to improve preconception and maternal health.

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Patient-centered care is gaining widespread acceptance by the medical and lay communities and is increasingly recognized as a goal of high-quality health care delivery. Patient-centered care is based on ethical principles and aims at establishing a partnership between the health care team and patient, family member, or both in the care planning and decision-making process. Patient-centered care involves providing respectful care by tailoring management decisions to patients' beliefs, preferences, and values. A collaborative care approach can enhance patient engagement, foster shared decision-making that aligns with patient values and goals, promote more personalized and effective cardiovascular care, and potentially improve patient outcomes. The objective of this scientific statement is to inform health care professionals and stakeholders about the role and impact of patient-centered care in adult cardiovascular medicine. This scientific statement describes the background and rationale for patient-centered care in cardiovascular medicine, provides insight into patient-oriented medication management and patient-reported outcome measures, highlights opportunities and strategies to overcome challenges in patient-centered care, and outlines knowledge gaps and future directions.

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The field of environmental epigenetics is uniquely suited to investigate biologic mechanisms that have the potential to link stressors to health disparities. However, it is common practice in basic epigenetic research to treat race as a covariable in large data analyses in a way that can perpetuate harmful biases without providing any biologic insight. In this article, we i) propose that epigenetic researchers open a dialogue about how and why race is employed in study designs and think critically about how this might perpetuate harmful biases; ii) call for interdisciplinary conversation and collaboration between epigeneticists and social scientists to promote the collection of more detailed social metrics, particularly institutional and structural metrics such as levels of discrimination that could improve our understanding of individual health outcomes; iii) encourage the development of standards and practices that promote full transparency about data collection methods, particularly with regard to race; and iv) encourage the field of epigenetics to continue to investigate how social structures contribute to biological health disparities, with a particular focus on the influence that structural racism may have in driving these health disparities.