Journal Review

Adeyemi HS
Neurology Department
Oauthc, Ile-Ife
05/10/2023
Outline
• Title
• Authors/Contributions
• Aim
• Background
• Methods
• Limitations
• Recommendations
• References
Title
• Recommendations on Social Determinants of Health In Neurologic
Disease
Authors/Contributions
Lead author:
• Amytis Towfighi, MD

Co-authors:
• Rachel P. Berger, MD, MPH
• Alexandra M.S. Corley, MD, MPH
• M. Maria Glymour, ScD, MS
• Jennifer J. Manly, PhD
• Lesli E. Skolarus, MD, MS

• Written by authors across 5 states in 6 US universities and cited 68 articles

• Accepted for publication on May 9, 2023
• Published in Neurology Journal Vol 101 on the 15th August, 2023
Aim
• Identifying gaps in eliminating inequities in neurologic risks, care, and
outcomes through addressing specific SDOH

• For future research priorities in screening SDOH, epidemiologic

research and interventions
Background
• Social determinants of health (SDOH) are major drivers of inequities in health

• SDOH are controlled by fundamental, or structural determinants of health –

upstreams SDOH

• The upstreams SDOH stratify people according to factors such as race/ethnicity,

sex, income, education and occupation

• The upstreams SDOH operate via intermediate SDOH and downstreams SDOH to
shape health outcomes
Background Ctd
• Mounting evidence exists that SDOH affect the incidence of
neurologic disease and outcomes

• Adverse individual SDOH, neighbourhood socioeconomic status

(SES) and living in a state with poor public infrastructure are
associated with stoke incidence

• Neighbourhood measured and individually perceived disadvantage are

linked with poorer cognitive function in middle aged and older adults
Background Ctd
• SDOH screening has become more widespread in health care settings

• Little is known regarding optimal tools and timing for screening for
SDOH in populations with neurologic disease

• knowledge about the complex biopsychosocial mechanisms behind

SDOH’s impact on neurologic disease is at infancy stage
Background Ctd
• Despite the interplay between SDOH and neurologic disease, it is
unclear whether there are specific factors to target first for intervention

• Understanding the interactions between specific SDOH and neurologic

disease and knowing whether addressing each SDOH alters the
outcome will be starting points to combat inequities
Background Ctd
• Paucity of data regarding optimal interventions and timing for
addressing SDOH to influence neurologic risks and outcomes

• Addressing these gaps will be pivotal to eliminating inequities in

neurologic risk, care and outcomes
Methods
• The SDOH subgroup of the National Advisory Neurological Disorders
and Stroke (NANDS) Council Working Group for Health Disparities
and Inequities in Neurological Disorders

• NANDS performed a literature review related to the impact of SDOH

on neurologic disease and interventions designed to either prevent the
risk of neurologic disease or alter outcomes of neurologic disease
Methods Ctd
• They identified key research gaps and developed priorities for subsequent
research

• These priorities were presented at the NINDS Health Disparities and

Inequities in Neurological Disorders (HEADWAY) Workshop in
September 2021

• The workshop recommendations were subsequently refined by the authors

Methods Ctd
• The authors structured the article into 4 sections

• key considerations regarding screening for SDOH

• Literatures exploring the associations of several key structural, intermediate, and

proximate SDOH on neurologic disease

• Overview of types of interventions to address SDOH

• The final set of recommendations

Methods Ctd
• SDOH screening:
• Screening adverse SDOH is divided into social risks and social needs

• Social risks involve screening for individual risk, for instance food insecurity

• Social needs involve screening for individual preferences and priorities for instance
food assistance

• Assessment of social risk is important for epidemiological studies, the design and
deployment of programs or policies to address social risks
Methods Ctd
• Assessment of social needs may be most important for caring for individual patients

• Identifying and addressing adverse SDOH may lead to positive outcomes

• Screening without the resources to respond can have potential negative consequences
and ethical implications

• Most SDOH screening tools such as PhenX have not been validated in neurologic
populations
Methods Ctd
• Impact of Key SDOH on Neurologic conditions:
• Place-level Determinants:

• Place of residence can influence neurologic risk and quality of life

through exposure to risk factors or multiple mechanisms

• Different mechanisms operate more powerfully at different geographic

levels
Methods Ctd
• Place-level Determinants Ctd:

• People who lived as children in “Stroke Belt” have markedly elevated

stroke rates throughout life

• Birth or residence in the Stroke Belt increases dementia risk, likely driven
by vascular dementia

• Racial segregation has been linked to multiple mechanisms associated

with stroke or dementia risk
Methods Ctd
• Place-level Determinants Ctd:
• Older adults with their social network in place had higher levels of
social interactions and lower dementia rates than their counterparts
living with strangers

• Place-level inequities can be seen as a window into the importance of

modifiable social factors

• Research priorities involve identifying the mechanisms accounting for

geographic differences and evaluating effective strategies to reduce
inequities
Methods Ctd
• Poverty and Economic Instability:
• Black and Latinx people remain overrepresented among those living in
poverty

• Poverty is a risk factor for the development of neurologic disease

• Children who grow up poor have increased risk for cognitive defects
compared with their peers
Methods Ctd
• Poverty and Economic Instability:
• In adults, as poverty increases, so too does the risk for stroke, cognitive deficits,
and dementia

• Screening for poverty may occur at both the individual and community levels

• Future priorities include evaluating the impact of poverty and neighborhood

disadvantage on neurologic disease and assessing the impact of policies and
interventions addressing poverty on neurologic disease and outcomes
Methods Ctd
• Schooling and Education:
• Pathways that link education and risk of neurologic disease and
recovery from neurologic illness are complex and vary across subgroups

• More schooling is associated with higher cognitive level, less cognitive

decline, and lower dementia risk among older adults

• Autopsy measures of brain structure indicate that education increases

cognitive reserve or resilience against Alzheimer and cerebrovascular
disease
Methods Ctd
• Schooling and Education:

• The cognitive reserve hypothesis has also been examined in multiple sclerosis,
traumatic brain injury, and HIV-associated neurocognitive function

• Future research priorities should focus on heterogeneity of education effects across

population subgroups

• And evaluating long-term impacts of schooling, informal learning, and cognitively

engaging activities on cumulative neurologic disease risk
Methods Ctd
• Food Insecurity:

• More than 10% of Americans are believed to be food insecure, and there are racial
disparities

• Black and Latinx households are more likely to be food insecure compared with
the national average

• The relationship between food insecurity and chronic disease is cyclical

Methods Ctd
• Food Insecurity:

• Studies have found associations between food insecurity and migraine

headaches, cognitive impairment, and stroke

• Further research is needed to understand the association between food

insecurity and neurologic disease and the extent to which addressing
food insecurity alters neurologic outcomes
Methods Ctd
• Housing:
• Housing is one of the most well researched SDOH

• Homelessness and housing insecurity are associated with poor physical and
mental health outcomes

• There is little research on the impact of housing insecurity on neurologic

conditions

• A recent study of veterans revealed that the prevalence of Alzheimer disease and
related dementias was higher among housing insecure veterans than those who
were stably housed
Methods Ctd
• Housing:

• Epidemiologic studies have shown that those who are homeless

experience higher rates of cardiovascular events, including stroke,
compared with the general population

• More research is needed to explore the relationship between housing

and neurologic conditions and whether interventions aimed at
addressing housing affect neurologic health
Methods Ctd
• Health care:
• Access to health care is the timely use of personal health services to
achieve the best health outcomes

• Barriers to access include lack of health insurance, linguistic barriers,

disability, inability to take time off work, and provider shortages

• Out-of-pocket costs have risen considerably for neurologic

medications, particularly for multiple sclerosis
Methods Ctd
Health care:

• Higher out-of-pocket costs are associated with lower medication adherence among
neuropathy, dementia, and patients with Parkinson disease

• Black, Hispanic, poor, uninsured, and low-educated Americans are less likely to
have a neurologic visit than their counterparts

• Teleneurology overcomes some barriers to access

• Acute telestroke has been at the forefront of teleneurology

Methods Ctd
Health care:
• Telemedicine has expanded outside of stroke to include other
neurologic conditions and accelerated during the COVID-19 pandemic

• Older adults, those with low socioeconomic status and minority

race/ethnic populations, have lower digital access and use of
telemedicine than their counterparts

• Language barriers in health care are associated with decreased access

to care, reduced follow-up, and decreased patient satisfaction
Methods Ctd
• Health care:
• Overall, patients report more satisfaction and rated their physicians as more
participatory when receiving care from a provider of the same race

• Whether this extends to neurologic patients is unknown

• Future research priorities include identifying neurologic disease–specific drivers

of health care access, understanding how these affect outcomes among neurologic
patients, and developing and testing interventions to enhance access to care for
medically underserved populations
Methods Ctd
• Health Literacy:
• Limited health literacy is more common among older populations,
minority groups, people living in poverty, and persons with lower
education

• A survey of neurology clinic patients found that 20% had low health
literacy

• Low health literacy is associated with lower medication adherence and

higher emergency services utilization and health care costs
Methods Ctd
• Health Literacy:

• Evidence from 8 European countries suggests that health literacy is an independent,

direct determinant of self-reported health

• Numerous stroke literacy interventions have aimed to improve stroke preparedness in

the community

• Multicomponent secondary prevention interventions have addressed stroke literacy

and self management skills among individuals with previous strokes, with mixed
results
Methods Ctd
• Psychosocial Factors:
• There is compelling evidence that early traumatic experiences affect health,
behavior, and quality of life across the lifespan

• The ACE study found a dose-response relationship between exposure to abuse

and household dysfunction in childhood and adult morbidity and mortality

• Children with increased ACEs had worse overall adult health, were more likely
to have executive functioning deficits, and had increased likelihood of stroke
Methods Ctd
• Psychosocial Factors:
• ACEs impact health via allostasis and weathering mechanisms

• The effect of exposure to trauma on neurologic disease remains unclear

• Suggestive association exist between post-traumatic stress disorder and elevated

risk of stroke

• Social support and integration may influence neurologic disease incidence,

prognosis, quality of life, and long-term outcomes
Methods Ctd
• Psychosocial Factors:
• Various dimensions of social integration are linked to incidence of stroke and
dementia and prognosis after stroke

• Social ties also shape access to timely care, influence depression and other factors
affecting health

• Depression is a major determinant of quality of life and survival among people

living with neurologic disease

• Up to 50% of individuals with multiple sclerosis, a third of stroke survivors and

neurology outpatients experience depression or elevated depressive symptoms
Methods Ctd
• Psychosocial Factors:
• Depression may be due to limitations attributable to disease or to biological
processes directly linked to disease etiology

• Optimal tools for diagnosing and managing depression among individuals with
neurologic disease are needed

• Stress, discrimination, and stigma related to minority status including

interpersonal and structural racism are potentially important causes of neurologic
disease

• Future research priorities include supporting training of researchers with expertise

in psychosocial risk factors to understand psychosocial drivers of health inequities
in neurologic disease
Types of Intervention to Address SDOH

• The interventions are divided into:

• Social needs – informed care
• Social needs – targeted care
• Social risks – informed care
• Social risks – targeted care
Types of Intervention to Address SDOH Ctd

• Social needs–informed care:

• It involves modifications to traditional medical care to account for
patients’ social circumstances (e.g., transportation, after hours clinics,
interpreter services)

• Approaches include using point-of care testing to avoid follow-up

visits and teleneurology

• It does not address the underlying social risks that adversely affect
patients’ health
Types of Intervention to Address SDOH Ctd

• Social needs–targeted care:

• It addresses patients’ social needs directly (e.g., linking patients with transportation,
food, income assistance, or housing support)

• While these approaches may improve patients’ health, they have little impact on
population health

• To enhance population health, policy changes at federal and state

levels, partnerships between health care systems and other sectors and services, and
community-based approaches may be necessary
Types of Intervention to Address SDOH Ctd

• Social risks–informed and social risks–targeted care:

• These indirectly and directly address the risks identified respectively

• Needs are left unaddressed due to poor resources

Final Set of Recommendations
• Elucidating the interactions between specific SDOH and neurologic disease

• Ascertaining whether addressing each SDOH alters the trajectory of outcomes

will be key stepping stones to addressing inequities

• Future research priorities relevant to screening include:

validating SDOH screening tools in neurologic populations
encouraging collection of SDOH using common data elements
determining how and when to screen for social risks and needs
and ensuring social needs are addressed when identified
Final Set of Recommendations

• Key epidemiologic priorities include:

training a workforce with skills and competencies to lead rigorous research on
the multilevel drivers of inequities
evaluating effects of SDOH on neurologic disease, using representative
samples with oversampling of racial/ethnic minorities
Powering studies to test heterogeneity of effects across subpopulations
using adaptive recruitment designs
incorporating known information about differential mortality and loss to
follow-up among previously excluded populations
and evaluating external validity of effect estimates for exposures previously
derived in specialized or convenience samples
Final Set of Recommendations

• For intervention research, key priorities include:

determining optimal interventions on the individual-level vs place-
level, systemic, or policy
interventions to address population burden and inequities
creating and evaluating neighborhood resources
developing and testing multilevel, multidisciplinary interventions
supporting infrastructure for community engaged research
Limitations
• Difficulty in ascertaining if the authors were part of the SDOH
subgroup of NANDS

• It was not pointed if the literatures the authors reviewed differ

somewhat from that of NANDS

• It was not clear the extra gaps they noted in literatures that was not
captured in NANDS report
Limitations Ctd
• The article did not state what exactly were refined in the NANDS
recommendations

• No studies of SDOH on developing nations from their literature

reviews

• Understanding of the effects of SDOH is still at infancy stage

Recommendations
• Anecdotal experiences and quasi experimental study will be needed to
know what specific SDOH to be targeted for intervention

• More researches are needed to understand the mechanisms of SDOH

on neurological disease

• To include data from developing nations and encourage heterogeneity

studies across countries
Thank you for Listening