How Social Determinants of Health Affect Premature Deaths in Racial and Ethnic Groups

Unfavorable social determinants of health are associated with increased rates of premature death and can be categorized by racial and ethnic groups, showing an increased premature mortality rate among Black adults, according to a paper published in The Lancet Public Health.

Investigators from Tulane University School of Public Health and Tropical Medicine analyzed a nationally representative sample of nearly 50000 adults aged 20 to 74 years to understand the contribution of social determinants of health to racial and ethnic disparities in premature deaths.

These social determinants of health are important because increasingly, the importance of addressing the inequities is being realized, the study authors wrote. The pillars of the health factors include “conditions in the environments where people are born, live, learn, work, play, worship, and age,” the investigators explained.

The investigators pulled a nationally representative sample of 48170 adults aged 20 to 74 years from the US National Health and Nutrition Examination Survey, which was conducted between 1999 and 2018. The participants in the study self-reported their status every 2 years for employment, family income, food security, education, access to health care, health insurance, housing instability, and being married or living with a partner. From there, the study authors categorized the participants into 4 groups based on race and ethnicity: non-Hispanic Black, Hispanic, non-Hispanic White, and other. (The investigators noted that the Survey did not list Asian as a separate race and ethnicity category until 2011-12.) The investigators followed up with the participants until December 31, 2019.

Overall, the investigators included about 22% Black participants, about 27% Hispanic participants, 40% White participants, and nearly 10% other racial and ethnic groups. The mean age was 44 years and about half the participants were women.

Compared to the White participants, Black and Hispanic participants had lower levels of employment, family income, food security, educational attainment, health care access, private health insurance, and home ownership. Additionally, a lower proportion of Black participants were married or living with a partner compared to the other racial and ethnic groups.

There were nearly 3200 deaths before the age of 75 years recorded during about 10 years of follow up, with Black adults having a higher premature death rate compared to the other racial and ethnic groups for men and women. The premature mortality rate was similar across all groups until about age 40, the study authors observed, but it began to separate after that age. There were higher rates among Black people for premature death compared to other racial and ethnic groups, the study authors wrote. Additionally, patterns in men and women were similar, but men had a high premature mortality rate.

The investigators found that unfavorable levels of each social determinant of health were significantly associated with higher premature mortality, but unemployment, family income-to-poverty ratio less than 300%, food insecurity, less than a high school education, government health insurance or no health insurance, and not being married or living with a partner were significantly associated with increased premature mortality. These rates were mostly similar by race and ethnicity, the study authors found, and were also similar among cardiovascular, cancer-related, and other specific causes of death.

“Black and Hispanic adults in the USA had higher prevalence of unfavorable social determinants of health compared with White adults,” the study authors concluded. “In addition, unfavorable social determinants of health were associated with higher premature all-cause mortality.”