Social Determinants of Health Among Older Population

Due to increase aging population, screening elderly relate to social determinants of health (SDOH) requires thoughtful investigation the present state of the science. The objective of the study is to systematically evaluate SDOH among elderly to manage, maintain and promote healthier stage of life. A comprehensive electronic search was done through online database of PubMed. Studies that focused on screening elderly for various SDOH were reviewed. Particularly, areas comprised of study demographics, screening tool used, SDOH present, and the procedure for conducting follow up.

Conducting the screening of inclusion and exclusion criteria from a total of 5155 studies returned only 14 studies was retained and was fully reviewed. Results revealed diversity to gender, race and ethnicity. Family context and economic stability was the most common SDOH present among the sample. While most studies described the referral and interventions that proceeded after SDOHs were identified. Author has limited search with other database unavailability and time constraints for submission of the review. The level of degree pertaining to how SDOH are significant to elderly population was evaluated.

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Future researches are recommended to further evaluate with broader resources to address SDOH and enhance elderly lifestyle.

Introduction

As per World Health Organization, social determinants of health (SDOH) are “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.” Moving forward towards Healthy People 2030, SDOH are classified into five domains particularly education, economic stability, social and community context, health and health care, and neighborhood and built environment.

While SDOH impact wellbeing and health among individuals of all age group, however due to increased aging population with life expectation of 80 years old it is vital to consider SDOH among older population in order to address the increasing healthcare needs as well. These SDOH factors guides as a key prevention against future conditions and better health management in order to provide a more meaningful and fulfilling life.

The challenges affecting rural communities and the seniors who live there are unique. According to the Centers for Disease Control, the population 65 years and older is expected to double to about 71 million. Although 50 million people live in two-thirds of counties outside metropolitan areas, healthcare services are less available there than in cities. This is even more challenging for seniors who don't have public transportation or other services to rely on to get to and from the grocery, bank, doctor's office and more. Compared to seniors living in urban areas, rural seniors have higher poverty rates, lower incomes and fewer employment opportunities. Elderly usually live in less adequate and older housing. They rely more heavily on themselves and informal networks for transportation. They are less healthy and have less access to community-based social, health and mental health services. Also, the vulnerable to having fewer long-term care options.

Methodology

Search strategy. The study aimed to review social determinants of health (SDOHs) with a focus on elderly population. Using PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalysis) guidelines to systematically search online databases, screening published researches, employ both inclusion and exclusion criteria, and chose relevant literature for review. As a doctorate student proficient to perform comprehensive electronic search of publications using the PubMed database as per availability. Search will be limited to English language only articles. Results from the database until December 2019 was screened and only those that are published within the past 5 years were only included. The search terms were used to retrieve articles were SDOH, older or elderly population, and assessment administered by a elderly service provider (such as clinician, social worker, or public health worker) in a geriatric office. Returned search results were copied using RefWorks, while duplicates were removed.

Inclusion Criteria. The researcher aims to include published studies in which a specific tool was used to screen elderly that is age of 65 years old or older for SDOH. SDOHs were defined according to Healthy People 2030 and studies that was conducted in the United States, peer-reviewed, and published in English language.

Exclusions of studies that only screened for SDOH in general or only conducted screening from birth up to 64 years or from their carers or relative, studies that were not published in English, either were classified into book chapters, reviews, letters, abstracts, and dissertations.

The author searched the online databases using a reference manager software called RefWorks to accomplish screening and collection of the studies. Initially, the title and abstract was screened independently. The author conducted appraisal for the full-text review to confirm that each study met the inclusion criteria. The author further reviewed the reference lists of included studies to recognise any supplemental studies for added.

Results

Study Selection. After conducting electronic search of databases returned a list of 5155 studies, after including 5-year filter, English only database result narrowed down to 1722 studies. After screening the title and abstract, the researcher considered 1648 studies inappropriate, leaving seventy-four full texts to review. Subsequently, thirty-seven studies passed the full screen review, and finally recognized that two additional studies from the reference lists of included studies. Ultimately there were fourteen studies that was retained. Figure 1 reveals the PRISMA flow diagram.

Study demographics revealed various study differences from the fourteen studies that span eleven unique assessors. Except for one study, all thirteen studies were conducted in a medical setting. It was identified that twelve studies reported the screening for SDOHs exclusively among older population (ages 65 years and above). It was also evident that the gender was evenly divided among the study samples. Also, majority of the studies in which the races or ethnicities of elderly were reported.

SDOH demographics from the eleven unique assessors was included in the review. Although, screening was conducted in a geriatrician’s clinic, accompanied usually by a relative or caretaker as the primary information provider. Provider assessment were completed through various methods, including traditional documentation, desktop computer, one to-one interview, and telephonic interview. All assessment tools were available in English. Three assessors had reliability testing in the study. With respect to the time frame that respondents were asked to ponder on when answering questions about SDOH, the majority of assessors did not have a clearly defined referent period; the referent periods for other assessors varied by question and only one assessors had a single, clearly defined referent period for all included questions. In establishing the SDOH assessments, four assessors reported being informed by practice and consulted with an expert opinion. The rest of the providers only adopted previous tools and did not report how they were developed. Validity and reliability of a tool is important in the scholarly endeavor so that results can be used for decision making in the public health sector.

The SDOH areas assessed in each study. The familial context was assessed in all studies, and the economic stability area was assessed in thirteen studies. Shared areas examined under the family context included domestic violence, neglect and abuse, and mental disorder or substance abuse present in the relative or other household members. Other common areas investigated under the economic stability included availability of food, housing issue, and debts, making ends meet, or meeting basic needs. Seven assessors assessed the access to support care. Six assessors assessed the health and health care domain, with availability of health insurance being the most common area examined. Seven assessors assessed the neighborhood district and built environment with concerns about the physical conditions of housing being the most common inquiry, followed by violence and safety. Three assessors assessed social and community context, which included questions which are concerns about the immigration status, social discrimination, religious belief, and social support. Three assessors assessed protective factors under the social and community context and family context domains particularly whether family members feel close if the elderly has a relationship with a caring adult, religious affiliation, and if has other kind of social support available. This are vital so that appropriate interventions can be performed, and elderly client is referred to proper community resource available in the community.

Identification of SDOH among the elderly, it is also important to know what are the follow-up procedures that was used from the fourteen studies included in this endeavor. In exception of the three studies who reported no follow-up procedures after SDOH screening. There were five studies reported that screening results were discussed with respectively with the elderly’s caretakers or referred to another community resources and other outside agencies, but no intervention was delivered. Four studies on the other hand reported that referrals were given to the caretakers without reporting that screening results and without reporting that an intervention was delivered. Two studies reported that screening results were discussed with the relative or caretaker and with referrals and importantly that an intervention was delivered. Interventions described was in the form of providers using motivational interviewing to engage caretakers to help gain more access and understand resources available to the elderly client.

Conclusion. In this review the author identified eleven exceptional SDOH assessors. Systematic search of the database from the last five-year publication. The focus of SDOH among elderly within the published literature in the last decade are considered few and demand increased attention within the public nursing community. The review can provide a comprehensive and updated list of SDOH areas that can used to survey current population. As populations age in rural communities, the need leverage in digital technologies have the potential to address issues like care coordination for chronic conditions, social isolation and loneliness, and medication management, and can transform health and wellness for elderly while also meeting caregiver needs. This also calls for a unified data gathering tool and platform that can be used by all states to better guide public health and policy.

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