1 Associations between social determinants of health and 10-year change in everyday functioning within Black and White older adults from the ACTIVE study
Authors: Clark Alexandra L. , Weigand Alexandra J. , Clay Olivio J. , Marsiske Michael , Owens Joshua , Fiala Jacob , Crowe Michael , Thomas Kelsey R. 
Published: December 2023

Objective:Social determinants of health (SDoH) are structural elements of our living and working environments that fundamentally shape health risks and outcomes. The Healthy People 2030 campaign delineated SDoH into five distinct categories that include: economic stability, education access/quality, healthcare access, neighborhood and built environment, and social and community contexts. Recent research has demonstrated that minoritized individuals have greater disadvantage across SDoH domains, which has been linked to poorer cognitive performance in older adulthood. However, the independent effects of SDoH on everyday functioning across and within racial groups remains less clear. The current project explored the association between SDoH factors and 10-year change in everyday functioning in a large sample of community-dwelling Black and White older adults.Participants and Methods:Data from 2,505 participants without dementia enrolled in the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) study (age M=73.5; 76% women; 28% Black/African American). Sociodemographic, census, and industry classification data were reduced into five SDoH factors: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community contexts. The Observed Tasks of Daily Living, a performance-based measure of everyday functioning with tasks involving medication management, finances, and telephone use, was administered at baseline, 1-, 2-, 3-, 5, and 10-year follow up visits. Mixed-effects models with age as the timescale tested (1) racial group differences in OTDL trajectories, (2) race x SDOH interactions on OTDL trajectories, and (3) associations between SDoH and OTDL trajectories stratified within Black and White older adults. Covariates included sex/gender, vocabulary score, Mini-Mental Status Examination, depressive symptoms, visual acuity, general health, training group status, booster status, testing site, and recruitment wave.Results:Black older adults had a steeper decline of OTDL performance compared to Whites (linear: b = -.25, quadratic b=-.009, ps < .001). There was a significant race x social and community context interaction on linear OTDL trajectories (b =.06, p=.01), but no other significant race x SDoH interactions were observed (bs =-.007-.05, ps=.73-.11). Stratified analyses revealed lower levels of social and community context were associated with steeper age-related linear declines in OTDL performance in Black (b = .08, p=.001), but not White older adults (b =.004, p=.64). Additionally, lower levels of economic stability were associated with steeper age-related linear declines in OTDL performance in Black (b =.07, p=.04), but not White older adults (b =.01, p=.35). Finally, no significant associations between other SDoH and OTDL trajectories were observed in Black (bs = -.04-.01, ps =.09-.80) or White (bs = -.02-.003, ps=.07-.96) older adults.Conclusions:SDoH, which measure aspects of structural racism, play an important role in accelerating age-related declines in everyday functioning. Lower levels of economic and community-level social resources are two distinct SDoH domains associated with declines in daily functioning that negatively impact Black, but not White, older adults. It is imperative that future efforts focus on both identifying and acting upon upstream drivers of SDoH-related inequities. Within the United States, this will require addressing more than a century of antiBlack sentiment, White supremacy, and unjust systems of power and policies designed to intentionally disadvantage minoritized groups.