Developing an Index of Social Determinants of Health and Exploring its Association with Physical and Mental Health Outcomes in the Population of Sin El Fil in Lebanon

Abstract

Introduction: Social Determinants of Health act synergistically to define health outcomes and drive health inequities. Studies have until recently focused on assessing individual social indicators in isolation, and little evidence is available from low- and middle-income countries and among populations in vulnerability. This study adapted the polysocial risk score approach with the aim of addressing the cumulative, multidimensional effects of SDH on psychological well-being (depression and anxiety symptoms) and non-communicable diseases (NCD) management, within the context of the Lebanese polycrisis, and among the population of Sin El Fil residing in low-socioeconomic neighborhoods and experiencing multiple intersecting vulnerabilities.

Methods: A nested population-based cross-sectional analysis of a broader longitudinal cohort was conducted among n=1,924 adult participants residing in low-SES areas. SDH indicators were identified from the survey based on the literature and used to construct outcome specific, coefficient weighted, SDH indices. Outcomes included depression severity, (PHQ-9), anxiety severity (GAD-7) and NCD medication uptake. Adjusted multiple logistic regression models were used to assess the association between each index and its outcome, using both continuous and tertile-categorized scores.

Results: Psychological distress was highly prevalent, with around half the sample presenting mild to severe symptoms of anxiety and/or depression. Only 6% of participants with NCDs did not take all their prescribed medications. The higher accumulation of unfavorable SDH was significantly associated with worse depression symptoms (OR=1.27, 95% CI: 1.21-1.34) anxiety symptoms (OR=1.26, 95% CI: 1.20-1.34), and NCD management (OR=1.42, 95% CI: 1.22-1.66) in adjusted analyses using the continuous weighted scores. The significance was retained after categorizing each score into tertiles, with the people in the highest SDH tertile having significantly worse outcomes than those in the lowest, most favorable tertile.

Conclusion: The accumulation of unfavorable SDH is associated with worse physical and mental health outcomes, even among populations in vulnerability. This study emphasized the need to address the compounding effects of SDH in epidemiological studies, and highlighted the importance of shifting the focus of health equity policies towards more upstream, cohesive, sustained action.