Improved understanding of social determinants of health
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EULAR – The European Alliance of Associations for Rheumatology – acknowledges the impact of socioeconomic factors on the persistence of rheumatic and musculoskeletal diseases (RMD), and the society’s manifesto includes tackling lifestyle determinants, promoting active ageing, and developing RMD education and communication programmes.¹ Health literacy has also been flagged as central to the prevention and control of noncommunicable diseases – including RMD – by the World Health Organization.²

Social determinants of health (SDH), such as socioeconomic status and educational background are factors that are increasingly recognised as critical contributors to health outcomes in chronic diseases. Understanding how certain factors impact different RMDs is important, and new research into this for both systemic lupus erythematosus (SLE) and inflammatory arthritis was presented at the 2025 annual EULAR congress in Barcelona.

SLE is a chronic autoimmune disease that exhibits considerable clinical heterogeneity, and is associated with substantial morbidity and mortality. While disparities in SLE outcomes have been linked to SDH, research exploring these associations in unselected populations – particularly in Europe – is limited. A population-based cohort of 2,434 people newly diagnosed with SLE in Sweden set out to change this by examining the association between SDH and key health outcomes, including organ damage and mortality.

SDH variables included earned income, education level, marital status, work ability, employment, and immigration status. Models were used to estimate the hazard ratio for first organ damage accrual and mortality associated with each SDH variable, adjusted for age and sex.

The findings showed that 39% of people accrued damage over a median time of 2.8 years, and 5.0% died. Having a lower annual earned income and nine years or less of education were both associated with a 30–40% higher risk of first organ damage compared to people with a higher income and more than 12 years of education. Marital status was also associated with organ damage, with divorced or widowed people showing a significantly higher risk compared with those who were partnered. Perhaps less surprisingly, a history of sick leave or disability was associated with a greater than 40% increased risk in organ damage.

Similar patterns were found for mortality, with individuals in the lowest income and education categories experiencing over 2- and 1.5-fold increased risk, respectively, compared to those in the highest categories. Again, people who were single, separated, or widowed had higher mortality risk compared to people in relationships, and having had any days of sick leave or disability was associated with a 78% increased risk of mortality. But being born outside Sweden was not associated with either damage accrual or mortality.

Presenting the work, Daniel Guimarães de Oliveira said “our study identifies key social determinants of health that could be used to predict who is at risk of poor outcomes – and if we know that then we can apply targeted interventions, including improved healthcare access, support for medical and non-medical treatment, improved health literacy and community-based networks, all of which could help improve outcomes”.

As in SLE, the association between social determinants of health, patient-reported outcomes, and clinical outcomes in people with inflammatory arthritis remains poorly understood. Mrinalini Dey and colleagues from King’s College London in the UK – through a FOREUM-funded project awarded to senior author Elena Nikiphorou – aimed to investigate the association between health literacy and social determinants of health, clinical and non-clinical outcomes. This work was undertaken in people recruited into the National Early Inflammatory Arthritis Audit in England. 995 participants completed an online survey, which included the nine-domain Health Literacy Questionnaire. This encompasses aspects such as feeling understood and supported by healthcare providers; having sufficient information and social support to manage their health; and having the ability to actively engage with healthcare providers, navigate the healthcare system, and find good health information.

Findings showed that health literacy across all domains was associated with higher self-reported disease activity within the past 2 weeks, and greater anxiety and depression. Limited health literacy in all domains – with the exception of being able to appraise health information – was significantly associated with more severe joint pain and stiffness and higher tender and swollen joint counts.

Increased likelihood of corticosteroid use in the past 2 weeks was associated with three different findings: having high health literacy in the domain around feeling understood and being supported by healthcare providers – but also limited ability to find good health information, and limited literacy around knowing health information well enough to know what to do.

People on conventional synthetic disease-modifying antirheumatic drugs (csDMARD) were more likely to have high health literacy around social support for health and were better able to actively engage with healthcare providers – as compared to those not taking a csDMARD.

People on a biologic or targeted synthetic DMARD (b/tsDMARD) were more likely to have high health literacy in the domain around feeling understood and being supported by healthcare providers.

Looking at work, people were more likely to be employed if they had high health literacy in their ability to find good health information, and understood health information well enough to know what to do. Limited health literacy across six of the nine domains was associated with high levels of absenteeism. Limited health literacy in eight of the nine domains was associated with greater levels of presenteeism and greater work productivity loss. Limited health literacy across all domains was associated with greater activity impairment.

Taken together, these two abstracts highlight that a better understanding of the impact of SDH on outcomes in RMD provide valuable insights that can be used to design targeted interventions and ultimately improve health equity in disease management.

Source
Gomez A, et al. Associations Between Social Determinants of Health and Outcomes in Systemic Lupus Erythematosus: Evidence from a European Nationwide Population-Based Cohort. Presented at EULAR 2025; OP0200. Ann Rheum Dis 2025; DOI: 10.1136/annrheumdis-2025-eular.B2043.

Dey M, et al. Health literacy associates with clinical, treatment and work status in people with inflammatory arthritis: Results from a national cohort. Presented at EULAR 2025; OP0026.
Ann Rheum Dis 2025; DOI: 10.1136/annrheumdis-2025-eular.B1218.

References
1. EULAR manifesto. https://www.eular.org/eular-manifesto#:~:text=Quality%20of%20care:%20improving%20RMD,return%20to%20education%20and%20work.

2. WHO. https://www.who.int/news-room/fact-sheets/detail/health-literacy