Perception of dementia risk among Black adults: an ecological analysis of causal loop diagrams with a structural and social determinant of health composite index.

INTRODUCTION: To investigate drivers of dementia risk disparities among older Black Americans using a community-based system dynamics (CBSD) approach. METHODS: Over 18 months, 234 participants created 36 causal loop diagrams (CLDs) on dementia risk. An ecological analysis compared structural differences across groups based on scores on a structural and social determinants of health composite index (S/SDOH-CI). RESULTS: Groups in the highest SDOH-CI quantile were more likely to identify key protective pathways linking mental health, substance use, exercise, medication, and community support to reduce dementia risk. In contrast, fewer than 25% of low-SDOH-CI groups identified these connections, and under 15% recognized the mental health benefits of community support or the educational and emotional advantages of higher income. However, low-SDOH-CI groups more often linked income to health insurance and family ties to health literacy and stress reduction. DISCUSSION: Participants' perceptions of dementia risk reflect their lived experiences, with distinct system substructures emphasized across SDOH-CI strata. Understanding how causal beliefs vary by socioeconomic context is essential for developing effective, equity-focused dementia prevention strategies for Black Americans. These findings highlight the need to tailor public health interventions to target the most socioeconomically disadvantaged groups. Highlights: Workshop discussions revealed that dementia risk among Black adults is closely linked to S/SDOH, with perceived causal pathways varying according to the degree of S/SDOH deprivation.Groups experiencing higher S/SDOH deprivation, as measured by a composite index of 37 indicators based on the NIA HDRF, more frequently emphasized the role of higher income and better health insurance, as well as the protective effects of strong family relationships in enhancing health literacy, reducing stress, and lowering dementia risk.Recognizing the socioeconomic drivers of dementia and addressing inequities in S/SDOH through sustained public health interventions may be critical to improving long-term health outcomes and reducing dementia risk.