Across global contexts, proportions of older people living in rural places are increasing. Given that place of residence and rurality have both been identified as potential determinants of health inequity, it is important to understand how, and in what circumstances, rural living affects healthy aging. This foundational review examines the academic literature to identify and critique specific rural social determinants that drive health inequities for older people and to examine how these have emerged and evolved. Using a healthy aging framework, this Review identifies the contextual, socioeconomic, demographic and intermediary determinants associated with rural places and populations. This Review demonstrates that rural communities are not necessarily synonymous with poor health outcomes for older people. However, weaknesses at the policy, environmental and community levels can adversely affect older people’s own efforts to address rural health inequities, especially for those who already face disadvantage. The intersection of age-related and rural environmental changes also creates new health inequities among previously healthy populations. Achieving health equity for rural aging populations requires an understanding of conditions that make diverse older people and rural communities vulnerable, and providing adequate and equitable resources to support place-based approaches to address enduring challenges. It is important to understand how living in a rural environment affects older people. This Review identifies social determinants of rural healthy aging, showing that rurality alone does not drive inequity. It highlights policy, environmental, community and socioeconomic factors shaping health outcomes for rural older people.
There is accumulating evidence that social isolation has a serious impact on the health and well-being of older adults, with this concern endorsed by the US Surgeon General, the World Health Organization Commission on Social Connection report, and other national and international policy forums. Social isolation can be viewed as part of the broader agenda of the social determinants of healthy aging. Evidence from higher-income countries on the relationship of isolation with poor health outcomes is supported by research in lower- and middle-income countries, indicating that these processes have global relevance. The biological and behavioral processes linking social isolation with specific health outcomes are being intensively studied, and new developments in geroscience provide opportunities for greater understanding of associations with biological aging. Lack of engagement in community leisure activities has been neglected as a factor contributing to social isolation, but it is important to expand its conceptualization and explore further given that it is particularly amenable to modification. Community participation and the mobilization of community assets at the global level can help to ameliorate social isolation and other social deficits and may enhance healthy aging. Steptoe and Fancourt highlight that community engagement can reduce social isolation, emphasizing the importance of fostering social connections to promote healthy aging and improve health outcomes in older adults.
Population aging has widened the gap between life expectancy and healthspan. Yet aging trajectories remain strikingly heterogeneous even among populations facing comparable harmful environmental exposures, including air pollution, extreme temperatures, toxic metals, unsafe water and sanitation, noise and poor housing. Why similar environmental risks produce divergent patterns of multimorbidity, disability and functional decline is a central research question. This Review proposes environmental health resilience factors, features of physical, social, ecological and built environments that act as protective effect modifiers, flattening the exposure–response curve and attenuating the biological translation of adverse exposures into harm rather than reducing exposure itself. Drawing on longitudinal cohorts, natural experiments and policy evaluations, we show that green and natural environments, age-friendly urban design, climate-resilient infrastructure and social connectivity flatten exposure–response curves and help to explain divergent aging trajectories under comparable urban environmental conditions. We propose both building resilience and reducing exposure are complementary strategies to compress morbidity and advance healthspan equity in aging societies. Ji et al. define environmental health resilience factors such as green spaces, age-friendly design and climate-resilient infrastructure as modifiers of exposure–response relationships, which help to explain divergent aging trajectories and offer a framework to advance healthspan equity.
Social determinants of health, the conditions in which people are born, grow, live, work and age, shape brain aging and dementia. Yet evidence is dominated by Global North populations and often relies on single indicators (for example, education or income), limiting risk characterization and generalizability across settings. This Perspective provides a global, integrative overview of multidimensional, multilevel and life-course approaches to social determinants of health and exposome research in brain health. We examine composite indices and social-exposomal factors, their need for harmonization, contextual adaptation and local validation, and biological embedding through stress-related, inflammatory, metabolic, vascular and epigenetic pathways. We also discuss interactions with genetic susceptibility and the analytical challenges of modeling cumulative, time-varying and nonlinear exposures. These advances require feasible, policy-relevant implementation in resource-constrained settings. Moving beyond static, single-domain proxies towards context-sensitive measures and multilevel designs can improve risk characterization and support more equitable, globally relevant strategies for dementia prevention and precision public health. Migeot et al. explore how social and environmental conditions across life shape brain aging and dementia through biological pathways, and advance context-sensitive, globally inclusive measures to guide equitable prevention and promote brain health.
Healthy aging is shaped by the exposome—the accumulation of exposures experienced across the life course arising from intersections of the natural, physical, social, community and policy environments in which people age. This Consensus Statement reports recommendations from the Gateway Exposome Coordinating Center to accelerate life-course research on the exposome’s impacts on healthy aging, including Alzheimer’s disease and related dementias. Recommendations centered on five themes are presented: the promotion of interdisciplinary collaboration; the integration of life-course perspectives on the timing, accumulation and sequencing of exposures; systematically quantifying and incorporating broader contexts of time and place into health research; the adoption of mechanistic thinking to develop pathway-relevant exposure metrics; and leveraging new data streams, including wearable sensors, administrative records and remote sensing, to improve exposure measurement. These priorities emphasize harmonized measures, transparent methods and attention to bias, with the goal of identifying actionable intervention and policy targets across diverse populations that can shape individuals’ exposures, lived experiences, behaviors and, ultimately, health as they age. This Consensus Statement outlines recommendations from the Gateway Exposome Coordinating Center for advancing research on how environmental exposures across the life course shape healthy aging, including Alzheimer’s disease and related dementias.
