Section outline

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    • Advanced Concepts and Methods in Research on Health Disparities and the Social Determinants of Health

              Spring 2018 (2 units)
      .
      Course Director: Christine Dehlendorf, MD, MAS
      Associate Professor, Department of Family and Community Medicine
    • EPI 223 Forum

  • Monday, April 2, 2018; 1:00 PM - 3:00 PM

    Lecture:  Classic conceptual papers

    Seminal theories and frameworks that have shaped discourse about the nature and etiology of health disparities and the role of social determinants of health.

    Faculty:  Christine Dehlendorf

    Location:       Mission Hall 1406

    • Session Slides:

    • Session Audio/Video Recording (Access restricted to registered students):

    • Watch URL
      Not available unless: You belong to a group in Registered Students Only

    • Required Reading:

    • Link and Phelan, Social conditions as fundamental causes of disease File
      Not available unless: Your ID number contains 02
    • Phelan JC, Link BG. Is racism a fundamental cause of inequalities in health. Annual Review of Sociology. 2015 Aug 14;41311-30 File
      Not available unless: Your ID number contains 02
    • Krieger N. Theories for social epidemiology in the 21st century an ecosocial perspective. International journal of epidemiology. 2001 Aug 1;30(4)668-77. File
      Not available unless: Your ID number contains 02
    • Krieger N. Epidemiology and the web of causation has anyone seen the spider. Social science medicine. 1994 Oct 1;39(7)887-903. Required reading starting on page 896 until the end. The rest of the article is optional. File
      Not available unless: Your ID number contains 02

    • Optional Reading:

    • The Krieger article, as above

    • Lynch J and Kaplan G. Chapter 2, Socioeconomic Position. In: Berkman LF and Kawachi I (eds). Social Epidemiology. New York: Oxford University Press (2000), pp. 13-35 URL
      Not available unless: Your ID number contains 02
    • Susser M, Susser E. Choosing a future for epidemiology I. Eras and paradigms. American Journal of Public Health. 1996 May;86(5)668-73. File
      Not available unless: Your ID number contains 02
    • McMichael M. Prisoners of the Proximate Loosening the Constraints on Epidemiology in an Age of Change. Am J Epidemiology 1999 149;10887-97. File
      Not available unless: Your ID number contains 02

    • Resources:


    • Assignment:

      Below are discussion questions we will consider in class for each reading. Please think about these as you do the readings and be prepared to discuss them. If you will not attend class, please submit written responses to each question of approximately one half to one page per question (email to christine.dehlendorf@ucsf.edu).

      Link and Phelan:
      1. How would you describe the essential shift in thinking within epidemiology that the authors of this paper urge?
      2. What are the key insights of fundamental cause theory about the role of social conditions on health?
      3. What are the implications of the fundamental cause theory for research on health disparities?
      Phelan and Link:
      1. What is the shift in thinking about the role of race in health that is evidenced between this paper and the original fundamental cause paper published in 1995 (the first reading)?
      2. Do you agree that “a large proportion of the racial differences in health outcomes are attributable to racial differences in SES”? Why or why not?
      3. What implication does considering racism as a fundamental cause have for research on health disparities?
      Krieger papers:
      1. What is meant by the “spiderless web”?
      2. What are the strengths and limitations of psychosocial theory? Of social production of disease?
      3. How does ecosocial theory relate to fundamental cause theory?
      4. Is theory necessary to advance health equity? Why or why not?
      5. Describe the central concept of embodiment.

  • Monday, April 9, 2018; 1:00 PM - 3:00 PM

    Lecture:  Multi-level and causal analyses

    Approaches to analyzing complex data to investigate influence across multiple levels and to estimate causal effects.

    Faculty:  Meghan Morris & Kelsey Holt

    Location:     Mission Hall 1406


    Guidelines for leading journal article presentations during class:

    Here is a rough guide to help you prepare. You're welcome to adapt to meet the journal article or your needs.

    o   5 minute high-level summary – one slide to introduce the key points of the article (objective/methods/key results)

    o   Some reflections/questions about the paper and the content for discussion.

    o   Then start the larger conversation for the article – this could be you answering or starting a conversation about each of the article discussion question or pose new questions related to theory, methods, or application/implications of the article.  

    • Session Slides:

    • Session Audio/Video Recording (Access restricted to registered students):

    • Required Reading:

    • Diez-Roux multilevel File
      Not available unless: Your ID number contains 02
    • Kawachi CausalInf MoneySchoolingHealth File
      Not available unless: Your ID number contains 02
    • Tomita-Multilevel modeling File
      Not available unless: Your ID number contains 02
    • Beck-Causal Inference File
      Not available unless: Your ID number contains 02

    • Resources:

    • Assignment: Below are discussion questions we will consider in class, that you should be thinking about as you do the reading. If you will not attend class, please submit written responses to each question (email to meghan.morris@ucsf.edu).

      Multilevel modeling:

      Diez-Roux article:

      1. Multi-level modeling approaches aim to analyze contextual effects beyond individual characteristics. Briefly describe the benefits of conducting a multilevel analysis for health disparities research areas. 

      2. Draw from your own research or interest area to give an example of macro-level factors or group-level properties that influence individual health.

      3. Define the ecological and atomistic fallacies and explain how these fallacies differ from psychologistic and sociologistic fallacies. 


      Tomita article:

      1. The authors research stems from social disorganization theory which emphasizes the importance of one’s neighborhood and social place on their quality of health. In your own words summarize the author’s study rationale and main hypothesis. 

      2. What are the various community, social and individual measures included in the analyses? In your opinion, what are the strengths of including these measures? What additional measures could have further strengthened the author’s analytic model?

      3. The authors included three interaction terms into the full model (model 2h). Describe the value of including these interaction terms in relation to the author’s study objective. How would you interpret these interaction terms? 


      Causal Inference:

      Kawachi article:

      1. Describe what reverse causation and omitted variable bias (“confounding”) are, and give examples of how these might be present in an area of health disparities research that you are interested in.

      2. In what ways does conducting a longitudinal study address reverse causation and confounding in a way that cross-sectional studies are unable to do?

      3. Why are experiments considered the strongest study design to allow for causal inference?


      Beck article:

      1. DAGs, like the one presented in this article, are critical tools for researchers interested in drawing causal inferences from study findings. Draw a simple DAG relevant to an area of health disparities that you are interested in.

      2. How is the concept of race conceptualized differently in this study compared to other epidemiologic studies you have read where race is included as a predictor variable?

      3. The IPTW method described in this article is complex and it is beyond the scope of this course to expect a complete grasp on this analytical approach. However, in simple terms, what is this approach trying to accomplish?


  • Monday, April 16, 2018; 1:00 PM - 3:00 PM

    Lecture:  Racism and Intersectionality

    Methods for investigation of impact of racism, as well as the intersection between different dimensions of vulnerability

    Faculty:  Christine Dehlendorf

    Location:      Mission Hall 1406

    • Session Audio/Video Recording (Access restricted to registered students):

    • Watch URL
      Not available unless: You belong to a group in Registered Students Only

    • Required Reading:

    • Bowleg Intersectionality 2012 File
      Not available unless: Your ID number contains 02
    • Viruell-Fuentes IntersectionalityImmigration 2012 File
      Not available unless: Your ID number contains 02
    • Braveman PTB File
      Not available unless: Your ID number contains 02
    • Williams racism review 2009 File
      Not available unless: Your ID number contains 02

    • Resources:


    • Assignment: Please consider these questions below when reading each article. If you are unable to attend the class session, please post answers to these questions to the forum by midnight on the 18th.
       
      Williams article:
       
      1.    How does racism and other forms of discrimination lead to health disparities?
      2.    What are some identified challenges in measuring discrimination?
      3.    What are the most important areas to focus on in research on racism? How can this lead to interventions to impact health disparities?
       
      Braveman article:
       
      1.    What type of interventions could be informed by the findings of this study?
      2.    What are the implications for the findings of this study on the intergenerational impact of racism?
       
      Bowleg:
       
      1.    How does intersectionality relate to the socioecological model? To Krieger’s metaphor of the fractal?
      2.    What are the biggest challenges you see to incorporating intersectionality into your work? What are the benefits?
       
      Viruell-Fuentes: (Focus on reading through the first half of the first column on page 2012. If you are interested in immigrant health and policy, the rest of the article will also be interesting, but just trying to target your assignments.)
       
      1.    What do you think of Viruell-Fuentes’s critique of “cultural” explanations for health disparities?
      2.    How does intersectionality add to the understanding of health disparities impacting Latinx populations?
       

  • Monday, April 23, 2018; 1:00 PM - 3:00 PM

    Lecture:  Community based participatory research

    Theory and practice of community-based participatory research, including its challenges and benefits.

    Faculty:  Christine Dehlendorf

    Location:       Mission Hall 1406

    • Session Audio/Video Recording (Access restricted to registered students):

    • Watch URL
      Not available unless: You belong to a group in Registered Students Only

    • Required Reading:

    • Vasquez CBPR File
      Not available unless: Your ID number contains 02
    • Andrews CBPR File
      Not available unless: Your ID number contains 02
    • Minkler CBPR File
      Not available unless: Your ID number contains 02

    • Optional Reading:

    • Yeary CBPR File
      Not available unless: Your ID number contains 02
    • Comm Engaged Research Guide USC File
      Not available unless: Your ID number contains 02
    • Wallerstein and Duran 2010 File
      Not available unless: Your ID number contains 02
    • AJPH.2014 Cacari Wallerstein Garcia Minkler File
      Not available unless: Your ID number contains 02

    • Resources:


    • Assignment:

      Please consider these questions below when reading each article. If you are unable to attend the class session, please post answers to these questions to the forum by midnight on the 25th.

      Minkler:

      • What do you think of the claimed benefits of CBPR?
      • Which challenges in doing CBPR  do you think are most significant?
      • What do you think Minkler means by “systems development and local community capacity development”? How can this be accomplished?

      Andrews:

      • What do you think of the “origin story” of this collaboration?
      • What do you think of how CBPR principles were applied in this project?
      • How did the use of CBPR influence the intervention development? The study design?
      • How did they address sustainability?

      Vasquez:

      • What do you think of how CBPR principles were applied in this project?
      • What challenges did they face? How did they address them?
      • How was this project effective in changing policy? What aspects of this could be generalized to other projects?
      • What do you think of the academic partner’s statement that “the motivation for involvement did not lie in identifying policy goals but rather in trying to fill scientific gaps”?



  • Monday, April 30, 2018; 1:00 PM - 3:00 PM

    Lecture:  Measurement

    Focus on research to develop and validate measure in diverse populations, as well as understand heterogeneity in scale response by sociodemographic characteristics and implications of failing to consider these factors.

    Faculty:  Christine Dehlendorf/Kelsey Holt

    Location:       Mission Hall 1406

    • Session Audio/Video Recording (Access restricted to registered students):

    • Watch URL
      Not available unless: You belong to a group in Registered Students Only

    • Required Reading:

    • Ram-rez et al-2005-Health Services Research File
      Not available unless: Your ID number contains 02
    • Stewart1 measurement File
      Not available unless: Your ID number contains 02
    • Stewart et al-2007-Health Services Research File
      Not available unless: Your ID number contains 02
    • McMahon measurement File
      Not available unless: Your ID number contains 02

    • Resources:


    • Assignment: Please consider these questions below when reading each article. If you are unable to attend the class session, please post answers to these questions to the forum by midnight on May 2.

      1.    Ramírez M, Ford ME, Stewart AL, A Teresi J. Measurement issues in health disparities research. Health Services Research. 2005 Oct 1;40(5p2):1640-57.

      a.    What are some reasons that biased estimates of self-reported health status can result among different populations?

      b.    What are differing explanations for heterogeneity in scale response by sociodemographic characteristics?

      c.    What are the implications of failing to consider differential functioning of a measurement tool among different groups?

      2.    Stewart AL, Nápoles-Springer AM. Advancing health disparities research: can we afford to ignore measurement issues?. Medical care. 2003 Nov 1;41(11):1207-20.

      a.    What are some of the psychometric and conceptual challenges related to health disparities research discussed by authors?

      b.    Building on prior class sessions’ discussions, what are the different ways in which self-reported race/ethnicity can be used and interpreted in health disparities research?

      c.    What did you think of the future research agenda laid out by the authors?

      3.    McMahon JM, Volpe EM, Klostermann K, Trabold N, Xue Y. A systematic review of the psychometric properties of the sexual relationship power scale in HIV/AIDS research. Archives of sexual behavior. 2015 Feb 1;44(2):267-94.

      *Note – this paper includes a lot of detail on the adaptation of this scale for different settings; no need to get lost in the weeds on the methodology – it is meant to be illustrative of the broad concept of how a measure can be adapted.

      a.    Briefly describe how the SRPS was initially developed – what did they do to “validate” it?

      b.    What questions or critiques do you have about the adaptation of this measure across the studies reviewed here?

      c.    Using the SRPS as an example, describe in plain English what it means to say a scale is “valid” versus what it means to say it is “reliable.”

      4.    Stewart AL, Nápoles‐Springer AM, Gregorich SE, Santoyo‐Olsson J. Interpersonal processes of care survey: Patient‐reported measures for diverse groups. Health services research. 2007 Jun 1;42(3p1):1235-56.

      a.    Briefly describe how the IPC scale was initially developed – what did they do to “validate” it?

      b.    In what way did the initial development of the IPC scale differ from initial development of the SRPS scale in terms of how applicability to diverse populations was considered from the beginning?

      c.    What questions or critiques do you have about the development of this measure?


  • Monday, May 7, 2018; 1:00 PM - 3:00 PM

    Lecture:  Health care disparities

    Influential papers establishing health care disparities as a factor contributing to health disparities, as well as studies using novel methodologies to investigate and address health care disparities, including standardized patients and between and within hospital comparisons.

    Faculty:  Christine Dehlendorf

    Location:      MIssion Hall 1406

    • Session Audio/Video Recording (Access restricted to registered students):

    • Watch URL
      Not available unless: You belong to a group in Registered Students Only

    • Required Reading:

    • Van ryn Coronaryartery File
      Not available unless: Your ID number contains 02
    • Li Y.JAMA.2011.Lect.2pdf File
      Not available unless: Your ID number contains 02
    • health equity curriculum File
      Not available unless: Your ID number contains 02
    • Anand healthcaredisparities File
      Not available unless: Your ID number contains 02

    • Optional Reading:

    • Bias Review 2017 File
      Not available unless: Your ID number contains 02
    • neff File
      Not available unless: Your ID number contains 02
    • Dehlendorf File
      Not available unless: Your ID number contains 02
    • dovidio File
      Not available unless: Your ID number contains 02

    • Resources:


    • Assignment:

      Please consider these questions below when reading each article. If you are unable to attend the class session, please post answers to these questions to the forum by midnight on May 8th.

      If you are interested in more detail about the scope and causes of implicit bias among providers, you can review some of the optional reading. The Bias_Review provides an overall overview of the literature on implicit bias, including the fact that health care providers have consistently been found to have the same level of bias as members of the general population. The Dovidio article goes into more depth on the underlying nature of bias.


      Van ryn:

      1.       What insight do the findings of this study provide about the origin of health care disparities?

      2.       How can the findings of this study be used to inform interventions designed to minimize health care disparities?

      3.       What hypothesis do you have for why there may have been differences by race in recommendations for men, but not women?

       

      Li:

      1.       Put into your own words what this study found, and what these results suggest as potential causes for health disparities.

      2.       What interventions would be warranted given these findings?

       

      Health Equity Curriculum:

      1.       How does the implicit association test isolate implicit bias?

      2.       What other types of interventions could have an effect on provider bias?

       

      Anand:

      1.       How is the intervention described in this study designed to affect health care disparities?

      2.       While this is designed to be a multi-level intervention, there is one source of health care disparities that this approach does address. What is it? (Think about the Li study). What additional interventions are necessary to address this cause?                                                                                                                             

  • Monday, May 14, 2018; 1:00 PM - 3:00 PM

    Lecture:  Epigenetics

    Studies investigating relationship of genetic ancestry with race/ethnicity and implications for health disparities.

    Faculty:  Christine Dehlendorf

    Location:      MIssion Hall 1406

    • Session Audio/Video Recording (Access restricted to registered students):

    • Watch URL
      Not available unless: You belong to a group in Registered Students Only

    • Required Reading:

    • Thayer Kuzawa 2011 Epigenetics File
      Not available unless: Your ID number contains 02
    • Kuzawa et al-2009-American Journal of Human Biology (1) File
      Not available unless: Your ID number contains 02
    • Mendoza epigenetics File
      Not available unless: Your ID number contains 02

    • Optional Reading:

    • critphilrace.1.2.0190 File
      Not available unless: Your ID number contains 02
    • parets epigenetics File
      Not available unless: Your ID number contains 02
    • Gravlee-2009-American Journal of Physical Anthropology File
      Not available unless: Your ID number contains 02
    • wallack epigenetics File
      Not available unless: Your ID number contains 02

    • Resources:


    • Assignment:

      Please consider these questions below when reading each article. If you are unable to attend the class session, please post answers to these questions to the forum by midnight on May 15th.


      Thayer:

      1.       What are the three pathways by which environment can influence epigenetics described in this article? How are these pathways linked to social disadvantage?

      2.       Discuss how the epigenetic pathways described in this article relate to the Fundamental Cause Theory from the first week. When answering this, remember that in Fundamental Cause Theory, the hypothesis is that flexible resources can be deployed to overcome known threats to health and well being.

      3.       Do you agree with the authors of this paper that studies of epigenetic pathways has the potential to overcome popular sentiment towards genetic determinism? Why or why not?

       

      Kuzawa

      1.       What are the pathways by which early social environments can affect racial disparities in CVD?

      2.       How do the concepts and data discussed in this paper inform the debate over a social vs. genetic definition of race?

      3.       How do the epigenetic data and model presented in this paper relate to potential interventions to address health disparities by race in cardiovascular outcomes? After reading the paper, are you more or less optimistic about the potential to impact disparities? Why?

       

      Mendoza

      1.       What are the implications of these findings for how we thinking about mechanisms by which racism affects health?

      2.       How do these findings relate to the Williams article in week 3, in which they considered different types of measurements of racism?

  • Monday, May 21, 2018; 1:00 PM - 3:00 PM

    Lecture:  Student led-discussions

    Research on relationship of incarceration and the penal system on health outcomes and health disparities, as an example of research on a policy-level social determinant and its downstream impacts.

    Faculty:  Meghan Morris

    Location:      MIssion Hall 1406

    • Session Audio/Video Recording (Access restricted to registered students):

    • Watch (Part I) URL
      Not available unless: You belong to a group in Registered Students Only
    • Watch (Part II) URL
      Not available unless: You belong to a group in Registered Students Only

    • Required Reading:

    • Optional Reading:

    • Resources:


    • Assignment: Below are discussion questions we will consider in class, that you should be thinking about as you do the reading. If you will not attend class, please submit written responses to each question of approximately one half to one page per question (email to christine.dehlendorf@ucsf.edu).

  • Monday, May 28, 2018; 1:00 PM - 3:00 PM

    Lecture:  No Class - Memorial Day

    Faculty:  Christine Dehlendorf

    Location:      MIssion Hall 1406

  • Monday, June 4, 2018; 1:00 PM - 3:00 PM

    Lecture:  Student led-discussions

    Faculty:  Christine Dehlendorf

    Location:      MIssion Hall 1406

    • Session Audio/Video Recording (Access restricted to registered students):

    • Required Reading:

    • Optional Reading:

    • Resources:


    • Assignment: Below are discussion questions we will consider in class, that you should be thinking about as you do the reading. If you will not attend class, please submit written responses to each question of approximately one half to one page per question (email to christine.dehlendorf@ucsf.edu).