1. Write a paragraph describing the extent to which an socioecological framework incorporating issues related to social determinants has been applied to your area of research. Are there opportunities for improving our understanding of or approach to disparities in your area with a greater emphasis on a socioecological framework?
In lung transplantation there are health disparities which prevent access to transplantation in general. The socioecological framework which has been applied to this area has been in assessing if there are issues related to health care disparities based on insurance. In the United States, patients with cystic fibrosis who had Medicaid as their primary insurance had higher rates of death on the waiting list compared with those with private insurance. It is unclear why cystic fibrosis patients on Medicaid are less likely to survive to transplant than patients on private insurance; however, it may be due to access to care. Patients with a lower socioeconomic status and those on Medicaid are less likely to be referred for lung transplantation. Moreover, even when they are referred, they are more likely to be declined for listing despite adjustments for demographics, disease severity, and contraindications. The disparities extend to the posttransplant period as well, and posttransplant survival is worse in patients on government-sponsored insurance than in those on private insurance. More of a focus on improving access to transplantation with a greater emphasis on understanding why there are disparities would be beneficial. There are opportunities to improve research in access to transplantation using a socioecological framework by focusing on which patients are transplanted and which patients are not given the opportunity for transplantation.
2. In the WHO reading, A conceptual framework for action on the structural determinants of health, the authors describe structural stratifiers (e.g. income, education, etc) and intermediary determinants such as material and psychosocial circumstances. Pick 3 of these factors (at least one structural and one intermediary). Explain why you chose the factors (might use Braveman article to provide justification) and describe how each could be an important determinant of a health outcome of your choosing. The association could be reported in published research or it could be your hypothesized relationship. Consider whether how these factors might function over the lifecourse and/or intergenerationally.
My primary outcome of interest is listing for lung transplantation. The process that goes into a patient being listed for transplantation is quite complex. In the context of a patient being evaluated for transplantation they are evaluated to ensure that they (1) do not have any medical issues that would attenuate their life independent of the lung transplant and (2) do not have any issues that would prevent them from being able to take care of their transplant after the surgery. The primary way that social determinants of health may impact the transplant status of a patient is in the evaluation of the second aim of the assessment. There are both structural stratifiers and intermediary factors that go into this determination.
One such structural stratifier that goes into this is income. For example, at UCSF we require that patients spend 6 weeks in San Francisco after their transplant. If a patient does not have the income to afford this then they cannot be a transplant candidate. Furthermore, the meds are very pricy so having enough income to cover the meds after the transplantation is important. As such, patients need to show that they have enough financial capital to cover the transplant. Without a certain income level a patient would not be able to get a transplant. This factor can change over a life course but is often intergenerational.
Another such structural stratifier is education. Part of this is related to education and medical literacy. People with a higher education level are often more able to research the complexities of transplantation because they are more familiar with the way to acquire medical knowledge due to their formal education level. During the assessment of transplant candidates our social workers assess if the patient may be able to understand the complexities of post-transplant care and if they are going to be able to organize taking up to 20 different medicines at a time. They are often given a little quiz to determine their ability to retain what they are taught. They may impact the ability to get transplanted because education makes a person more likely to be able to understand and synthesize knowledge they are taught. This factor can change also over a life course but is often intergenerational in that educated parents often want to educate their children.
One of the intermediary determinants is psychosocial circumstances, specifically, social support. After transplantation patients are required to have a family member be with them 24/7 for at least 6 weeks after transplantation as part of a “care team”. In addition, our center requires a second family member to be on backup for the same period of time. While the structural stratifiers listed above can be overcome with donations/fundraising or education efforts, this social support aspect is much harder for a patient to overcome. I have seen a number of patients who were not transplant candidates due to a lack of social support and lack of qualified caregivers. This factor is less likely to change over a life course than income or education.