Please post answers to the following to the forum before the start of class on January 16th:
1. Write a paragraph describing the extent to which a 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?
Colorectal cancer (CRC) is the second leading cause of cancer deaths in the United States. Despite evidence that screening is effective in reducing CRC mortality, screening is underutilized in the health safety-net population. The safety-net health system is an integrated network comprised of publically subsidized health services to the low-income population. Within safety-net health systems, fecal immunochemical test (FIT) with colonoscopy follow-up has been a preferred option for population-level screening. However, low-income, recent immigrants, and non-English speaking populations who often receive care from safety-net health systems may experience difficulty comprehending and completing FIT using word-based and English instructions. Despite effectiveness for population-level screening for CRC, screening relies on patients properly completing FIT tests for laboratory processing and adequate bowel preparation for colonoscopy follow-up. Timely and proper FIT and colonoscopy completion is required for accurate up-to-date CRC screening. My experience points to multiple barriers to CRC screening, at the level of patients, care teams, and the health care organization; therefore, improving follow-up will require a multilevel interventional approach which considers the multiple layers of a patient’s health. Completing screening can be challenging; patients must understand susceptibility, benefits, follow a multistep stool collection method and bowel preparation instructions, and then attended repeated clinical visits. Improvements in CRC screening completion and effective follow-up strategies holds strong potential to reduce cancer disparities in other settings with similar populations.
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.
*The three selected factors are chosen due to their potential associations to CRC screening in underserved communities
Race/ethnicity (structural): There is overwhelming literature that supports race/ethnicity to be a primary variable effecting CRC screening. However, the way each race/ethnicity impacts lower screening rates can be very different. For example, with the interplay of culture attitudes, African Americans tend to not complete screening due to feelings of ‘disgust’ over CRC screening, especially at a younger age. Hence, when a GI disease is diagnosed, prognosis is often poor as compared to if caught earlier by virtue of screening. Another example, with the addition of health literacy, Hispanics/Latinx tend to find CRC screening difficult due to logistics and understanding screening instructions. Hence, CRC screening among Hispanic/Latinx communities are often poor and are not socially encouraged between community members. These aforementioned examples suggest while race/ethnicity is a contributing factor to lower screening rates, more nuanced interpretations and considerations are required when designing new patient-centered interventions.
Material circumstances (intermediary): Broadly, literature supports material circumstances (e.g. housing situation, dwelling location distance to clinic, financial means to attend clinic visit etc) to be a variable effecting the degree of engagement between a vulnerable patient and the healthcare team across a multitude of preventable diseases. As alluded to earlier, patient from the health safety-net system may find it logistically and financially challenging to attend clinical visits and follow-up with providers of their screening outcomes. Compounding this issue over a patient’s life, underserved patients tend to be poorer in overall health as they are not update with their own healthcare plan, and hence, cancer screening. This intermediary factor suggests perhaps flexibility in timing of appointment and location of visit may be helpful in helping to reduce cancer disparities among these communities.
Behavioral and Biological Factors (intermediary): Literature has supported poor health behavior factors contributes to poor cancer screening outcomes as these individuals tend to not be as up to date in their healthcare plan, and hence, cancer screening. Socially, poor health behaviors also effect the people around you (e.g. kids picking up bad habits from parents) leading to poorer health outcomes later in their lives. Biologically, literature has supported CRC may also have a hereditary and familial linkage component. While controlling for these two intermediary variable may be difficult, working towards ameliorating behavioral life style choices and factoring family histories may immensely help reduce cancer disparities.