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? Consider drawing a DAG or a socioecological model (like the one shown in class for obesity) to illustrate your point (you can take a picture to post on the forum).
For many decades, the conversation, funding, and research done in under resourced settings in pediatrics aimed at lowering child mortality. However, little research has been done on the likely inverse increase in childhood morbidity. Minimal services exist to support families, few to no services have been adopted or created to address childhood disability, and no one has examined potentially worsening disparities for families now caring for a childhood with significant neurocognitive disability. My research, to date, has been working with a cohort study of cerebral malaria survivors to characterize long term neurocognitive and developmental sequalae. Families are participating in the study for up to five years, which has allowed our team the opportunity to begin a qualitative analysis of some of the many challenge, including changes in SES, these families face.
2. In the WHO reading, 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.
Income (structural): Initial research as well as our baseline SES data suggests that families with an initially lower SES typically report more familial stress when caring for a child with severe neurocognitive disability, epilepsy, or developmental delay post cerebral malaria. This could potentially be explained by the family having fewer resources to access the few support services that currently exist. For example, in the community served by Queen Elizabeth Hospital in Blantyre, Malawi, there are intermittent physical therapy services available (from one physical therapist based at the hospital). Families with lower income may not have the funds to travel to and from the hospital (even by public transportation). Families with an initially lower income illness may also struggle to take time away from work or to find alternative caregivers for the disabled child.
Psychosocial factor/stigma: the increase in childhood morbidity after severe illness in low resource settings may also be associated with an increase in stigma towards the family or primary caregiver. For example, after cerebral malaria, children are 1/3 more likely to develop epilepsy. Seizures can be negatively attributed the devil or other evil spirits. This can lead the family from losing status in their village community and lead to worsening health disparities for these individuals and their families. Caregivers in our cohort study have also expressed feelings of guilt as their child was previously “normal” but now is so different and unable to care for themselves or do things they were once able to do.
Health System (intermediary): Malawi, and many other under resourced countries often have some version of a public hospital. However, these hospitals typically have longer wait times, fewer staff members, and fewer medications or supportive services for pediatric care. Families may have issues obtaining access to these public hospitals or may not trust the government run hospital.