1. Write a brief paragraph discussing what social determinants are most relevant to your area of research and why. Consider both structural stratifiers (e.g. income, education, etc) and intermediary determinants such as material and psychosocial circumstances, as described in the WHO reading. Explain why you chose the factors (might use Braveman article from last week to provide justification. 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.
Most recently, my work has been focusing on reproductive health and family planning. The social determinants that are relevant are both structural and intermediary. Even the notion of “family planning” is historically and culturally constructed. The fact that some people have a positive attitude toward “planning” and others do not, as well as the unequal access to the ability to “plan” one’s life, is socially embedded. The structural stratifiers include income/savings, education, institutional racism, and health care access as well as intermediary determinants which include psychosocial factors effecting patient preferences and behaviors. For example, income and education are related to people’s ability to learn about and access contraception that is preferable to them, as well as access abortion care and health care during their pregnancy if they continue the pregnancy. We also know that historical factors such as stratified reproduction have influenced black populations and minority populations to be coerced into use of particular contraceptives, and this leads to distrust of contraceptives and health care professionals in many of these communities. It becomes complicated, however, when we consider health outcomes of unintended pregnancies because as I mention above, even the concept of planning interacts with communities differently and we know that there are differing levels of ambivalence toward pregnancy based on race. This is likely related to different experiences of institutional racism as well as economic factors. Many of these factors function intergenerationally because income/savings and education are related to family income/savings and education. Additionally, the experience of racism which has limited both accruement of savings and educational opportunities also effects mistrust of institutions.
2. Write a brief 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?
For the area of reproductive health, the last decade has seen an encouragement to incorporate a socioecological framework. This has been driven by both the incorporation of reproductive justice frameworks into the area of family planning and reproductive health, as well as led by Dehlendorf and her team. Nonetheless, I believe that there is still a need to develop an even greater emphasis on a socioecological framework in this area. As I alluded to above, I still feel that it is so difficult to tease apart the issue of what health outcome we are looking at without having that outcome be skewed toward one that preferences a population of researchers who value planned pregnancy as an outcome. This means thinking about a larger socioecological framework that incorporates in the notion that preferences are also embedded in community frameworks. I like using the example that a teenager in some communities may have not have planned or desired a pregnancy, but may feel that the pregnancy brings her social value at that time once she is pregnant because it brings different kinds of resources to her. In our frameworks, this may be considered a “negative health outcome” because it is undesired and unplanned and unintended and yet, it may be just the experience that individual might need to help her change her social status, potentially. In any event, if one were to aggregate different examples like that, we might be able to change our outcome measures. But, I think that takes using an approach that is always embedded in a socioecological approach. Another example of the lack of this approach that has surprised me is from a systematic review that I am currently working on which is looking at preferences for contraceptive counselling in the peripartum period. I have been surprised by how many studies assume that continuation of a long-acting contraceptive equates to preference for that contraceptive rather than lack of access to health care to get that contraceptive removed, or possibly lack of advocacy of oneself to ask for its removal. In any event, I think this nearsightedness of research is due to a lack of incorporating in a socioecological perspective from the beginning of the research plan.