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.
In kidney disease, race has historically been a predominant SDOH and a focus of much epidemiologic research with the goal of elucidating the drivers of disparities. Black patients have a higher incidence of ESKD compared to white patients, a disparity that cannot be explained by differences in CKD prevalence. CKD as a disease is most commonly a consequence of longstanding hypertension and diabetes, and so progressive CKD and ESRD are apt to reflect differences in a wide range of upstream factors, such as healthcare access and care quality, but also may reflect factors outside of healthcare system such as diet (eg access to healthy food), etc. Racial differences in access to transplant have also been well described with respect to referral, evaluation, waitlisting. My research focuses on an equity-oriented evaluation of existing clinical decision rules (such as clinical prediction models, eGFR equations, guideline-based cutoffs for referral/treatment) and their potential for exacerbating health disparities when implemented to make real world clinical decisions. Such decision rules even if not overtly biased can be sensitive to the changing prevalence of varying clinical, demographic, and social characteristics and may have varying impact on equity (however we define it) regionally and temporally. Ensuring equity across multiple strata becomes rapidly complicated, which is why I intend to focus on race as it is the most visible, historically relevant, glaring disparity in the kidney care today.
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?
An example of how a framework has been applied to this research area is in the investigation of the "survival paradox" - the observation that black ESRD patients have better survival compared to white.(2) While there may be some biological factors at play, such as differing age of ESRD onset between groups, differences in body composition and how it affects dialytic dose, etc, the difference persists even after adjustment for the typical clinical/demographic characteristics. It is unlikely that any single factor can account for this difference. Hypotheses have been proposed and/or tested at multiple levels looking at differences in insurance mix, institutional mistrust, background mortality (e.g. rates of suicide, neighborhood violence, car crashes), and more recently the differential utilization of palliative care services (and intentional discontinuation of dialysis (3)). Appreciation of the broader framework of factors describing social determinants of health is thus vital to understanding the root causes of health disparity and how to mitigate them.
References
(1) https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1681/ASN.2016010027
(2) https://dx.doi.org/10.1053%2Fj.ajkd.2012.02.321
(3) https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1681/ASN.2019020122