Week 2 Assignment

Week 2 Assignment

by Meghan Ferrara -

1. A growing body of literature documents the relevance of all the social determinants—both structural stratifiers and intermediary determinants—identified in the WHO CSDH Framework to rural health inequities. That said, arguably the most thoroughly researched SDH in the field of rural health is the intermediary determinant of the health system as a social determinant. This area of research looks at health systems factors such as availability and access, both in geographic and economic terms, for example, such as hospital or provider population density and insurance coverage. The intermediary determinant of behavioral and/or biological factors has also been well-studied in rural health, documenting the various ways that rural residents engage in more health risk behaviors and fewer health-promoting behaviors. Given the predominance of these research approaches, I would argue that it is now most relevant for the field of rural health to look more closely at the structural stratifiers of income, education, and occupation, and the intermediary determinants of material and psychosocial factors. I believe these are especially important to look at precisely because of their lifecourse and intergenerational impacts. The structural determinant of race/ethnicity in rural health has also been less studied, but what research does exist indicates that this SDH functions differently across rural/urban populations, pointing to the importance of addressing this aspect in future research. This area of inquiry is of increasing importance given the demographic shifts that are happening in rural areas across the U.S. The most illuminating recent developments in rural health inequities research have come from the exploration of the ways that the social determinants operate differently between rural and urban areas and the exploration of rural status as a social determinant in itself.

2. The field of rural health and rural health inequities research is very broad and diverse, and the application of a socioecological or social determinants framework is similarly so. These frameworks have been incorporated across different scales, for example by the CDC, HRSA, and Healthy People 2020 in their respective work on rural health, as well as by policy and research institutes, and collaborative and individual academic research initiatives. This breadth of application reflects a well-developed theorization of the social determinants in rural health. Although there are many examples of rural health disparities research that effectively incorporates the social determinants into rigorous empirical design, the overall impact of the field could be strengthened by a more comprehensive and coherent application of a social determinants framework.

Re: Week 2 Assignment

by Jerrine Morris -
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.
As a Reproductive Endocrinology and Infertility Fellow, my eventual research goals are to examine and reduce health disparities in infertility. Disparities in infertility prevention and treatment are vast spanning both the individual and across society. In terms of the structural stratifiers, previous research has shown limitations in the evaluation of infertility or fertility treatment based on socioeconomic and ethnic barriers. Individuals with a college education, higher income, and often Caucasian are more likely to be referred to an infertility specialist and have a greater likelihood of obtaining treatment. Besides from access to care, we see individuals from disadvantaged backgrounds more likely engage in behaviors that are detrimental to their own natural fertility leading them to increased risk for tubal factor disease and have a higher prevalence of untreated comorbidities such as diabetes and hypertension. Furthermore, limited education of infertility within some populations can manifest as late entry into care at which point a more aggressive and often unattainable treatment may be recommended. I think about this intergenerationally as infertility is viewed as a disease with reproduction considered a human right. For those who desire to conceive, limitations of infertility evaluations/treatments to those who are the economic elite limits social justice for these disadvantaged groups. Lastly, limitations in diversity among those able to afford these services consequently limits the research potential to improve outcomes among specific population. It is well known that African American women, even after adjustment for education and intrauterine fibroids along with other potential confounders, still have worse IVF outcomes then Caucasian women. Similar trends can be seen among Asian women as well. By limiting those with access to treatment, researchers have focused little on subtleties in evaluations/treatments that may have ethnic implications.
2. Write a brief 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?
Fortunately, expansion of access to fertility care and investigation of health disparities is a recent initiative of the American Society for Reproductive Medicine. While it is challenging to apply the socioecological framework to this area of research given the inherent financial limitations currently associated with this field, my goals will be to investigate how changes in legislation/policy affects the likelihood for evaluation and acquisition of treatment particularly among diverse populations.