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.
Sarcoidosis is an inflammatory disease involving systemic granulomatous inflammation that affects the lungs in 90% of patients, but can affect almost any organ system. While granulomas are the immune system’s response to certain infections such as mycobacteria (e..g Tuberculosis) or endemic fungal infections (e.g. coccidioides), the granulomas found in sarcoidosis are non-necrotizing (i.e. they show signs of cell death within the granulomas). The cause of sarcoidosis is unknown and in fact, the diagnosis of sarcoidosis requires tissue biopsy of these granulomas and no definitive cause for the granulomas such as infections, immune system disorders, or specific exposures are present. This lack of a known cause for the disease has presented challenges to epidemiologic studies of risk factors for developing the disease and disease outcomes. Nevertheless, studies have shown that incidence and outcomes in the disease are associated with several structural stratifiers, including race, sex, income, and occupation. African Americans have the highest incidence of the disease and have been shown in several studies to have worse outcomes, mainly with respect to disease extent and outcomes. Women also have a higher incidence and are more likely to have multi-organ involvement. Although there is no known cause for the disease, there have been studies assessing risk factors for incidence and/or more severe disease have included exposure to pesticides, work associated with mildew/mold exposure, construction materials. Higher income level has been associated with a lower risk of systemic disease. These structural factors are inter-related and suggest that those with sarcoidosis are significantly affected by structural disparities. The intermediary determinants in the disease include access to healthcare especially specialists, housing, and psychological factors such as depression. Since sarcoidosis is an uncommon disease and requires a biopsy, access to healthcare providers affects the latency between the start of symptoms and establishment of a diagnosis, which also affects how quickly patients start treatment, which ultimately affects outcomes, especially quality of life. Patients without health insurance or who are averse to seeing physicians can be particularly vulnerable to having chronic and debilitating disease long before it is properly diagnosed. Housing affects patients’ exposure to specific irritants that make symptoms worse and likely play a role in risk of exposure to causative agents. Finally, the disease is associated with higher rates of depression, fatigue, and decreased cognitive function. How well a person is able to cope with these symptoms affects their own perception of their health status and also affects their ability to maintain their occupation and adhere to treatment. Over a patient’s lifetime, these structural stratifiers and intermediary disparities can result in patients with delayed diagnoses, delay or lack of treatment, and lead to disability, which reduces their productivity and ability to provide for their family members. These disparities may be compounded over generations due to the fact that family members must help support the patient and may have more limited educational and occupational opportunities.
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?
As described above, several studies have assessed how structural determinants affect the incidence of sarcoidosis and outcomes in the disease. The most attention has been applied to assessing differences based on race since African Americans have the highest incidence of the disease. In the Black Women’s Health Study, sarcoidosis diagnosis was associated with significantly higher mortality rate ratio for all age groups in African American women in the U.S.1 African Americans have a higher incidence that Whites, and have disease that presents later in age. 1-4 In addition, African Americans are more frequently afflicted with multi-organ involvement, more frequently succumb to the disease compared to Whites, and more frequently treated for their lung disease.5-7 With respect to income, studies have shown that more extensive lung involvement was significantly associated with lower income and there have been strong associations between severity of dyspnea and socioeconomic/insurance status.8 For those undergoing treatment, corticosteroid therapy is associated with higher emergency department use, which may reflect a selection bias for more severe disease or side-effects of corticosteroids.9 Despite these known disparities, the field would benefit from more rigorous epidemiologic studies that can help differentiate the effects of structural stratifiers and underlying biologic factors such as genetic risk factors to help develop markers for disease progression and treatments.
References
1. Cozier YC, Berman JS, Palmer JR, Boggs DA, Serlin DM, Rosenberg L. Sarcoidosis in black women in the United States: data from the Black Women's Health Study. Chest 2011;139:144-50.
2. Bresnitz EA, Strom BL. Epidemiology of sarcoidosis. Epidemiologic reviews 1983;5:124-56.
3. Baughman RP, Teirstein AS, Judson MA, et al. Clinical characteristics of patients in a case control study of sarcoidosis. American journal of respiratory and critical care medicine 2001;164:1885-9.
4. Rybicki BA, Iannuzzi MC, Frederick MM, et al. Familial aggregation of sarcoidosis. A case-control etiologic study of sarcoidosis (ACCESS). American journal of respiratory and critical care medicine 2001;164:2085-91.
5. Gideon NM, Mannino DM. Sarcoidosis mortality in the United States 1979-1991: an analysis of multiple-cause mortality data. The American journal of medicine 1996;100:423-7.
6. Judson MA, Boan AD, Lackland DT. The clinical course of sarcoidosis: presentation, diagnosis, and treatment in a large white and black cohort in the United States. Sarcoidosis, vasculitis, and diffuse lung diseases : official journal of WASOG 2012;29:119-27.
7. Reich JM. Mortality of intrathoracic sarcoidosis in referral vs population-based settings: influence of stage, ethnicity, and corticosteroid therapy. Chest 2002;121:32-9.
8. Rabin DL, Richardson MS, Stein SR, Yeager H, Jr. Sarcoidosis severity and socioeconomic status. The European respiratory journal 2001;18:499-506.
9. Ligon CB, Judson MA. Impact of systemic corticosteroids on healthcare utilization in patients with sarcoidosis. The American journal of the medical sciences 2011;341:196-201.