Thanks all to your responses to Homework #2, for Week #3 on social determinants. Sorry to take a while to get feedback to you all.
As I did for the first assignmnt, I have replied to some of you individually, and here have some general comments for everyone. I wanted to highlight Meghan Ferrara’s excellent response to this homework, and encourage you all to read it. One additional factor related to health seeking behavior that I would encourage her to look at in addition to insurance status would be race/ethnicity.
Some of you had trouble answering the second question about a study design looking at the relationship between a behavior and your outcome, taking into account a social factor. I recognize that in some cases this question did not fully apply, often because the relationship had been well established. One of you (Leslie Suen) acknowledged that even when behaviors are known to have an effect, the ability for individuals to have those behaviors can be limited by social factors (such as transportation), and these social factors can be a target of study (rather than the behavior itself). One other option that you could have all thought about more is the possibility of doing a mediation analysis (more on this next week) looking at the extent to which sociodemographic differences in health outcomes are mediated by differences in behaviors.
Many of you identified the value of qualitative methods to elucidate the relationship between social factors and behaviors, which I think is a valuable approach. Engaging with the community that is impacted by the health outcome, and by health inequities, has the potential to clarify mechanisms by which patterns of health outcomes occur, and suggest new and different approaches to ameliorating disparities. Hunter Holt did a particularly nice job of describing this in his answer to the first two questions.
For the third question, several of you pointed out that we need to continue to investigate and understand how social factors impact the behaviors that lead to disparities as a way of understanding better how to positively impact these inequities – and I agree! This is in fact one of the main things I hoped you would get out of the course, so I am so glad to see all these responses. This question was also designed to get you all thinking about whether there is any value in the status quo – e.g., studying the impact of behaviors on health outcomes - given the strong influence of social determinants. As indicated by many of you, I believe the answer is yes, but only if it is done in a contextualized way. As I mentioned above, Meghan Ferrara did a nice job of addressing this question, and I encourage you to read her answer. I have also included some other individuals’ answers below that did a good job of addressing the question.
Jonathan Amatruda
First, it will always be important to understand the behavioral interventions that could improve health; to given up on this because of the difficulties in achieving behavioral change is fatalistic. But it is certainly true that for behavioral interventions to be effective, we need to understand the social factors that will stand in the way of these behaviors. Ultimately, a thorough understanding of behavioral factors and the social factors that influence them will be necessary to improve public health. For example, if we know that regular exercise reduces the rate of some cancers but exercise is inhibited by neighborhood factors, we can design public health interventions that seek to increase exercise by making neighborhoods more conducive to walking, jogging, and other activities.
Michelle Lee
Yes, it is critical to study health behaviors even if they are influenced by more concrete, immutable factors like neighborhood and education. By identifying these health behaviors, strategies to uncouple their link to immutable factors can be developed and hopefully modify patients’ health behaviors. For instance, if smoking is part of the culture of certain districts/neighborhood, grassroots education campaigns can target these areas to influence health outcomes.
Chi Chu
It is still important to study these behaviors because they are on the pathway and still influence health. Even if they are not root causes, they are still targets for intervention, which can still be effective (even if it is limited by lack of a full accounting for social factors). Understanding upstream factors such as neighborhood, income, education that impact behaviors is helpful for leveraging them for improving health
Thanks all! See you next week.