Health Disparities Forum

1. After reading the article by Thomas et al., comment on where your research, or your research interests, fit into the generational framework for health disparities research. If your work is 1rst or 2nd generation, comment on how your work could lead in the future to 3rd or 4th generation work. If your work is 3rd or 4th generation, comment on what 1rst and 2nd generation work was necessary as a foundation for your current work (or current interests).

The Thomas paper describes three generations of health disparities research, including 1^st gen: detection of health disparities, 2^nd gen: causal relationships underlying health disparities, and 3^rd gen: examining solutions to the health disparities. The 4^th generation is then proposed (roughly summarized) as a means of providing context to the research and interventions, in part through critical race theory, such that the conclusions and solutions about and for social determinants of health and disparities are derived from multiple levels, from individual to social/environmental.

I would place my research as mostly 1^st generation. One focus of my research involves implementing a mobile health application and an activity monitoring device as a means of remotely monitoring cognitive decline. The application collects data about cognition, but also collects data from surveys focused on mood, caregiver burden, daily living and function, location, other apps installed, and battery life (phone usage). The activity monitoring device collects heart rate, sleep, and step count. With the data collected in the study, we might find significant differences or trends among participants based on individual components like age, education, and activity, and social components like self-reported race/ethnicity and neighborhood.

I think that this work could be continued through 2^nd generation research by identifying specific patterns that lead to worse cognitive decline amongst individuals who have certain combinations of social determinants of health. For 3^rd generation research, the mobile health app (if patterns of decline are indeed monitorable through the app) could track trial endpoints for interventions. Lastly, for 4^th generation research, the mobile health app can continue to be used in conjunction with interventions with a critical appraisal directed towards the intervention’s effectiveness within varied contexts of social and environmental conditions at multiple levels of the socioeconomic model of health. The 4^th generation research would then be continued and modified over time to ensure it’s continued effectiveness as the relationship between variables in the socioeconomic model themselves continue to change.

2. The barbershop hypertension intervention, while essentially a clinical services intervention operating at either the fence or safety-net level as described by Jones, has some engagement with the social determinants of health. Interventions like that described in the Gottleib article are designed to mitigate the impact of social determinants. How could you apply one of these two types of interventions to your area of research? Propose one or two interventions that engage with social determinants on some level.

My thoughts about the two studies: Both the BARBER-1 study and Gottleib’s study were implementing community-level interventions to address health disparities. BARBER-1 supported barbers within the barbershop setting such that they could promote blood pressure screening and physician/clinic referrals, whereas Gottleib supported research assistants and health navigators within a clinical setting such that they could help study participants navigate a variety of health resources. I was personally more enticed by the idea of community members directly helping other community members to find health services, but I also feel that the effectiveness of such measures may be limited if more than one or a few health services are included. Health system navigation is currently a skill that could take years to master, let alone the additional knowledge required to know which services are appropriate. Ultimately, I imagine that community members and health system navigators could work well together if multiple specialized community members reported to navigators and referred fellow community members to the navigators for further assistance. Placing a trusted community member into the network of health care providers may actually benefit the medical system in many cases by generating a feeling of trust and familiarity.

How such interventions may fit into my own research: There currently exists a program at the UCSF Memory and Aging Center called the CareEcosystem. This program is designed similarly to the Gottleib study in that a navigator who is well versed in the needs of individuals with cognitive decline, as well as the needs of the caregivers, is able to stay in contact with patients and help them find services that would benefit their situation. The mobile health app that I am using is currently designed with such an interface in mind. Moving forward, perhaps the CareEcosystem and the health app could combine, allowing for cognitive testing and survey monitoring to be available at a distance, and navigators would have the ability to incorporate formal testing results from physicians into their recommendations for health services and referrals.