Thank you all for your work submitting homework so far. The TAs have been reviewing your submissions. I wanted to take a moment to highlight some answers that may be helpful for other people to read to give a sense of how to integrate the content of this course into your work.
For Question 1 of Week 1, Adam Zakaria did a great job talking about how the specific clinical condition of Skin and Soft Tissue Infections is impacted by social determinants:
1. Write a brief paragraph discussing what social determinants are most relevant to your area of research and why. 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.
One of my areas of research is investigating risk factors for Skin and Soft Tissue Infections (SSTIs) due to Group A strep (GAS). This is an important question because the treatment of GAS SSTIs differs from the treatment of SSTIs due to Staph aureus (most common cause of SSTIs overall), and therefore it is important to determine which patients should receive empiric antibiotic coverage for GAS. Through investigation of this question, it has become increasingly clear that, as with many health-associated questions, social determinants of health are very relevant. For example, two important risk factors for GAS SSTIs include a chronic wound/ulcer and homelessness. It is clear how homelessness can be tied to social determinants of health, but the presence of a chronic wound is also strongly tied to social determinants of health. For example, one of the most common lower extremity ulcers is due to venous insufficiency. These ulcers are primarily treated/managed through strategies that will reduce swelling in the lower extremities, including the use of compression stockings, leg elevation, and adequate management of conditions that result in leg swelling (heart failure, CKD, etc.). We could imagine how patients of a lower socioeconomic status may also have poorer health literacy due to fewer educational opportunities and less access to medical care, which may lead to poor adherence to the use of compression stockings. Additionally, patients of a lower SES may work more labor-intensive jobs that require being on their feet for long periods of time, and therefore leg elevation throughout the day is not a feasible option. Poor health literacy and the poor health outcomes that portends can definitely be an intergenerational phenomenon to consider.
For Question 2, Kristen Azar provided an important overview of considerations related to the impact of social determinants and racism on engagement in primary care and self-management of chronic disease.
2. Describe 2-3 health behaviors that are relevant to your area of interest. Write a paragraph exploring how these may be influenced by the social determinants you described in #1, and another paragraph considering how they are influenced by the levels of racism described in the Gardner’s Tale assigned in Week 1.
Health behaviors that are relevant to my research area of interest include preventive and primary care engagement as well as adherence to chronic disease self-management for individuals with ambulatory sensitive chronic conditions that require long-term care. For individuals experiencing housing insecurity and/or homelessness, self-management of chronic conditions is extremely challenging. There may be a need to deprioritize self-care in favor of securing basic needs or survival. This alone can increase risk for developing a chronic disease as low-cost foods are preferred to higher quality, more expensive options. Also mental health and depression, as well as substance use are associated with housing insecurity and can contribute to the development of chronic disease. There may be a lack of resources to purchase medication or to store necessary supplies for disease management. Further, without a residence or permanent address, it will be harder to access insurance and primary care services.
These health behaviors, of accessing primary care services and self-care/management, are influenced by all three levels of racism I the Gardner’s Tale framework. Institutionalized racism is defined as “differential access to the goods, services and opportunities of society by race”. As noted in the article, institutional racism results in “differential access to quality education, sound housing, gainful employment, appropriate medical facilities, and a clean environment” all of which are relevant to long term housing security and development of chronic disease. Government policies historically implemented decades in the past still have ramifications for distribution of wealth and resources. Generations of families can be prevented from prospering as a result of inequities in access to affordable housing or home ownership. Personally mediated racism can also play an important role in the intentional (or unintentional) exclusion of some race/ethnic groups from housing resources, in turn impacting their ability to manage chronic conditions. Finally, internalized racism can lead to low self-esteem, low self-efficacy and distorted negative self-image; all of which can have negative health impacts and hinder the individual’s ability to self-manage or perform self-care activities.
And for Question 3, April Bell and Amanda Irish took different approaches to possible methods to investigate the relationships, with April describing a mixed-methods approach and Amanda using quantitative methods to investigate the impact of structural racism.
2. Describe a qualitative or quantitative study design that could deepen your understanding of the relationship between social determinants of health, racism, health behaviors, and your health outcome of interest.
April:
Black youth are currently experiencing three, ongoing pandemics – racism, COVID-19, and police violence. Racial disparities in poor birth outcomes have burdened Black birthing people regardless of age in the United States. In more recent years, exposures to racism and other biases over the life course, rather than race, are recognized as actual risk factors informing differences in these outcomes. COVID-19 has starkly revealed how structural injustices, such as systemic racism and economic deprivation, cause a disproportionate burden, including mortality for Black people, including Black youth. Additionally, Black youth deal with high rates of exposure to police violence wherever they live, learn and play. Moreover, there is a plethora of evidence demonstrating the ways in which U.S. law enforcement system targets Black children, along with their caregivers and neighborhoods, at a disproportionately high rate.
This project will take a mixed methods approach, including surveys, focus group discussions (FGDs), key informant interviews (KIIs), and digital storytelling (DST), to explore how the intersecting crises of COVID-19, police violence against Black people, and racism impacts the lives of youth in Oakland, San Francisco, and Fresno, particularly Black youth, and their health decision-making.
Amanda:
I will be performing a quantitative study to examine the effects of historical redlining on current West Nile virus infection rates. Unfortunately the data I have access to will not allow inclusion of physical activity as a possible mediator of risk, but I can examine whether mosquito control district interventions are associated with neighborhood status. I plan to perform a mediation analysis to assess whether interventions were applied equitably, independently of actual risk (e.g., controlling for the number of mosquitoes which would be the main “objective” criteria for the mosquito control district to intervene).