1. The health outcome I am most interested in is cardiovascular mortality, and in particular how social determinants of health impact the control of chronic diseases which are major drivers of cardiovascular mortality. While nutrition and physical activity also play an important role in control of chronic diseases, I’d like to focus on the successful use of medications to control chronic diseases that lead to cardiovascular mortality – chiefly diabetes, hypertension and hyperlipidemia.
When mapping out barriers and facilitators to adherence to medications, one important structural stratifier is income which at the most surface level impacts the ability to purchase medications but also impacts patients’ abilities to purchase supplies (blood pressure monitors, diabetes test strips, glucometers, refrigeration to store insulin) and to access additional education on chronic disease management. As newer very expensive cardiovascular drugs are brought to market which may be safer or more effective than existing therapies (PCSK-9 inhibitors for hyperlipidemia, new classes for diabetes and hypertension medications) the impact of income on disparities in CV mortality is likely to widen. A second important structural stratifier is education as successful chronic disease control often involves understanding fairly complex health topics such as following sliding scale insulin schedules and recording blood pressure and blood sugar measurements at regular intervals and adjusting medications accordingly over long time periods. Finally, the intermediary factor which is of the most interest to me is the health system as a social determinant of health. Having worked in clinics which provide different services to patients based on insurance (i.e. a diabetic educator or psychologist only available to patients with certain commercial insurances but not those with Medicaid) I have seen first-hand how unequitable systems create unequal opportunities for patients to achieve disease control. Conversely, health systems may help address disparities in CV mortality through developing pharmacy and educational resources for all patients, developing pathways to help low income patients afford medications, and developing disease monitoring plans at appropriate literacy levels for patients
2. Many socioeconomic factors experienced early in the life-course are likely to being driving causes for developing hypertension and diabetes, most notably poor childhood nutrition as a result of inadequate supply to healthy food. As mentioned in question one, education which is an early life course experience may impact ability to manage diabetes and hypertension medications. Perhaps the most important neighborhood characteristic which is likely to impact chronic disease management is geographic access to healthcare, as low income neighborhoods are less likely to have access to pharmacies and primary care clinics. When these health resources are more difficulty to access we should expect it to be more difficult for patients to maintain chronic disease control.