1. In Chapter 5 of the WHO document, A conceptual framework for action on the structural determinants of health, the authors describe structural stratifiers (e.g. income, education, etc) and intermediary determinants such as material and psychosocial circumstances.Pick 3 of these factors (at least one structural and one intermediary). Explain why you chose the factors (might use Braveman article to provide justification) and describe how each could be an important determinant of a health outcome of your choosing. The association could be reported in published research or it could be your hypothesized relationship.
I am interested in investigating health disparities in mortality following diagnosis with high grade glioma (an aggressive primary brain tumor), specifically progression-free survival and overall length of survival. The first structural straifier that I believe is important in this discussion is income. I believe that income plays an important role in determining outcomes for this disease because in order to be treated for glioma, people must first be diagnosed. This means that people must be able to present to a primary care physician after they develop symptoms and have the necessary workup (brain MRI) performed to make the diagnosis and then go on for further subspecialized care including oncology and neurosurgery. However, people with low income may not have health insurance that allows them to see a healthcare provider which would prevent them from presenting for care. A second structural stratifier that I believe is important is education level. The recommended treatment for glioma is surgery followed by chemotherapy and radiation. Patients with limited education may have difficulty navigating the health care system to coordinate such complex care for themselves. If this is the case and patients are unable to undergo the chemotherapy and radiation therapy required, they will certainly experience increased mortality. One intermediary determinant that may be involved is the health system as a social determinant of health. The divide in access to care for various patients can be striking. For example, some hospital/insurance systems have the primary care, surgical team, radiation, and oncology teams integrated such that all visits are arranged for the patient. Whereas other systems require the patient to travel to multiple sites and arrange each appointment separately. In this latter case, follow-through with care is much more difficult and therefore, more likely not to be completed leading to worse outcomes of mortality.
2. In the Braveman et al 2005 JAMA article,authors write, “Past socioeconomic factors could act independently or modify the effects of current factors on health.”Also, “Socioeconomic characteristics of neighborhoods could affect health…” For the same health outcome that you chose to answer Question #1, describe how socioeconomic factors earlier in the lifecourse and neighborhood characteristics could contribute to incidence of your outcome of interest (you could be describing protective or harmful effects). If you believe that neither of these are relevant for your outcome of interest, explain why.
My outcome of interest is investigating health disparities in mortality following diagnosis with high grade glioma (an aggressive primary brain tumor), specifically progression-free survival and overall length of survival. Socioeconomic factors earlier in the lifecourse of a patient may influence this outcome. The Braveman article describes how SES in childhood may be related to SES in adulthood such that it is more likely for someone who was raised in an environment where access to health care was limited or education level of one’s parents was limited to also have limited means and limited education. These factors can lead to disparities of mortality following glioma diagnosis. In addition, neighborhood socioeconomic conditions may play a role as well because geography does influence which health care systems one has access to which, as discussed in #1 above, the health care system from which a paitnet receives care can greatly influence outcome following high grade glioma diagnosis.