-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.
One known health disparity within the scope of my practice are the varying rates of preterm birth in the US. Two known structural stratifiers/determinants of preterm birth are education and race. However, the relationships between the multiple structural determinants of preterm birth are highly complex and interdependent. Socioeconomic status is difficult to measure directly; education is a proxy that can be used. In this clinical scenario, it is hypothesized that differences in understanding of the importance of prenatal care and differences in cultural value of this care across educational strata may influence the risk of preterm birth. Additionally, education is also known to be associated with access to care in general, which is likely to influence this risk as well. With regards to race, its affect on risk of preterm birth has been shown to be independent of socioeconomic status. In fact, depending on how it is measured, race has been shown to be a stronger risk factor for preterm birth than socioeconomic status. For example, one study found that amongst Black women, there was no difference in preterm birth when comparing low neighborhood SES to high neighborhood SES. It is hypothesized that this association is a biologic manifestation of systemic racism and associated chronic stress. One intermediary determinant could be psychosocial circumstances. Social, behavioral, stress, and maternal psychological factors have been associated with pregnancy outcomes; and chronic stress has been related to low socioeconomic status. Specifically, associations between perceived stress and preterm birth have been reported. Chronic stressors may include financial insecurities, poor and crowded living conditions, unemployment, stressful working conditions, domestic violence, and unsatisfying relationships.
-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.
Both of these—past socioeconomic factors and current neighborhood socioeconomic characteristics—could lead to exposures to environmental factors that increase the risk of preterm birth. Additionally, there may be psychosocial stressors that may be more or less likely to occur depending on childhood SES or neighborhood SES. For childhood SES, differences in access to health care and parental health literacy as a child may affect the risk of preterm birth as an adult.