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.
1. Social Class/Income
I consider social class and income to be one juxtaposed entity (especially when classifying the population as lower, middle and upper class) and thus will be used interchangeably for the purpose of this discussion.
Studies have shown that the lower class or poor and disadvantaged members of society suffer disproportionately from common mental disorders such as anxiety and depression when compared to those consisting of the upper class (WHO 2016). For example, a systematic review of 115 studies on common mental disorders among the impoverished and low-middle income countries revealed that 70% of the studies had a positive association between a variety of poverty measures and mental illnesses. This relationship can be attributed to the higher levels of psychosocial stressors (which will be described in more detail below) among those in poverty compared to those in the upper social class. To elaborate, it is logical to say that those deemed lower class are more likely to be struggling to meet their financial obligations for their families and thus more likely to have exacerbation of anxiety and depression, whether genetically present or not, than those in the upper class.
2. Psychosocial Factors
As mentioned above, psychosocial stressors such as negative life events (i.e, death or illnesses in family, domestic violence, etc) job strain and financial obligations, and stressful living circumstances (e.g. high debt, lack of social support, coping styles, etc) can all greatly exacerbate the underlying consequences of anxiety, depression and bipolar disorders. Thus with this in mind, the higher levels of financial strain among the lower to middle class can be one explanation to the disproportionate prevalence of these mental disorders among these individuals when compared to those in the upper class. Therefore these factors must be greatly considered when conducting any population based clinical trial involving mental health outcomes.
3. Race/Ethnicity
In addition, race/ethnicity is also a profound factor in the disparity of mental disorders. For instance, studies have shown that minority groups such as African Americans, Hispanics and Asians tend to have either lower lifetime risks of psychiatric disorders compared with whites in the U.S. (McGuire and Miranda, 2008). Conversely, studies done on American Indians showed a higher risk of PTSD and alcohol dependence but lower risk for major depression compared to White Americans. However, when looking at disparities in access to mental health care, ethnic minorities are shown to have less access to mental health services than whites. Therefore, when considering any clinical trial Possible explanations can be genetic factors, access to healthcare as well as specific behavioral lifestyles.
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.
In regards to mental health illnesses, past socioeconomic lifecourse experiences as well as neighborhood conditions are in my opinion, both vital in the outcomes seen among individuals. For instance, a large percentage of American Indians live in impoverished lands and are at high risk for PTSD, alcoholism and suicide. Thus, an individual who is born and raised in this type of neighborhood will also tend to be exposed and acclimate to the behavioral lifestyles associated with the area and be at risk for the disorders mentioned above. Furthermore, living in such an environment can also exacerbate any underlying mental disorders, increasing the prevalence of these health outcomes any skewing the levels more to when compared to other races of similar conditions.