1. State your health outcome of interest. (It could be the one you used for week #2 or another one.) Pick two key behaviors that are important factors leading to your health outcome. Explain the importance of these behaviors either for etiology, prevention, or intervention. (If none of the behaviors in the readings are important for your health outcome, suggest another behavior that is.)
One of my interests is hypertension control in primary care. In other words, if you have hypertension, was your blood pressure below goal at your most recent measurement in clinic, or if you have white coat hypertension, on your most recent home measurements. Two key behaviors leading to my health outcome are diet and medication adherence.
Diet is important through several mechanisms; a high-sodium / low potassium diet can increase blood pressure, thus worsening HTN control. Poor diet can lead to obesity and worsening HTN control. The article by Muraven and Baumeister is important in this sphere, as changes to diet and abstaining from unhealthy foods requires significant restraint and self-control, which are difficult in situations of stress and instability.
Medications can lower BP and decrease complication rates. However, as BP meds are long-term, not usually linked to symptoms, and often times have side effects, adherence can be a problem. Agency and feelings of control, as discussed by Arreola, play an important role when we are asking patients to prioritize their own long-term health (by controlling their blood pressure so as to avoid heart disease or stroke), over other short-term concerns.
2. Describe how you would study the role of one of the behaviors described for question #1 and your health outcome of interest. Incorporate a social factor (e.g. race/ethnicity, social exclusion, stress) in the study approach.
Several social factors can have an impact on medication adherence, and therefore hypertension control, via multiple mechanisms. Life instability and stress can make taking meds a lower priority, and economic hardship can make it difficult to afford meds. We will be using a very large EHR dataset with 170,000 patients. Unfortunately the only socio-demographic information available to us from the EHR are race, ethnicity, insurance status and zip code. We are primarily interested in the association between individual health systems and clinics and hypertension control. However, it is important that we understand the role of socioeconomic status in hypertension control if we are to adequately control for these elements. Clinics caring for patients of lower SES should not be ‘penalized’.
3. If key health behaviors (e.g. smoking, exercise, nutritious diet) are strongly influenced by neighborhood, income, and/or education, do we need to continue to study how these behaviors influence health outcomes? Why or why not?
Yes, it is important that we continue to study these factors in order to prioritize areas for intervention. If health behaviors are primarily a result of lack of knowledge, our role as clinicians is mostly to inform our patients of the repercussions of their current actions on long-term health. However, if our patient’s current behaviors are primarily a result of lack of agency due to childhood experiences and/or their environment exhausting their ability for self-restraint, we need to go beyond simply educating our patients. Further, if I want to understand differences in hypertension control between different clinics with different patient populations, I need to go beyond assuming that clinicians are not doing enough to instruct their patients and provide prescriptions for medications.