Health Disparities Forum

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.)

Outcome of interest: Hepatitis C infection

Behavior 1: Sharing injection equipment

An association between sharing injection equipment and Hepatitis C is widely accepted, and this is an important behavior to consider for prevention efforts. There are many individual-level interventions aimed to prevent the transmission of HCV through sharing injection equipment – for instance, increasing safe injection education for IDU. Among participants in our studies, virtually none of them report sharing syringes, which comes from decades of strong HIV education in SF. However, it surprises me that individuals still report sharing injecting paraphernalia (cookers, cotton, ties etc) which of course still puts you at risk for HCV transmission. Prevention strategies around individual-level education have benefit here. However, as the readings indicate, individual-level behavioral interventions are only one approach to activating population-based change. Another big issue for sharing equipment among IDU population is not just education and knowledge, but also access. If IDUs do not have access to clean injection equipment then improving education and motivation for behavior change on an individual level will prove ineffective. Many states (or counties, neighborhoods) do not provide adequate access to clean injection injecting equipment. Indeed, even certain neighborhoods in SF (e.g. Bayview) do not have consistently adequate access to clean equipment, and SF is a city with robust harm reduction programming. Access – in this case a structural/political barrier – is also an important driver of sharing injection equipment.

Behavior 2: Medication adherence

I am currently coordinating a study to treat HCV+ injection drug users with an 8 week regimen of Harvoni – we are evaluating the feasibility and acceptability of two treatment modalities: DOT vs. unobserved weekly dosing. We know that medication adherence among this population is difficult – and may be worse if unobserved. Poor medication adherence is not only a barrier to curing HCV, but it also can have more significant negative implications for treatment e.g. building resistance to Harvoni thereby making future treatment more difficult. There are many reasons why medication adherence is difficult for this population: lost/stolen meds, chaotic lifestyle, lack of adequate storage, not being able to make appointments for new med pick-ups etc (*side effects used to be an enormous barrier to adherence for HCV treatments, but Harvoni has limited side effects).

I want to mention another behavior that we’ve noticed during this study that was unexpected: emotional apathy. Some of our participants appear emotionally apathetic about contracting and curing HCV. I’m hoping to explore this as our study continues. It seems like the availability/ease of Harvoni has made some individuals more apathetic to treatment and also less concerned about their diagnosis (e.g. sentiments like: “It only takes 8 weeks to treat, so I can do it anytime, I can do it later” or “It’s not a big deal if I contract HCV since it’s curable now…”). This not only affects medication adherence, but could also affect transmissions as well. I think this is an important behavioral characteristic to explore in future studies.

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.

This may not be the answer you’re looking for, but as a qualitatively trained researcher, I would like to conduct a qualitative study around the “emotional apathy” that I discussed earlier. I think this could have significant implications for transmission and successful treatment and is a mentality that has not been researched before. In fact, previous studies (prior to Harvoni) have shown “psychological and behavioral transformation” during HCV treatment leading to reduced stigma and shame, and reduction in substance use.[1] What we’re hearing now, however, seems like the opposite sentiment. I would like to conduct qualitative interviews with newly diagnosed HCV individuals, and those who either did not finish treatment or who were not cured. Social factors are built into this study as IDUs experience high rates of stress, social exclusion, low SES and include minority races/ethnicities.

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?

Of course! We need to continue to study how behaviors are influenced by external/life course factors and how behaviors influence health outcomes, as these relationships are neither static overtime nor across populations. Understanding these interactions will help us determine where/when/how to intervene. While environment certainly does influence health behavior, we also know there are other factors (e.g. human agency, social acceptability) that also influence behavior outside of environmental context.