1. Write a paragraph describing the extent to which a socioecological framework incorporating issues related to social determinants has been applied to your area of research. Are there opportunities for improving our understanding of or approach to disparities in your area with a greater emphasis on a socioecological framework?
My area of research is in diabetes management and prevention in the food pantry setting. Socioecological models involving influences from the surrounding home, work, school, and community environments have been applied to the area of diabetes as far back as the 1990s (Hurositz, NEJM, 1993). One such model was developed by the American Diabetes Association Prevention Committee (Hill et al., Diabetes Care, 2013). This model, developed as a scientific statement, recognizes the various levels and sectors of influence on both obesity and diabetes risk. These levels include individual factors (demographics, SES, psychosocial factors, gene-environmental interactions), behavioral settings (home, worksites, communities, health care, and schools), sectors of influence (government, public health, heath care, media, foundations, industry, land use and transportation, education, agriculture), and social norms and values. The social and environmental influences are mediated through increases in energy intake relative to energy expenditure.
There are definitely opportunities for improving our understanding of disparities in the area of diabetes management and prevention with a greater emphasis on a socioecological framework. Most research to date involving socioecological determinants in this field involves associational studies, which are increasing in number in the literature. Given that a large proportion of clinical trials in diabetes prevention and management which involve only individual level variables show only modest results at best, public health approaches including environmental and social influences are needed.
2. In the WHO reading, 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. Consider whether how these factors might function over the lifecourse and/or intergenerationally.
Structural stratifiers (income, education, occupation, social class, gender, and race/ethnicity) and intermediary determinants (material circumstances, psychosocial circumstances, behavioral and/or biological factors, and health systems) are important determinants of health outcomes in diabetes management. I will focus on the factors of income, education, and psychosocial circumstances.
Income: Income may influence health through a direct effect on material resources that are mediated by such factors as behaviors. One could hypothesize that having a low income could be associated with worse glycemic control, given the high costs associated with diabetes management (including costs associated with medications, diabetic supplies, and healthy food options). Indeed, it has been shown that low income is associated with poor diabetes self-management (e.g. Levine, Ethn Dis, 2009). The effects of poverty on A1c levels may be mediated by avoidance coping and depressive symptoms (Houle, BMJ Open Diab Res Care, 2016). Income could certainly function both other the life course and inter-generationally (children of low income parents are more likely to eventually be low income themselves).
Education: Low education may be related to low health literacy. Indeed, a study has shown that health literacy may partially mediate the association between low education and low self-reported health status (van der Heide, J Health Commun, 2013). Health literacy, or “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions,” has been theorized to be an important mediating factor in the development of adverse outcomes in diabetic patients. More than one-third of US adults may have difficulty managing common health-related tasks, and the prevalence may be even higher in patients with diabetes (Schillinger, Public Health Rep, 2006). Health literacy skills specific to diabetes include reading labels on pill bottles, understanding medication dosing and insulin requirements, and interpreting food labels. To date, studies examining the potential association between health literacy and adverse diabetic outcomes have been mixed. This factor likely functions over the life-course, as once one has completed their education, it is less likely that they will continue to obtain higher degrees in time.
Psychosocial Circumstances: These include psychosocial stressors, stressful living circumstances, and lack of social support. As mentioned above, the effects of poverty on A1c levels may be mediated by avoidance coping and depressive symptoms. Further, children living in lower SES environments have more cognitive, behavioral, and emotional difficulties (Brown et al., Arch Ped Adol Med, 2012), which has been associated with obesity (Duarte et al., J Ped, 2010), which is associated with the development of diabetes. This factor may function over both the life-course and inter-generationally (if parental depression and stress is associated with child depression and stress).