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 renal recovery after dialysis-requiring acute kidney injury (AKI-D), for which the current literature predominantly focuses on outcomes and care in the acute setting: that is, hospitalized patients who are critically ill in the ICU (ADQI statement on acute kidney disease and renal recovery, Nat Rev Nephrol 2017). While I am not aware of (and could not find in PubMed) studies examining disparities specifically in AKI or AKI-D patients, one area that I think deserves close scrutiny is how outpatient AKI-D patients are monitored for renal recovery. Disparities in the chronic kidney disease (CKD) and end-stage renal disease (ESRD) populations are well documented (e.g., Nicholas et al, Adv Chronic Kidney Dis 2015; USRDS 2016 Annual Data Report), and AKI-D patients are essentially a subpopulation of dialysis patients who will eventually differentiate into patients with normal renal function (complete recovery), CKD (partial recovery), or ESRD (non-recovery). The socioecological framework has been applied to CKD progression, with a focus on the transition from CKD to ESRD. The literature discusses various social determinants that can contribute to CKD progression (often by influencing chronic diabetes or hypertension control) at several different levels: society at large (e.g., discrimination leading to higher rates of unemployment and resultant lack of medical insurance), the local community (e.g., residential segregation reducing healthcare access and care coordination, low health literacy), and the individual (e.g., socioeconomic status, poor nutrition, maladaptive health behaviors). I think a major opportunity for improving our understanding of disparities in renal patients would be to apply the socioecological framework to AKI-D patients who need to be monitored for recovery, particularly as they transition to the outpatient setting. All of the above factors that have been described in CKD care also need to be carefully considered among AKI-D patients, who are arguably more vulnerable and may have more at stake (since they are already on dialysis).
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.
The health outcome I would like to focus on is disparities in kidney transplantation rates. Kidney transplant is the preferred, most definitive treatment for end-stage renal disease and is associated with improved outcomes (e.g., survival, quality of life) compared to other renal replacement therapy modalities (e.g., hemodialysis, peritoneal dialysis). To receive a kidney transplant, patients must be referred for transplant evaluation, then approved after medical evaluation by a transplant center, and subsequently be placed on the actual transplant waitlist.
Education - Lower levels of education likely correlate with poor health literacy, which I hypothesize would be a significant barrier to patients’ choosing kidney transplant. There can be many misconceptions about what it means to accept an organ from a donor (deceased or living) that can persist because of poor health literacy, and some of these misconceptions can be passed down intergenerationally. In addition, differences in education about the practical logistics of being placed on the transplant waitlist likely also contribute to disparities: patients who understand the process are better able to advocate for themselves (e.g., requesting a referral to the transplant nephrologist, following up about waitlist status if they have not received any formal notifications) and navigate the healthcare system to complete the steps required. Lastly, education level can also influence how patients understand and weigh risks and benefits of the different renal replacement therapy options; those who are better educated will better be able to understand the long-term benefits of kidney transplant over dialysis, even if short-term risks (during the perioperative period) are higher.
Income - Inability to pay for the immunosuppressive medications required after a kidney transplant can be prohibitive for many patients. Medicare patients are guaranteed medical coverage for dialysis indefinitely, but Medicare only pays for immunosuppressive medications post-transplant for a few years - after which the patients are responsible financially. Post-transplant care also requires frequent clinic visits, and transportation costs may also make it less feasible for patients to choose kidney transplantation (as opposed to transportation to/from dialysis treatments, which are covered by the national ESRD program).
Psychosocial circumstances - Social support is very important for patients who undergo a transplant surgery, particularly during the perioperative period. I hypothesize that patients who lack social support may be less likely to choose kidney transplantation given the home support needed immediately post-procedure. Providers who assess a patient’s transplant candidacy also sometimes use lack of social support as a reason to reject a patient. Furthermore, stressful living circumstances and relationships could negatively impact a patient’s self-assessment of his/her own ability to manage the complex immunosuppressive medication regimens required post-transplant, which may deter them from choosing transplant. These factors also influence a patient’s health trajectory over the life-course: stressful relationships early in a child’s development may lead to low self-confidence as an adult and therefore contribute to fear of not being able to manage a complex medication regimens.