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 current research is focused on the use of home blood pressure monitoring to diagnose and treat hypertension in minority communities. In this field of study, the socioecological framework has been applied in an attempt to understand and target the factors that contribute to racial disparities in hypertension in the face of new and effective treatments. As early as the mid-1970's researchers were considering the impact of socioeconomic forces on differences in the hypertension-related death rate between White and Black Americans (James et al, American Journal of Public Health, 1976). More recently, efforts have been made at state and national levels to address this disparity to varying degrees of success (Mueller et al, American Journal of Hypertension, 2015), suggesting that there is ample opportunity to improve how we incorporate the model into our broader plan to eliminate disparities in hypertension. At the institutional level, governments can use the power of policy to reduce socioeconomic inequities that not only stress the individuals within a minority population, but also stress the hospitals and healthcare systems they rely on. At a community level, efforts to improve living and working conditions could lead to a reduction in the environmental stressors that contribute to high blood pressure. Finally, on an individual-level, there is space for greater interaction between patient and provider to 1) identify and manage behaviors that contribute to their high blood pressure, as well as 2) take a broader look at the patient's personal experience with their medical care (do they have insurance, are they close to their provider, can they afford their medications, etc) in order to provide a truly personalized treatment regimen that addresses all facets of the patient's life. I think that, at present, the field is doing a pretty decent job of utilizing the socioecological framework to understand hypertension disparities, however there is significant room for improvement at every level of the model, in terms of the implementation of practices and policies that actually address the factors causing the disparities.
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 life-course and/or intergenerational
Income: Income could influence blood pressure control through a variety of pathways including access to medical care. For individuals with limited financial resources, having access to comprehensive medical care, from doctor’s visits to medications, is not a given. As a result, chronic conditions like hypertension can go undiagnosed for long periods of time, and even when it is caught, the patient may not be able to afford treatment (Attaei et al, Lancet Public Health, 2017). As income is typically dependent on the employment status of an individual, it can fluctuate greatly throughout the life-course. Early on, during child and early adulthood, a patient’s income is likely to be best measured by assessing the income of parents or guardians and is thus an intergenerational measure. However, as a patient grows older, their income becomes a more personal measure of their circumstances. Low income later on in life could affect blood pressure control through an inability to procure healthy foods, a lack of time to exercise because of multiple jobs, or difficulty affording medical care. In addition to these more material manifestations, persistent low income could cause long periods of stress, resulting elevated blood pressure over time.
Race/Ethnicity: Race/ethnicity could have an impact on blood pressure control through it’s relationship with other socioeconomic factors. For example, racial disparities in access to medical care and education could be contributing to a lack of awareness in minority communities about the impact of diet and exercise on high blood pressure. Racial disparities are also due, in part, to a historically poor relationship between healthcare providers and minority communities. The distrust that minority communities often feel towards healthcare providers and systems could impact approaches that aimed at treating hypertension at the neighborhood-level. Race/ethnicity likely functions inter-generationally and I would expect that disparities an individual’s parents faced (as they relate to race) would typically impact that same individual, initially during their child and early adulthood as their parent would be their primary provider, and later on in their adult life as they dealt more personally with racial disparities.
Psychosocial Circumstances: I would associate psychosocial circumstances like long-term stress to high blood pressure. In this scenario, I would imagine that long-term stress would function over the period of one’s life-course and could vary greatly during that time. Issues like those touched on above, income and race, as well concerns about one’s family, employment or health, could all contribute to long-term stress, which could elevate one’s blood pressure overtime.