1. Write a paragraph describing the extent to which an 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 how older adults with serious or chronic illness make medical decisions and engage in the process of advance care planning. Health disparities in advance care planning have been investigated to some degree, finding less than 20% of older adults at the end of life have engaged in advance care planning, and even less so for minority patients and those with limited literacy. Some studies have shown that completing an advance directive form is complicated by issues of mistrust with the medical system and perceived racism with regard to limiting or withholding care, while other studies point to complex cultural and family values. At the institutional level, more attention needs to be made at identifying multiple “access points” for engagement in advance care planning and to starting these conversations early, while patients are still healthy. At the community level, better tools that are culturally and linguistically appropriate need to be available to aid patients, families, and clinicians by providing a framework for conversations and a place to document one’s values. At the individual level, conversations about preferences for medical care also need to happen early and be revisited as time goes on.
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.
Education: Education is a structural factor that influences one’s engagement in advance care planning. Oftentimes forms such as an advance directive are written in legal terms and have been found to be at a 20th grade reading level, well-beyond the average 5th grade reading level for most U.S. adults over the age of 65. In addition, life sustaining treatment options, and the realities of their effectiveness, are complex concepts that may be difficult to understand for those with lower levels of education. This would be a factor both over the life course and perhaps intergenerationally.
Race/Ethnicity: Race and ethnicity are known to be associated with engagement with advance care planning. At an individual level, some studies have shown that different cultural and spiritual attitudes toward the end of life often can be at conflict with a perception of what the goals of hospice and palliative care are. In addition, prejudice and discrimination on the part of the physician who may not be offering the same level of advance care planning to minority groups for a variety of reasons contributes to this disparity. At a systems level, minority patients often receive care in stressed health care systems with inadequate staffing and lower resources that may lead to disproportionate medical care with regard to advance care planning, which could also be considered an intermediary factor. This would be a factor both over the life course and intergenerationally.
Behavioral factors: Loneliness has been independently associated
with mortality in older adults. In relation to advance care planning,
loneliness or social isolation is often an impediment to engaging in advance
care planning. Oftentimes individuals who are socially isolated are unable to
name a surrogate decision maker and clinicians may be reticent to approach the
topic with socially isolated individuals. However, this has not been studied that extensively. This would be a factor both over the life course but not likely to be intergenerational.