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 research area of interest is the impact of obesity on outcomes for critically ill children. Childhood obesity is an increasingly appreciated epidemic in the United States and the health consequences of this disease are well documented. The literature reports social determinants that contribute to the high prevalence of this disease (Piontak JR at al., J ch Health 2016; Kellou N et al., Diabetes Metab. 2014; Swank M et al. J Public Health Management Practice2015). Firstly, individual factors contributing to obesity, and to the subsequent health effects, include race, ethnicity, education level, and family income to name a few. Additionally, there are several community and society associated determinants that play a great role in the childhood obesity epidemic. Access to stores and markets selling fresh produce, schools funding physical education, after-school classes and groups promoting physical activities and healthy eating, and community outreach education programs have been shown to greatly improve overall childhood health and reduce the prevalence and impact of obesity. Further, in 2010, under the Obama administration, the White House Task Force on Childhood Obesity published their goals and objectives to reduce the childhood obesity rate to just five percent by 2030 – the same rate before childhood obesity first began to rise in the late 1970s.
Despite many community, state and federal programs that have been instituted to reduce childhood obesity, much more can be done to specifically evaluate the social determinants that may contribute to onset of obesity-related chronic illnesses, including diabetes, asthma, hypertension, heart disease and stroke. This is especially important since approximately 20-40% of all hospitalized and critically ill children are overweight and obese (Woo et al. J Peds 2009).
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 address is survival and long term outcomes of critical illness in pediatrics. The mortality rate for children admitted to a pediatric ICU is 3%, with mortality rates increasing up to 20-30% for those with multi-organ disease such as sepsis and shock. Both 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 factors that likely affect survival and long-term outcomes of critical illness. I will focus on the factors of income, education, and psychosocial circumstances.
a. Income: Pediatric intensive care units are not found at most community hospitals and are based most often at large academic centers. As such, for many, critical illness of a child brings with it the cost of transportation to and from the hospital (including medical helicopter transportation), accommodations for family members, in addition to medical bills. Further, long hospital stays place parental employment at risk. As such, the potential financial burdens of an ill child may lead to delay in seeking tertiary medical care. The inability of the parents to stay by the bedside because of such constraints can increase patient anxiety and stress, and decrease the provider-family interaction and shared decision making.
b. Education: Poor health literacy likely plays a role at several time points in the course of childhood critical illness. Firstly, lack of knowledge of when to seek medical attention or how to access the medical system are common factors that may contribute to illness severity and clinical outcome. During the hospitalization, it is essential for the provider to assess the health literacy of the family and discuss clinical care of the child in way that can be understood by the family. If this is not done, the family will feel more overwhelmed and struggle to provide adequate medical history or participate in care and decision making throughout the admission. Furthermore, many children who survive critical illness may be discharged home with increased medical needs including new medications and equipment. The education level and understanding of the family plays a great role in decision to offer new medical care (for example tracheostomy and mechanical ventilation), to utilize long term care facilities, or simply may prolong hospitalization so that families may be trained to care for their child post-illness.
c. Psychosocial circumstances: Social support is a fundamental necessity when dealing with the stress of a critically ill child. No parent or guardian should have to make difficult decisions or accept the responsibility of caring for a sick child alone. Yet, very often psychosocial circumstances play a large role in medical decisions of critically ill children. Here are a few situations where I feel psychosocial circumstances affect the care, and possibly the long term outcome for critically ill children: (1) single versus two parent homes, (2) non-English speaking families, (3) stable home vs homeless or transitional living, (4) mental health and general health of parents and family members, (5) availability of other familial and community support systems. Such circumstances will affect ability to care for a medically complex child at home, need for long term care facility support, safety of child at home, and respite needs for the family.