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?
Currently, my research involves investigating whether providing developmental-behavioral pediatric services using a co-located, collaborative care model to primary care providers would increase the proportion of successful screening for developmental/behavioral problems and improve the efficiency of referring children with developmental/behavioral concerns to appropriate services (i.e., decreasing time between referral and evaluation for developmental/behavioral concerns) in child primary care settings. Children with behavioral or developmental concerns (e.g., ADHD, autism spectrum disorder, developmental delay) experience significant challenges accessing efficient and appropriate care. Primary care pediatricians are typically the first to see children with such concerns but often may not feel comfortable or competent enough to provide comprehensive assessments and referrals, if necessary. Thus, children are sometimes not referred to appropriate mental health care services or referred inappropriately to services that are oversubscribed with potentially long waitlists. Professional societies such as the American Academy of Pediatrics are pushing for primary care pediatricians to address these concerns by the medical home. One effort/model that has been recently tested is the co-location of a developmental-behavioral pediatrician in a primary care site to improve the education of primary care providers and instigate a collaborative approach. Past efforts have adapted a socioecological framework investigating social determinants of behavioral/developmental concerns among children. For example, early in the 2000s, Qi & Kaiser (2003) found that behavioral problems are more commonly found in children of low-income households due to increased exposure to environmental, familial, and psychosocial risk. Additionally, Larson et al. (2008) investigated multiple social risks on children’s health and found that children of racial/ethnic minorities (i.e., black/African Americans, Hispanics, etc.), low household education, unsafe neighborhoods, and lack of health insurance increased the odds for poor child health outcomes. More recently, Charach et al. (2017) explores screening for disruptive behavior problems in preschool children in primary health care settings and utilizes the Bronfenbrenner’s model to illustrate how disruptive behaviors in preschool children involve complex child-environment interactions. While these efforts and may others do a tremendous job at considering social determinants of health disparities to ensure more generalizable findings, more work is still needed. Future research needs to adopt a socioecological framework to children with behavioral/developmental concerns in various primary care settings to enhance our understanding of disparities in such concerns.
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 outcome I am focusing on is the proportion of children who have been successfully screened for developmental/behavioral problems.
Structural:
Income: Income plays an integral role in determining whether a child is successfully screened for developmental/behavioral problems. As mentioned earlier, research studies have found that children with an economic disadvantage (i.e., come from low-income households) are found to be associated with increased behavioral problems due to increased exposure to environmental, familial, and psychosocial risk (e.g., Qi & Kaiser, 2003). That being said, children with an economic disadvantage are in dire need to be screened and referred to mental health care appropriately. However, many factors can be associated with low income households such as living in rural neighborhoods which limits their access to effective services, lack of health insurance/sufficient health insurance, lack of education/awareness of mental health, all of which contribute to failing to screen for behavioral/developmental problems in a timely and appropriate manner. I believe this factor would function over the lifecourse and intergenerationally.
Race/Ethnicity: There is no doubt that race/ethnicity is also critical when assessing successful screening for behavioral/developmental concerns. The literature suggests that children of racial/ethnic minority backgrounds with behavioral/developmental concerns are neither being screened nor treated appropriately despite the serious need for it. Possible explanations include the stigma associating racial/ethnic minorities with mental health illnesses, lower income/less opportunities, and lack of representation (of their race/ethnicity) in mental health care settings. I believe this factor would function over the lifecourse and intergenerationally.
Intermediary determinant:
Psychosocial circumstances: psychological stressors, specifically lack of social support, have been found to be directly associated with increased risk of behavioral/developmental problems. When it comes to successful screening, children without a strong support system may not be taken for screening in the first place, may not be encouraged to take mental health care seriously, and may not be supported during treatment (in which its success is highly susceptible and vulnerable to a child’s environment). This factor would also function over the lifecourse and intergenerationally.