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 focuses on screening for and providing assistance with health-related social needs (social determinants) in the health care setting. My research is founded on the principle that we cannot impact a person or family’s health without addressing their health-related social needs, and that the health care system can and should play a role in addressing the social determinants. There is ample opportunity to improve our understanding and approach to disparities, given the need to better understand how to screen for social and economic needs (regarding patient and provider acceptability, implementation best practices, etc.), and how to connect patients with resources and assistance when a need is identified (e.g. community partnerships, reimbursement for social needs assistance), in addition to evaluating the effects of screening and interventions on health care outcomes and health care disparities, given that there can be unintended consequences of interventions that may have counterproductive effects if not all patients have equal access to resources. Screening for and addressing health-related social needs is important on many levels: on an institutional or policy level, government and organizational policy has ramifications for the reimbursement of health care services, health care access (e.g. insurance) and the direction of the health care system overall. The CMMI Accountable Health Communities initiative is a test case for 32 sites to focus on the social determinants of health, and could have widespread implications for how we screen for social needs and care for the entire patient. Within communities, relationships between clinics and community resources is an important and vital foundation for addressing health-related social needs, given the impracticality of clinics directly providing widespread social services; community structure and organization also directly impact the needs of the patients living within the community. At an individual level, the patient’s education, income, experience with the health care system (trust, relationship), family structure, perceived social standing, etc., influence how she/he may respond to screening for health-related social needs, and whether or not they would want assistance with needs through the health care system.
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.
Three factors of the structural stratifiers and intermediary determinants are: race/ethnicity (structural stratifier), education (structural stratifier) and material circumstances (intermediary determinants). I chose these factors because, although all of the structural stratifiers and intermediary determinants have unique (though with some overlap) and important implications for a person’s health, if I have to pick three, I view the previously listed factors as high priority to address. Race/ethnicity has significant implications for a person’s health, regardless of income/education (as Braveman points out in her article), due to the systemic racism endemic in our society. Race/ethnicity is an important determinant in arguably every health outcome, related to disparities in health care, ranging from access, treatment, trust. Racial disparities are commonly noted in cancer survival; African American/Black patients have been shown to have worse cancer outcomes (e.g. endometrial cancer, colorectal cancer), tending to present with more aggressive, later stage disease, thought to be related to unequal access to preventative health care, distrust in the medical system, unequal surgical care (and additional causes being explored). Race/ethnicity impacts a person starting before birth, when society may view and treat a pregnant mother of a certain race/ethnicity differently, and a pregnant mother may have differential access to prenatal care (in addition to her own baseline health being impacted by her own life experiences secondary to racism—one way race/ethnicity can also have intergenerational implications), which can impact birth outcomes. I chose education, as it has profound implications on income (without complete overlap, as Braveman pointed out), social mobility, self-empowerment, health education, among other factors. Education also has the potential to be modifiable, if children are allowed equal access and opportunity for educational achievement, which is obviously not a given. Education can also impact cancer survival; if a female patient does not have the health education regarding the importance of routine pap smears, for example, she may not have the routine screening vital in preventing cervical cancer. Thus, she may present with later stage cervical cancer and her survival be reduced. Educational differences can also impact over the life course, with one’s educational opportunities starting at birth related to home/day care, how much one’s family reads to them, up to opportunities to obtain a college or graduate education. Intergenerationally, one’s parent’s education can directly impact one’s own educational attainment.
I chose material circumstances because basic needs, such as safe housing, healthy food, adequate clothing, have profound implications for health and ability to care for oneself and one’s family. Sticking with cancer survival, it has been shown that housing status is associated with survival of head and neck cancer (as one example), independent of delays in presenting to care. Unstable housing/homelessness has profound implications for one’s ability to care for oneself, how a patient is treated within the health care system, and is highly related to social support/isolation, SES and other basic needs (e.g. food, clothing). If a patient diagnosed with cancer is homeless or marginally housed, he/she faces much more adversity related to ability to access cancer care, ability to recuperate from treatment, and can face disparities in the care received related to health care staff assumptions about the patient. Material circumstances can impact a person throughout the life course; when a person must focus on attainment of basic life needs, their ability to attain an education, access preventative health services, are continually impacted.