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?
In my past research position, we focused on designing and implementing innovative HIV-prevention interventions for a variety of target populations, especially those disproportionately affected by the HIV epidemic. In particular, I worked with male and female sex workers, substance users, and male couples with extra-dyadic sexual interactions that were at increased risk for HIV acquisition. In the male couples study, we identified serodiscordant couples and worked closely with them to improve HIV medication adherence for the HIV-positive partner. Our intervention was rooted in the socioecological framework: we focused on the HIV care continuum, meeting the patient where they resided in this framework, and supporting them in progressing toward undetectable viral load (Bazzi & Fergus et. al 2016). This meant that if a patient was unable to connect with a provider, we would problem solve on issues surrounding the social context (transportation, health insurance, housing, provider trust, etc.) in order to assist the patient in achieving their goal. The idea behind our intervention was to reinforce the lessons from public health and the socioecological context and implement an intervention designed to consider broader influences beyond simply “forgetting to take my medication.” Since we worked with couples, our counseling intervention worked at the level of the dyad, allowing the partner to play a role in supporting the HIV-positive partner in progressing toward undetectable viral load. Discussions surrounded the social network, access to alcohol and drugs, mental health, relationship strengths and weaknesses, as well as issues surrounding disclosure. I think more interventions that consider the socioecological perspective are necessary in this field indeed, and can be applicable to other fields focusing on medication adherence.
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.
Outcome of interest: Survival after HIV-infection
Structural Factors: 1) Income: It is well known that socioeconomic status and income affect both risk of HIV infection and survival after infection. As the WHO article states, the “neo-material” explanation that income inequality means “fewer economic resources among the poorest, resulting in lessened ability to avoid risks, cure injury or disease, and/or prevent illness” is well supported in the HIV epidemic literature. A simple example of this is access to housing: in San Francisco, those housed had a better 5-year survival than those without housing (homeless) 92% vs. 79%; however, this disparity decreased after a new housing program was implemented for HIV-infected individuals (Khanijow 2015). 2) race ethnicity: in addition, the role of race and ethnicity in HIV infection as well as survival is very important. The White House HIV/AIDS strategy considers reducing infections in Black and Latino populations a key strategy to stemming the tide of the epidemic. Strikingly, Black and Latino men who have sex with men are more likely to become infected even if their sexual behavior is identical to white men who have sex with men. This is due to networks and structures above and beyond individuals, is related to cultural practices, and affects the people one has access to in a sexual network (thereby increasing risk) (Tieu 2015). Numerous studies have also chronicled racial disparities in survival in various contexts (Sheehan 2015, Lesko 2015). As race is a social not a biological category as is mentioned in the WHO article, it is important to intervene to reduce these disparities in survival/mortality between racial minority and majority groups.
Intermediary Factor: 1) Psychosocial determinants: those who have life stressors (financial stress, racism, debt, lack of social support etc.) can be disproportionately affected by HIV as well. In fact, a lot of research is showing that these psychosocial determinants should not be “added up” into one sum, because the whole experience is greater than the sum of the parts. For example, those with mental health, substance use, and abuse as a child do much much worse in terms of HIV-acquisition than those struggling with one of these alone. This has given rise to the term “syndemics” in which these multiple influences have a bigger effect than maybe once surmised. The WHO article discusses the more subjective role of psychosocial determinants – it is not only the disproportionate burden of stress, but also how that stress is perceived. This comes down to whether a person perceives this events as in one’s control (internal) or out of one’s control (external). This difference underlies the disparities observed – people who perceive external influences may not feel empowered to try to change their circumstances.