1) My research focus is on atopic dermatitis, and recent studies have demonstrated there are specific genetic variants that predispose to all atopic conditions including hay fever and asthma as well as atopic dermatitis. In AD specifically, there is also a growing body of evidence that there are differences in AD prevalence and persistence (from childhood into adulthood) across race/ethnicities and across social/economic positions. However, studies that have examined these differences have not employed a socioecological framework to explore this question, and have reported inconsistent findings, likely because of the way SES was measured. Using this framework to address these questions would greatly contribute to the field, especially because of the breadth of exposures that have been shown or hypothesized to be associated with AD, including genetics and epigenetics, environmental factors (pets, diet, prenatal and postnatal smoking, household crowding, microbiome, etc…), SES factors (parental education and occupation, income, neighborhood characteristics, etc…), behavioral factors (maternal prenatal depression/anxiety, maternal prenatal alcohol and tobacco use, etc…), among many others. Using this approach over the life course would also be particularly relevant to AD because it is a chronic, relapsing and remitting disease with varying disease trajectories. Although it often begins in infancy, it may also begin in later adolescence, and may resolve or persist into adulthood. Given these varying trajectories, I think it is essential to apply this framework throughout the life course.
2) For the following examples, I am considering the influence of these structural determinants on the incidence and prevalence of atopic dermatitis in children:
1) Occupation: I would include occupation, a structural stratifier, and focus on the occupation of the mother during pregnancy. There is evidence to suggest that prenatal stress is associated with increased incidence of AD in the offspring, and that mothers who worked during pregnancy, particularly at manual jobs, have children with an increased risk of AD. This could be related to the mother’s environmental exposures as well as job stress during the gestational period, both of which have been hypothesized to increase the risk of AD in the offspring.
2) Material circumstances: I would include this intermediary determinant because, as the Braveman article suggests, income is not necessarily representative of wealth, which can vary across different social groups with similar incomes. Material living conditions can influence incidence and prevalence of AD in several dimensions, including environmental living conditions (i.e. number of people living in the same household can influence atopic sensitization) and ability to afford expensive topical treatments and non-prescription products such as body lotions/soaps/detergents/etc.. for atopic/sensitive skin. I think these factors likely function over the life course and should be considered at multiple points in time throughout childhood.
3) Education: I would include education, a structural stratifier, and focus on the highest education level of the child’s mother. I think this factor is particularly important to explore because despite higher education typically being associated with worse health outcomes, in AD, higher maternal education has been shown to be associated with increased incidence of AD in the offspring. The “hygiene hypothesis” has been suggested as a possible explanation, but recently this explanation has fallen out of favor. This is an area where further research is essential to better understand these structural determinants.