1. In Chapter 5 of the WHO document, 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.
- Many well-tolerated options for anti-retroviral therapy are now available, and government programs make these therapies widely available to patients living with HIV (PLWIH). However, significant disparities exist amongst vulnerable populations along the care cascade. Of those patients that know their diagnosis and are linked to HIV care, housing status plays a crucial structural determinant of poor health outcomes PLWIH (Aidala et al AJPH 2016), the most important of which in terms of reducing forward transmission of HIV is virologic suppression (Doshi et al Health Aff 2016). Along the causal pathway in housing status is race/ethnicity, which can be an important mediator of the impact of housing instability has on patient outcomes. Income, as well, can have an important role in mediating/mitigating the impact of housing status on clinical outcomes in HIV.
2. In the Braveman et al 2005 JAMA article, authors write, “Past socioeconomic factors could act independently or modify the effects of current factors on health.” Also, “Socioeconomic characteristics of neighborhoods could affect health…” For the same health outcome that you chose to answer Question #1, describe how socioeconomic factors earlier in the life course and neighborhood characteristics could contribute to incidence of your outcome of interest (you could be describing protective or harmful effects). If you believe that neither of these are relevant for your outcome of interest, explain why.
- Early life experiences of socioeconomic marginalization, including identifying as a racial minority, from low income household/neighborhood, can lead to cumulative exposure to violence, drug abuse, poor health behaviors (smoking, poor diet, etc), other traumatic life experiences (family incarceration, psychiatric illness, etc) and environmental exposure. These exposures can have deleterious impacts on health outcomes that can lead to adverse health outcomes over time. Moreover, early educational attainment could (theoretically) have a mediating effect on the impact of unstable housing status on health care outcomes, and specifically virologic suppression, in one’s adult years. Neighborhood characterics may play less of a role in people with housing instability in that frankly homeless and unstably housed individuals may live in multiple neighborhoods over a short period of time.