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?
My area of research is on physician-patient communication regarding contraception and abortion. It is well-established that access to medical care affects maternal mortality world-wide (“WHO | Maternal mortality”). There has been a growing volume of literature and more recently, media coverage, reporting on the effect of social determinants on maternal mortality and morbidity in the United States (Williams, 2018). More specifically, there is also a growing body of literature highlighting health disparities in unintended pregnancy and abortion. In a 2010 systematic review, Dehlendorf et al. applied a socioecological framework to describe the causes of disparities in family planning outcomes as three major factors: (1) patient preferences and behaviors based on differences in knowledge and attitudes, specifically concerns of safety and mistrust toward medical recommendations; (2) health system factors like access to family planning services; and (3) provider-related factors like provider bias and differential treatment based on patient’s race/ethnicity and socioeconomic status (Dehlendorf, Rodriguez, Levy, Borrero, & Steinauer, 2010). The systematic review presents several practical interventions for providers and policy-makers to address disparities in family planning, including improving communication about birth control options, striving to provide quality and patient-centered care with sensitivity to the underpinning historical and cultural context, implementing universal coverage for contraceptive methods, increasing access to abortion care, etc.
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.
Structural stratifiers and intermediary determinants of health, as defined by the WHO reading, are important determinants of access to a full range of reproductive care services.
Income (structural and intermediary): The WHO reading cites text by Galobardes et al., which argues that “income primarily influences health through a direct effect on material resources that are in turn mediated by more proximal factors in the causal chain, such as behaviours.” Under this definition, income’s direct effect on material resources could be interpreted as access to a car or transportation, and the resulting behavior affected is transporting oneself to appointments for preventive contraceptive services or abortion care. There is evidence that having to transport oneself a farther distance to an abortion clinic delays the receipt of abortions services (White, Turan, & Grossman, 2017), which can increase procedural risk and negatively affect health. Over the lifecourse, the individual income affects the household income, which affects income and subsequent material resources of the next generation.
Race/ethnicity (structural): There are deep and complex associations between race/ethnicity and access to a full range of reproductive services. As one example, the RCT by Dehlendorf et al. in 2010, demonstrated provider bias and differential contraceptive recommendations to women based on race/ethnicity (and socioeconomic status) (Dehlendorf, Ruskin, et al., 2010). As another example, there have been historical incidents of unethical and irresponsible research and control of fertility in minority populations, which have garnered distrust towards medical and public health institutions and continue to affect how populations of certain race/ethnicity engage with medical and public health care (Dehlendorf, Rodriguez, et al., 2010). Given that social influences affect contraceptive decision-making (Levy, Minnis, Lahiff, Schmittdiel, & Dehlendorf, 2015), a community-wide history of distrust and disengagement can affect future generations.
Health system (intermediary): The current health system in the United States promotes health inequities by allowing state governments and employers to determine services that their insurance will cover, rather than making a universal coverage plan. In the most literal sense, the state into which someone is born, or the employer of someone’s mother or father, determines whether or not they will have access to contraceptive or abortion services.
Dehlendorf, C., Rodriguez, M. I., Levy, K., Borrero, S., & Steinauer, J. (2010). Disparities in family planning. American Journal of Obstetrics and Gynecology, 202(3), 214–220. https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1016/j.ajog.2009.08.022
Dehlendorf, C., Ruskin, R., Grumbach, K., Vittinghoff, E., Bibbins-Domingo, K., Schillinger, D., & Steinauer, J. (2010). Recommendations for intrauterine contraception: a randomized trial of the effects of patients’ race/ethnicity and socioeconomic status. American Journal of Obstetrics and Gynecology, 203(4), 319.e1-319.e8. https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1016/j.ajog.2010.05.009
Levy, K., Minnis, A. M., Lahiff, M., Schmittdiel, J., & Dehlendorf, C. (2015). Bringing patients’ social context into the examination room: an investigation of the discussion of social influence during contraceptive counseling. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 25(1), 13–21. https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1016/j.whi.2014.10.001
White, K., Turan, J. M., & Grossman, D. (2017). Travel for Abortion Services in Alabama and Delays Obtaining Care. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health, 27(5), 523–529. https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1016/j.whi.2017.04.002
WHO | Maternal mortality. (n.d.). Retrieved January 16, 2018, from http://www.who.int/mediacentre/factsheets/fs348/en/
Williams, S. L. (2018, January 12). Serena Williams’s Birthing Nightmare Is All Too Familiar for Black Women. Retrieved January 16, 2018, from https://tonic.vice.com/en_us/article/43qb5m/serena-williams-birth-black-women-maternal-mortality