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 current research focuses on drug development for treatment of cutaneous T cell lymphoma, a rare lymphoma subtype. This includes translational research (testing drugs on pre-clinical models of disease) through early clinical trials. Cancer health disparities are defined by the National Cancer Institute (2008) as “adverse differences in cancer incidence (new cases), cancer prevalence (all existing cases), cancer death (mortality), cancer survivorship, and burden of cancer or related health conditions that exist among specific population groups in the United States”. Currently, a lot of emphasis is being placed on the issue of recruiting diverse racial and socioeconomic participants in cancer clinical trials. Minority groups are greatly underrepresented in many clinical trials, thus making the results less generalizable to those populations. Approaching recruitment of underrepresented groups from a socioecological framework that includes social determinants of health would improve overall engagement, trust, and retention of these communities.
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: Survival time after diagnosis of cutaneous T cell lymphoma
Structural stratifiers: Survival disparities by race/ethcnicity are evident in patients with cutaneous T cell lymphoma (Adams et. al 2016). Using two Texas cancer registries they found that blacks had a shorter survival times compared to whites in most subtypes of cutaneous T cell lymphoma. The WHO reading emphasizes that race is a social category and that “In societies marked by racial discrimination and exclusion, people’s belonging to a marginalized racial/ethnic group affects every aspect of their status, opportunities and trajectory throughout the life-course.” Thus addressing racial disparities in cancer survival will require a multipronged approach at a societal level.
Lower socioeconomic status has been shown to decrease survival of patients with many types of cancer. Cella et. al found that “People with lower annual incomes (below $5,000 per year in the years 1977 to 1981) and those with lower educational level (grade school only) showed survival times significantly shorter than those with higher income or education, respectively. These survival differences were associated with, but could not be fully explained by, severity of disease at initial presentation. SES continued to exert a small but significant impact on cancer survival, even after controlling for all known prognostic variables.” Those with lower incomes may have more advanced disease at time of diagnosis due to decreased access to care. After diagnosis, lower SES may decrease access to treatment and availability of caretakers.
Intermediary determinants: Material circumstances can greatly affect survival time after a rare diagnosis. Since cutaneous T cell lymphoma is a rare disease, treatment often requires access to a specialist clinic. For someone who does not have the financial means to travel long distances to go to appointments, this can mean greatly curtailed access to specialist care.