1. State your health outcome of interest. (It could be the one you used for week #2 or another one.) Pick two key behaviors that are important factors leading to your health outcome. Explain the importance of these behaviors either for etiology, prevention, or intervention. (If none of the behaviors in the readings are important for your health outcome, suggest another behavior that is.)
An outcome that I study is HIV acquisition, which in the individual responsibility model is felt to be related to several behaviors, including 1. High risk sex; 2. Use of condoms. In the individual responsibility model, people should avoid HIV acquisition by not practicing high risk sex and if one chooses to participate in high risk sex, reducing risk of transmission with condoms. High-risk sex is related to HIV acquisition in that certain types of sex are associated with higher risks of HIV acquisition. Condoms are commonly seen as a harm reduction strategy for those who have high risk sex. Unfortunately, condoms are not as effective as commonly thought, with some analyses suggesting efficacy only if they are used 100% of the time in men who have sex with men (MSM). The ability to avoid high risk sex and use condoms is strongly influenced by social determinants such as resources, power imbalance in relationships, etc., which influence the power of individuals to make informed choices.
2. Describe how you would study the role of one of the behaviors described for question #1 and your health outcome of interest. Incorporate a social factor (e.g. race/ethnicity, social exclusion, stress) in the study approach.
High risk sex has been previously studied extensively as a risk factor for HIV acquisition. Predominant strategies have included diaries, sometimes supported by smartphone apps, where participants self-report the frequencies, partners, and types of sex they have. Other strategies have included studying partnerships that may have higher risk of HIV acquisition, such as sero-different partnerships when the PLWH does not have ART available in their country, in those starting ART, or in partnerships in which the PLWH is virally suppressed. Race/ethnicity impacts high risk sex in that in certain racial-ethnic groups the choice of partners is influenced by attitudes towards homosexuality, and attitudes towards medical care and testing. These attitudes and behaviors also intersect with incarceration rates, education, and wealth. Research studying sex in different racial/ethnic groups could utilize qualitative research to learn terminology and themes that are relevant to the culture of interest, increasing quality of the research and engagement.
3. If key health behaviors (e.g. smoking, exercise, nutritious diet) are strongly influenced by neighborhood, income, and/or education, do we need to continue to study how these behaviors influence health outcomes? Why or why not?
Although I agree that there is an outsize focus on health behaviors rather than the social determinants of health which underlie them, study of how neighborhood, income, and/or education intersect with and influence behaviors can allow researchers to target disparities that will have the largest impact on health outcomes. Reduction of smoking via limiting targeted advertisements towards racial/ethnic groups could make a significant impact on mortality. Investing in fruit and vegetable stands within neighborhoods would necessarily need to study changes in diet as a proximate, relatively easy to study outcome of an intervention, that could to reduction in prediabetes. Behaviors are therefore seen as mediators and process indicators rather than the ends in themselves. By studying the intersection of social determinants of health and behaviors, researchers can target interventions towards interventions most likely to lead to benefits in outcomes such as mortality and perceived health status.