1. After reading the article by Thomas et al., comment on where your research, or your research interests, fit into the generational framework for health disparities research. If your work is 1rst or 2nd generation, comment on how your work could lead in the future to 3rd or 4th generation work. If your work is 3rd or 4th generation, comment on what 1rst and 2nd generation work was necessary as a foundation for your current work (or current interests).
- While we know housing status is a major driver for poor outcomes in HIV (generation 1), our understanding of the causes and drivers of these disparities remains under-developed (generation 2). Anecdotally, the intersection of race, psychiatric co-morbidities, drug abuse and violence/trauma are clear in clinical experience, the manners in which these causal relationships interplay is unclear. Co-morbid psychiatric disease and drug abuse (used as a surrogate for poor decision-making), specifically, are often viewed as confounding characteristics in the relationship between poor outcomes (eg virologic suppression), the marginal impacts of these co-occurring characteristics are often robustly examined. Structural and clinic-based interventions (generation 3), however, have started to be undertaken, but the impacts of these interventions have been minimal, likely owing to the unclear relationship between housing status and poor clinical outcomes. For instance, in one large RTC of “Housing First” strategy for addressing poor outcomes in HIV, Buchanan et al (AMJPH 2009) tried to evaluate the impact of providing intensive case management to obtain housing v typical social work referral and found that while a higher proportion of patients were housed in the intervention group, there was no significant difference in virologic suppression between the two groups. Incorporating 4th generation research that is community-based would improve evaluation of patient-centered/patient-informed interventions.
2. The barbershop hypertension intervention, while essentially a clinical services intervention operating at either the fence or safety-net level as described by Jones, has some engagement with the social determinants of health. Interventions like that described in the Walton article are designed to mitigate the impact of social determinants. How could you apply one of these two types of interventions to your area of research? Propose one or two interventions that engage with social determinants on some level. (Note: Next week we will discuss policy-level interventions designed to directly impact social determinants).
- 1) Community-based clinic interventions to mitigate the impact of homelessness and unstable housing on outcomes in HIV have not been tested. One possible intervention similar to the one described in Jones et al would provide mobile outreach units which locate, engage patients and provide clinical care in the community to people with homelessness and unstable housing. An example of a clinic-based intervention to mitigate the impact of social determinants of health would be to provide SW visits to minimize stigma and address unmet needs in an attempt to improve patient behaviors (Berkowitz el al JAMA Int Med 2017).