Melanoma Disparities among US Hispanics: Use of the Social Ecological Model to Contextualize Reasons for Inequitable Outcomes and Frame a Research Agenda

Table 1

Research questions and strategies by social ecological model levels of influence [89].

Research questions and strategies by SEM levels of influence
Level of influence	Sublevel of influence	Future research questions and strategies
Society/policy	(i) Healthcare infrastructure; (ii) Public health; (iii) Health policy and public laws; (iv) Societal norms; (v) Media and health communication efforts; (vi) Racism and discrimination; (vii) Hispanic medical workforce diversity	(i) How does health system infrastructure impede access to dermatologic care among Hispanics?; (ii) How can different media platforms be employed to increase knowledge and awareness among Hispanic subpopulations and influence CM societal norms?; (iii) What are the most effective methods of dissemination of CM education?; (iv) Can CM educational interventions designed for Hispanics influence outcomes?; (v) How does racism/discrimination influence CM outcomes?; (i) Training of physician extenders (and screen patients for skin cancer and melanoma.; (ii) Implement policies that remove barriers to access of primary and specialty care.; (iii) Diversification of the medical and dermatologic workforce to increase the representation of Hispanic care providers.; (iv) Development of culturally and linguistically appropriate melanoma educational campaigns targeted to Hispanic subgroups.; (v) Collaboration between Hispanic community stakeholders and professional medical organizations to facilitate dissemination of information/research findings to lay community.
Community	Neighborhood measures; (i) Income/level of poverty; (ii) Built environment; (iii) Workplace environment and exposures; (iv) Schools and availability of childcare	Are there unique environmental risk factors (aside from UV exposure) that increase CM risk among Hispanics?; Develop longitudinal cohort studies quantifying workplace exposures and their impact on CM outcomes in Hispanics.
Interpersonal	(i) English language fluency; (ii) Residence in predominantly Hispanic neighborhood; (iii) Degree of assimilation; (iv) Cohesion; (v) Social networks; (vi) Peer and family influence	What cultural factors contribute to CM risk/mortality? Do these factors vary by Hispanic country of origin?; Are there components of Hispanic culture that influence participation in skin cancer screening or seeking medical care for skin conditions?; How does melanoma risk vary by degree of acculturation?; Develop more precise constructs to measure effects of acculturation.; Development of community-based participatory research studies in which Hispanic stakeholders are included in early stages of study design.
Individual	(i) Age; (ii) Race & ethnicity; (iii) Gender; (iv) Ancestry and genetic factors; (v) Gene-environment interaction; (vi) Immigration status; (vii) Knowledge and behavior; (viii) Insurance status; (ix) Occupation; (x) Health insurance status; (xi) Income; (xii) Education	What is the phenotypic profile of Hispanic patents with CM?; Are kinetics of melanoma progression and metastasis different among Hispanics?; How do CM risk and mortality vary by Hispanic subgroup?; How does CM risk vary with immigration status and duration of time in US?; How do fatalism and its impact on skin cancer perceptions vary between Hispanic subgroups?; What role, if any, does fatalism play in CM inequities?; How can melanoma knowledge and awareness be increased amongst Hispanic subgroups?; Develop genetic studies (AIMS/GWAS) across Hispanic subgroups to understand the genetic basis for melanoma risk.; Identification of biomarkers for melanoma disease progression within Hispanics.; Case control studies of Hispanics with and without melanoma to help identify unique risk factors amongst this group.; Efforts to increase recruitment of Hispanics melanoma patients into clinical trials.; Transdisciplinary studies to understand the interlink between biological and social factors.