Social Epidemiology/Social Determinants of Health

Session 4 KNES 400

Instructor: Dr. Shannon Jette

Learning Objectives

•  Identify limitations (critiques) of chronic disease epidemiology

•  Define the concept ‘Social Determinants of Health’ (SDoH) – Define the difference between upstream and

downstream determinants of health •  Discuss hypothesized pathways of health/ill health

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CRITIQUES OF and ISSUES WITH CHRONIC DISEASE EPIDEMIOLOGY?

Critiques/Issues with Chronic Disease Epidemiology?;

�  A finding of association between presence of a risk factor (exposure) and a disease (outcome) does not prove causation – Just because the RR does not equal 1,

does not mean that a particular exposure CAUSED the disease (or is protective)

Thurston,;2014,;‘Causality’;

Association does not mean causation …

•  An association could be non-causal – It could merely be a one-time observation

due to random error OR due to errors in methods/procedures used (systematic bias)

Association does not mean causation …;

•  If, after controlling for bias/error, association seems to hold, one still should not infer causality – Best to think of exposure of interest as a risk

factor for outcome b/c association is statistical (as opposed to biological) – Must work through # of principles used to infer

causality • E.g., Temporality, Strength of association,

Consistency, Dose-response, Biological Plausibility

Critiques/Issues with Chronic Disease Epidemiology?

�  Loss of attention to wider social factors that play role in development of chronic disease – Excessive focus on lifestyle factors; individual

risk factors decontextualized from social and historical context (Pearce, 1996) – Why?

Indirect contributing

factors

Direct contributing

factors Determining

factors Health Issue

Cardiovascular disease

Obesity/overweight

Stress?

Inactivity

Low Self Efficacy

Lack Access

Lack Time Poor diet

Hypertension

Poor diet (high sodium)

Inactivity

Stress

Social Determinants of Health: “Social and economic conditions under which people live which determine their health. These conditions are shaped by the distribution of money, power, and resources at global, national and local levels”

(WHO definition cited in Thurston, 2014, p. 38)

•  Upstream Determinants of Health: influences more remote in time or position (i.e., distal) to outcome of concern and more difficult to link together

•  Downstream Determinants of Health: individual lifestyle factors (health related knowledge, beliefs, behaviors) that are closer in time and distance (i.e., proximal) to health outcome making it easier to trace links b/n them –  Influenced by upstream factors

Example: Concentrated Animal Feeding Operations (CAFO’s)

•  d;•  Downstream

solution? •  Upstream

solution?

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;

SocioLecological;model;(health);

Dahlgren;&;Whitehead,;1991;

Unnatural Causes

• Why is name appropriate? How does it capture main message of film?

Working conditions and health?

•  Physical (material) aspects – Repetitive movements; heavy workload – Desk job – Exposure to chemical hazards

•  Psychosocial aspects – Demand-control model (Karasek, 1979) – Effort-reward imbalance (Siegrist, 1996)

•  Work-related opportunities/resources

EducaOon;and;health?;;

Braveman,;2011;

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62.9%

72.7%

81.1%

83.1%

Education & Health? Red: Life Expectancy (yrs)

Blue: % residents w/ bachelors degree or more

72%%

48%%

11%%

75%%

Income, wealth, and health?

•  Economic resources for … •  Is economic INEQUALITY bad for our health? – More money does not necessarily mean a healthier

society? – Element of social comparison that impacts well-being? – http://www.ted.com/talks/richard_wilkinson.html

Wilkinson;&;Picke",;2009;

Wilkinson;&;Picke",;2009;

Wilkinson;&;Picke",;2009;

Wilkinson;&;Picke",;2009;

Proposed pathways

Material Factors

Health Behaviors

Psycho-social

1. Material factors

•  People who suffer from material deprivation have greater exposure to negative events like hunger, lack of good food, poor housing, poor work conditions; less exposure to positive resources like books, access to rec/leisure activities

•  Accumulate over life-course and are determined in large part by income (wealth) available to them

2. Psycho-Social

Wilkinson;&;Picke",;2009;

3. Health Behaviors •  Behavioral risk factors for chronic disease are well known

(poor diet, smoking, sedentary lifestyle) •  Associated with lower income and social status •  Patterns of health behaviors are strongly shaped by social

and economic environments; stress produces behaviors aimed at easing tension (fatty food, smoking, alcohol); Planning healthy meals and exercising difficult when worried about meeting basic needs of food, housing, clothing –  ‘Standing still’ (Messing et al., 2005)

Evolution of SDoH

•  For many years, even when social determinants of health were acknowledged, the focus was on downstream determinants (health beliefs/behaviors) instead of upstream determinants; give ‘downstream’ solutions (individual change) – Contaminated drinking water example

Braveman,;2011;

•  Downstream Question: How can we promote healthy behaviors?

•  Upstream Question: How can we target dangerous conditions and ensure healthy spaces and places?

•  Downstream: How can individuals protect themselves against

health threats? •  Upstream: How can community organizing and alliance

building help create policies that protect the public good? •  Downstream: Which populations have the worst health? •  Upstream: What causes the unequal production and

distribution of the conditions that promote and harm health?