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Social Determinants of Health

Social Determinants of Health. Objectives for today. Define income inequality, social support and social integration, and the life course perspective Describe how these and other social factors influence health. Socioeconomic Position & Health. Weber

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Social Determinants of Health

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  1. Social Determinants of Health

  2. Objectives for today • Define income inequality, social support and social integration, and the life course perspective • Describe how these and other social factors influence health

  3. Intro. to Health Care Organization Ty Borders, Ph.D.

  4. Socioeconomic Position & Health • Weber • Society stratified by class, status, and political power • Stratification results in unequal distribution of wealth and materials • Marx • Classes formed by a capitalistic system of production • Classes based on who owns the production means and the laborers who work for them

  5. Income and Health • Absolute deprivation: lack of material necessities (e.g. adequate housing, transportation, nutrition) • Poverty: low income • Income inequality

  6. Life Expectancy at Age 15: East/West Differences • Russia • in 1987…….52 years • in 1994…….45 years • Austria • rose for men and women from 1950 to 1995 • Czechoslovakia/Czech Republic • declined for men until fall of Communism • rose slightly for women • Hungary • Rose until 1970’s and then fell for men

  7. Environment and health • 30,000 cancer deaths a year due to environmental or occupational exposure • 230,000 kids have high blood lead levels • Air pollution causes or contributes to asthma

  8. Environment or constitution • Genetics and environment interact. • Smoking causes lung cancer, but not all smokers die of lung cancer (there must be a genetic factor) Intro. to Health Care Organization Ty Borders, Ph.D.

  9. Heredity and health • Strong link between genetics and disease • 5% of persons have a genetic disease which requires treatment before age 25 (Kindig) • One-third of infant mortality due to genetic problems

  10. Environment/Genetic Interaction Example • When persons change their environment, there risk of disease changes (Marmot) • Incidence rates of coronary heart disease are highest among Japanese men living in U.S. mainland, followed by Hawaii, and then Japan • Opposite true for stroke Intro. to Health Care Organization Ty Borders, Ph.D.

  11. Social factors in early life • Biological processes affected by social factors • Before birth: Maternal nutrients, smoking, affect fetal development • During infancy: malnutrition affects bodily growth as well as cognitive functioning (and subsequently, educational attainment) Intro. to Health Care Organization Ty Borders, Ph.D.

  12. Social integrationTheoretical foundations • Emile Durkheim (Division of Labor in Society and Suicide) • People are “bounded to society” by 2 types of integration: attachment and regulation. • Attachment: “Extent to which an individual maintains ties with members of society.” • Regulation: “Extent to which an individual is held in the fabric of society by its values, beliefs, and norms.” (Berkman and Glass 2000) Intro. to Health Care Organization Ty Borders, Ph.D.

  13. Social integrationTheoretical foundations • John Bowlby • Attachment Theory: Mother (usually) is a secure base from which a child can investigate the world. • Marriage is an adult form of the attachment between a mother and child. • Ability to form intimate relationships dependent upon experience with attachment, loss, and reattachment Intro. to Health Care Organization Ty Borders, Ph.D.

  14. Social integration, social support, and social cohesion • Social networks: Social relationships which an individual participates in. • Defining characteristics of social networks (Burt) • Size/range (e.g. # of persons in network) • Density (degree to which network members are connected) • Boundedness (degree to which network defined by traditional structures such as work, neighborhood) • Homogeneity (degree to which individuals are similar) Intro. to Health Care Organization Ty Borders, Ph.D.

  15. Quality and type of Social Support • Emotional (Informational and self-appraisal) • Instrumental or practical • Negative interaction (close relationships can have negative aspects) Intro. to Health Care Organization Ty Borders, Ph.D.

  16. Social support, morbidity, and mortality • Alameda County Study • Index based on marital status, no. contracts with friends and relatives, and church and group membership • Persons with low scores had 9-year mortality rates 1.9 to 3 times greater than those with high scores • Results have been replicated in U.S. and Europe • Lower social integration assoc. with higher likelihood of MIS and stroke Intro. to Health Care Organization Ty Borders, Ph.D.

  17. Social contact and 8-year mortality (Alameda County Study) Social Contact % Males Dead % Females Dead I Highest 9.6 7.3 II 12.1 4.9 III 18.2 8.0 IV Lowest 30.8 15.3 (Berkman and Syme 1978 as cited in Marmot) Intro. to Health Care Organization Ty Borders, Ph.D.

  18. Social integration and health • Direct effect hypothesis: support leads to positive health (encouraging exercise, healthy behaviors) • Buffering effect hypothesis: Social support mediates the effects of stressors on health (emotional help may enable individual to deal with stressor) Intro. to Health Care Organization Ty Borders, Ph.D.

  19. Social integration and health • Social influence: Behavior guided by comparisons to norms of social networks • Social engagement: Getting together with friends, attending social events • Participation is related to maintenance of cognitive functioning older age and lower risk of mortality • Person-to-person contact: Networks associated with exposure to disease • e.g. early spread of AIDS among gay men) Intro. to Health Care Organization Ty Borders, Ph.D.

  20. Social support and behavior • Social support affects adoption of behaviors such as tobacco and alcohol use, sexual practices, and diet • Alameda County Study: Lack of social connectedness assoc. with tobacco and alcohol use, lack of exercise, and obesity Intro. to Health Care Organization Ty Borders, Ph.D.

  21. Social support and psychological well-being • Self efficacy: confidence in one’s ability to perform a behavior • Social support affects self-efficacy • Evidence of improved coping abilities, ability to deal with depression, smoking cessation • Perceptions of social support more important than actual availability of support Intro. to Health Care Organization Ty Borders, Ph.D.

  22. Social support and hormonal pathways • Stress may initiate the secretion of adrenaline & nonradrenaline • Cyclical physiological responses can lead to illness • High levels of social support associated with lower heart rate, lower blood pressure, and lower cortisol, adrenaline, and noradrenaline levels (from Marmot and Wilkinson, 2000) Intro. to Health Care Organization Ty Borders, Ph.D.

  23. Diet and disease • Undernutrition • E.g. Iodine deficiency • Risk of diarrhea (most common cause of death among children in the world) associated with breast feeding • Overnutrition • E.g. cardiovascular disease, cerebrovascular disease, cancer, high blood pressure, overweight and obesity, dental caries Intro. to Health Care Organization Ty Borders, Ph.D.

  24. Individual Behavior • Unsafe sexual behavior • Poor diet - too many cheeseburgers and chicken wings • Lack of exercise • Do not wear seat belts • Crazy driving, especially in Texas!

  25. Life Course Perspective • Health is affected by environmental and social exposure during infancy, childhood, adolescence, and adulthood • 1958 British birth cohort study • Low birthweight babies more likely to have low quality housing, poorer families during childhood • More likely to have financial hardship as young adults • Height at age 7 predictive of adult unemployment

  26. Race versus class and health • U.S.A. is the only Western developed nation whose government does not collect vital statistics based on socioeconomic class • We focus too much on race, rather than class (Navarro, 1990)

  27. McKinlay and Marceau, AJPH, 2000

  28. McKinlay and Marceau, AJPH, 2000

  29. McKinlay and Marceau, AJPH, 2000

  30. McKinlay and Marceau, AJPH, 2000

  31. Social Policies • Helping the working poor • Minimum wage increases (help the working poor, but also teenagers from affluent families) • Job training • Subsidized housing, health care, education • Discrimination • Civil Rights Act (benefits minority individuals who may not be disadvantaged)

  32. Social Policies • Reducing poverty • Aid to Dependent Children (1935), part of the New Deal • Repealed in 1996 • Personal Responsibility and Work Opportunity Reconciliation Act • 5 year lifetime limit on assistance

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