social determinants of health

Social Determinants of Health

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

Objectives for todayDefine income inequality, social support and social integration, and the life course perspective

Describe how these and other social factors influence health


From Kindig, 1997


Socioeconomic Position & HealthWeberSociety stratified by class, status, and political powerStratification results in unequal distribution of wealth and materialsMarxClasses formed by a capitalistic system of production Classes based on who owns the production means and the laborers who work for them


Income and HealthAbsolute deprivation: lack of material necessities (e.g. adequate housing, transportation, nutrition)Poverty: low incomeIncome inequality


Life Expectancy at Age 15: East/West DifferencesRussiain 1987.52 yearsin 1994.45 yearsAustria rose for men and women from 1950 to 1995Czechoslovakia/Czech Republicdeclined for men until fall of Communismrose slightly for womenHungaryRose until 1970s and then fell for men


Environment and health30,000 cancer deaths a year due to environmental or occupational exposure230,000 kids have high blood lead levelsAir pollution causes or contributes to asthma


Environment or constitutionGenetics and environment interact. Smoking causes lung cancer, but not all smokers die of lung cancer (there must be a genetic factor)


Heredity and healthStrong link between genetics and disease5% of persons have a genetic disease which requires treatment before age 25 (Kindig)One-third of infant mortality due to genetic problems


Environment/Genetic Interaction ExampleWhen 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 JapanOpposite true for stroke


Social factors in early lifeBiological processes affected by social factors Before birth: Maternal nutrients, smoking, affect fetal developmentDuring infancy: malnutrition affects bodily growth as well as cognitive functioning (and subsequently, educational attainment)


Social integrationTheoretical foundationsEmile 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)


Social integrationTheoretical foundationsJohn BowlbyAttachment 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


Social integration, social support, and social cohesionSocial 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)


Quality and type of Social Support

Emotional (Informational and self-appraisal)Instrumental or practicalNegative interaction (close relationships can have negative aspects)


Social support, morbidity, and mortalityAlameda County StudyIndex based on marital status, no. contracts with friends and relatives, and church and group membershipPersons with low scores had 9-year mortality rates 1.9 to 3 times greater than those with high scoresResults have been replicated in U.S. and EuropeLower social integration assoc. with higher likelihood of MIS and stroke


Social contact and 8-year mortality (Alameda County Study)Social Contact % Males Dead % Females DeadI Highest 9.6 7.3II 12.1 4.9III18.2 8.0IV Lowest30.815.3(Berkman and Syme 1978 as cited in Marmot)


Social integration and healthDirect 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)


Social integration and healthSocial influence: Behavior guided by comparisons to norms of social networks

Social engagement: Getting together with friends, attending social eventsParticipation 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)


Social support and behaviorSocial 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


Social support and psychological well-beingSelf efficacy: confidence in ones ability to perform a behaviorSocial support affects self-efficacyEvidence of improved coping abilities, ability to deal with depression, smoking cessationPerceptions of social support more important than actual availability of support


Social support and hormonal pathwaysStress may initiate the secretion of adrenaline & nonradrenalineCyclical physiological responses can lead to illnessHigh levels of social support associated with lower heart rate, lower blood pressure, and lower cortisol, adrenaline, and noradrenaline levels(from Marmot and Wilkinson, 2000)


Diet and diseaseUndernutritionE.g. Iodine deficiencyRisk of diarrhea (most common cause of death among children in the world) associated with breast feedingOvernutritionE.g. cardiovascular disease, cerebrovascular disease, cancer, high blood pressure, overweight and obesity, dental caries


Individual BehaviorUnsafe sexual behaviorPoor diet - too many cheeseburgers and chicken wingsLack of exerciseDo not wear seat beltsCrazy driving, especially in Texas!


Life Course PerspectiveHealth is affected by environmental and social exposure during infancy, childhood, adolescence, and adulthood1958 British birth cohort study Low birthweight babies more likely to have low quality housing, poorer families during childhoodMore likely to have financial hardship as young adultsHeight at age 7 predictive of adult unemployment


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


McKinlay and Marceau, AJPH, 2000


Social PoliciesHelping the working poorMinimum wage increases (help the working poor, but also teenagers from affluent families)Job trainingSubsidized housing, health care, education

DiscriminationCivil Rights Act (benefits minority individuals who may not be disadvantaged)


Social PoliciesReducing povertyAid to Dependent Children (1935), part of the New DealRepealed in 1996Personal Responsibility and Work Opportunity Reconciliation Act5 year lifetime limit on assistance


social determinants of health

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