SOCIAL DETERMINANTS: A LEADING INDICATOR FOR THE HEALTH OF THE PEOPLE

PERSPECTIVES OF A SOCIOLOGIST

Katherine Clegg Smith, PhDAssociate ProfessorJohns Hopkins Bloomberg School of Public Health

Lecture objectives

Introduce a sociological perspective on public health

Describe major social determinants of health

Outline how understanding social determinants of health is critical to tackling diabetes

What does a sociologist have to say about health?

A sociological perspective on health

Sociology seeks to examine the nature of society and social structures – and the impact of these systems on various outcomes

Difficult for us to grasp at times, as we are so focused (our society makes us this way ) on the power of the individual. We don’t look for (or like to see) patterns in our behavior

Stand back and go upstream

Sociology focused on populations and groups

Population– a number of individuals with a common characteristic E.g., age, sex, region, occupation N.B. Demography is the study of the size of

populations N.B. Epidemiology is the study of the

relative size of two populations: sick and well

Group– a number of individuals who either: Interact with each other more than would be

expected by chance (behavioral definition) Think of themselves as a collective (mental

definition) Sociology is the study of populations

and groups

What is sociology? ‘The sociological imagination’

Term coined by C. Wright Mills

The idea that we need a greater understanding of the importance of the wider society on the experience of the individual

Human lives are shaped by historically conditioned social forces

Levels of influence on health

Image of Bronfenbrenner’s (1979) Ecological Model taken from: http://geopolicraticus.wordpress.com/category/integral-history/

Need to embrace complexity – study multiple rings!“We need to embrace and study

the complexity of the world, rather than attempting to ignore or reduce it by studying only isolated and often unrepresentative situations.”

Glasgow, Lichtenstein and Marcus (2003) Why don’t we see more translation to health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. American Journal of Public Health. 93: 126-67.

Application of sociological perspective to issues of health & illness

“There is no one-way determinism from nature and biology through to the individual and society. Rather, for sociologists, it is the structures of society that shape who will get sick, how they experience their condition, how they will be diagnosed and treated, and how they will recover.”

White (2002 pg. 11)

Take home message from sociological perspective

All experiences, including health, are patterned

The way that society/societies are organized and structured influences people’s daily experiences and life chances

Social structures and organization are not inevitable or natural – they are the result of power dynamics

What do we mean by ‘Social Determinants’?

Traditionally, when we have seen associations between behavior or lifestyle and health we have sought to fix the person’s decision making

These efforts have had limited impacts

Social determinants perspective pushes us to go deeper or further back

The relevance of a social determinants perspective

“… The gaps, within and between countries, in income levels, opportunities, health status, life expectancy and access to care are greater than at any time in recent history.”

Margaret Chan, Director-General, World Health Organization (2010)

How is health patterned globally? Life expectancy: In Sierra Leone is is 34 years

In Japan is 81.9 years Under 5 mortality: In Sierra Leone is 316 per

100,000 live births In Finland it is 4 per

100,000 live births

There are no biological explanations for this level of difference

WHO has set up a commission to understand and address these differences

Marmot (2005) Social determinants of health inequalities. Lancet. 365: 1099-1104

Why do we need to think beyond the individual? State licensing

boards grant more permits for the establishment of liquor stores in poor and minority neighborhoods (Willliams, 1998)

This liquor store is in Baltimore’s Sandtown Winchester neighborhood is for sale – boasts gross income of $33k per week

Dahlgren and Whitehead's model of the social determinants of health.

Bambra C et al. J Epidemiol Community Health 2010;64:284-291

©2010 by BMJ Publishing Group Ltd

What evidence is there that social determinants are relevant to health?

Overwhelming evidence about the relevance of social factors and health

Dirty water, poor nutrition, lack of medical care all have clear impact

These factors do not occur ‘naturally’ - nor is fixing them merely a technical issue

Less robust evidence about how to bring about effective change

Percentage of persons with fair or poor perceived health status by household income, United States, 1995.

(Healthy People 2010)

Poverty and ill health – obvious?

“Although it might be obvious that poverty is at the root of much of the problem of infectious disease, and needs to be solved, it is less obvious how to break the link between poverty and disease.”

Marmot (2005) Social determinants of health inequalities. Lancet. 365: 1099-1104

http://www.unfpa.org/about/report/2004/poverty.html

Oral health disparities in Colorado children 2002

Oral health disparities are evident with non-Hispanic white children having 13% less untreated decay and 17% more sealants than their Hispanic classmates (Colorado Basic Screening Survey, 2002).  Healthy People 2010 goals for the nation are 21% for untreated decay, 42% for caries history, 50% for sealants.

www.cdphe.state.co.us

Differences in Diabetes Rates

http://www.hhs.gov/asl/testify/t040511.html

Race and health: CVD deaths (2007 data)

Population Rate of CVD death (per 100,000)

Overall 251.2

African American Men 405.9

White Men 294.0

African American Women

286.1

White Women 205.7

American Health Association. Heart disease and stroke statistics – 2011 update. Dallas, Texas: American Heart Association 2011

Race and health: Thinking beyond genetics

Race & Ethnicity shape the nature and quality of healthcare obtained

Race & Ethnicity also inform the nature of one’s social experience

Liburd et al (2005) Intervening on the social determinants of cardiovascular disease and diabetes. American Journal of Preventive Medicine. 29(5S1): 18-24

Education & Health

Education level/access is a predictor of health outcomes

Education interacts with other determinants (e.g. education predicts income, job satisfaction etc)

Death rates by gender & education level

Access to effective care

One of the factors shaping differential health outcomes for populations and groups is access to quality health care.

Money or resources certainly contributes to quality care, but also important are:

Geography Culture

Manifestions of differentials in access to quality careRacial Trends in the Use of Major Procedures among the ElderlyJha et al (2005) N Engl J Med; 353:683-691

http://www.nejm.org/doi/full/10.1056/NEJMsa050672

Example interventions to address social determinants

Housing & Health: e.g. Rental Assistance & Environmental Improvements (‘Move to Opportunity’)

Food pricing and agricultural policies e.g. support for fruit and vegetable production and affordable pricing – establishment of community gardens and accessible and affordable farmers’ markets

Social determinants & diabetes

Social determinants of racial disparities in diabetes risk in Detroit.Schulz et al (2005) doi: 10.2105/AJPH.2004.048256

Social determinants model for diabetes

Individual behaviors shaped by local contexts, which are in turn shaped by historical, cultural and political forces

Interventions must focus on social & economic policies and social and physical environments

Figure from: http://www.idf.org/diabetesatlas/5e/the-social-determinants-of-diabetes-and-the-challenge-of-prevention

Whiting et al. Diabetes: equity and social determinants. In Blas E, Kurup A, editors. Equity, social determinants and public health programmes. World Health Organization; 2010. p77-94.

Overweight: 77% of African American women & 61% of African American men are overweight (NHANES, Hedley, 2004)

African American women are more likely to experience obesity than white women at every income level (Schulz, 2005)

What contributes to such high levels of overweight? What shapes differences in rates between populations and groups?

Pathways to patterned differences in diabetes

Consider……

“Residents of poor neighborhoods have fewer places in which to exercise and more limited access to high-quality food and are more likely to report functional limitations and physical health problems compared with residents of wealthier neighborhoods.”

(Schulz et al, 2005)Schulz et al (2005) ‘Healthy eating and exercising to reduce diabetes: exploring the potential of social determinants of health frameworks within the context of community-based participatory diabetes prevention’ American Journal of Public Health. 95(4): 645-651.

A social disparities approach to tackling diabetes: Healthy Eating and Exercising to Reduce Diabetes (HEED) Schulz et al (2005)

Overall goal Reduce the risk, or delay the onset, of diabetes by encouraging moderate physical activity and healthy eating among residents of Detroit’s East Side

Objective 1 Increase knowledge about how to reduce the risk, or delay the onset, of type 2 diabetes among village health workers and other community members of Detroit’s East Side

Objective 2 Increase resources (e.g., community gardens, cooperative buying clubs, social support for a healthy diet) and reduce barriers (e.g., lack of affordable fresh produce in local stores) to healthy meal planning and preparation

Objective 3 Identify and create opportunities for safe, enjoyable, low-impact physical activities for community members of Detroit’s East Side

Objective 4 Strengthen and expand social support for practices that help to delay the onset of diabetes or reduce the risk of complications in a high-risk population in Detroit’s East Side

TABLE 3—

Objective 3Objective 4

What is to be gained by studying social disparities?“The importance of understanding the

context in which the incidence and management of diabetes occur will help public health researchers and practitioners to better understand what creates health disparities, which is the necessary first step to developing traditional and nontraditional transdisciplinary intervention models.”

Liburd et al (2005) Intervening on the social determinants of cardiovascular disease and diabetes. American Journal of Preventive Medicine. 29(5S1): 18-24

Achieving greater equity in health is a goal in itself

“…We have not sufficiently recognized and appropriately dealt with the inequities underlying average health statistics. This has meant that even when overall progress has been made, large parts of populations, and even whole regions of the world, have been left behind.”

World Health Organization (2010) Equity, Social Determinants and Public Health Programs

Thank you!

Questions?