social conditions as fundamental causes of health disparitiespercent current smokers by education...
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Social Conditions as Fundamental Causes of Health Disparities
Bruce LinkGlasgow Scotland
December 11, 2007
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New York City All Cause Age-adjusted Death Rates In Lowest Versus Highest Income Neighborhoods 2001
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New York City All Cause Age-adjusted Death Rates Per 100,000
by Race – 2004
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New York City Percent Fair or Poor Self-Reported Health by Income Level (% Poverty Level) and
Race/Ethnicity
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New York Centric View
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All Cause Age-adjusted Death Rates Per 100,000 People Ages 25-64 by
Education -- 2004839
619
251
486
345
167
0100200300400500600700800900
Males Females
< 12 years12 years13+ years
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US All Cause Age-adjusted Death Rates Per 100,000 by Race – 2002
993
1341
701
902
0
200
400
600
800
1000
1200
1400
males females
whiteblack
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US Percent Fair or Poor Self-Reported Health by Poverty Level and Race/Ethnicity (age adjusted)
21
14
6
21
14
6
26
17
10
20
15
9
0
5
10
15
20
25
30
Overall White Black Hispanic
Below 100%100%-less than 200%200% or more
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Age Adjusted Death Rates 100,000 (Men) 25-64 England and Wales
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Scottish National Survey 2003 -- Percent Reporting Fair/Bad/Very Bad Health (Age Adjusted)
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SES,Race
MechanismsSmoking, Diet, Exercise, Stress,
Etc, etc. ?
MortalityMorbidity
?
What Are the Mechanisms that Accountfor the Association?
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Deaths Per 1000 Among Taxpayers andNon-Taxpayers in Rhode Island 1865
Age Categories Taxpayers Non-Taxpayers(examples)
Under 1 93.4 189.8
30-39 4.5 15.5
60-69 15.1 39.5
Chapin AJPH 1924
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Deaths per 1000 (age adjusted) by SESof Census Tract -- Chicago 1930
SES Males Females
1--Lowest 15.1 12.3
2 11.6 10.2
3 10.2 9.0
4 9.2 7.9
5--Highest 8.7 6.8
Coombs, Medical Care, 1941
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What is the point?
• Imagine yourself back in Rhode island in 1865 and doing what we just did for the current data –we might have asked what were the mechanisms involved?
• Contaminated water, poor sanitation, crowded substandard housing – the diseases were cholera, TB, small pox…
• We did something about the risk factors, we developed vaccines, and people don’t die of TB, small pox and cholera in Rhode Island any more.
• But the SES association is resilient.
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The Concept of Fundamental Social Causes
Fundamental social causes involve resources such asknowledge, money, power, prestige and beneficial social connections that determine the extent to which people areable to avoid risks and adopt protective strategies so as toreduce morbidity and mortality.
Because such resources can be used in different ways in different situations, fundamental causes have effects ondisease even when the profile of risk and protective factors and diseases changes radically.
It is their persistent effect on health in the face ofdramatic changes in mechanisms that leads us to call them“fundamental.”
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How Social and Economic Resources Affect Health – The Importance of Contexts
• Resources operate at the individual level – people use their knowledge, money, power, prestige and beneficial social connections to obtain healthy outcomes.
• But resources also provide access to generally salutary contexts – neighborhoods, occupational conditions, marriages – access to health consequential circumstances comes with access to contexts in a sort of “package deal.”
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US Life Expectancy at Birth 1900-2000
47
55
61
7074
77
40
45
50
55
60
65
70
75
80
1900 1920 1940 1960 1980 2000
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Scottish Life Expectancy at Birth 1910-2000
50.1
56
64.467.3
72.1
53.2
59.5
68.7
73.777.6
40
45
50
55
60
65
70
75
80
1910 1930 1950 1970 1995
Women
Men
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US: Heart Disease -- Age-adjusted Death Rates Per 100,000 People
587559
493
412
321 293258
40
140
240
340
440
540
640
1950 1960 1970 1980 1990 1995 2000
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Cancer (green) and Stroke (Yellow) -- Age-adjusted Death Rates Per 100,000 People
181 178
148
96
65 63 6150
194 194 199208
216 210200
186
406080
100120140160180200220240
1950 1960 1970 1980 1990 1995 2000 2004
National Center for Health Statistics – Health United States 2006
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US : Flu (blue) and HIV (green) -- Age-adjusted Death Rates Per 100,000 People
1016
5
4854
42
3137
33
24
0
10
20
30
40
50
60
1950 1960 1970 1980 1990 1995 2000
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Scotland Ischamemic Heart Disease -- Age-adjusted Death Rates Per
100,000 People 15-74
350395 400 390
300
185195160 150 150
125
6540
90
140
190
240
290
340
390
440
1950 1960 1970 1980 1990 2000
Men
Women
Leon et al: Understanding the Health of Scotland in and International Context 2003
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Scotland Lung Cancer -- Women (green) and Men (Yellow) -- Age-adjusted Death Rates Per 100,000
People Ages15-74
68
100
140
120
98
65
12 15 20
45 45 43
10
30
50
70
90
110
130
150
1950 1960 1970 1980 1990 2000
Leon et al: Understanding the Health of Scotland in and International Context 2003
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Percentage Self Reporting Health as Excellent or Good by Age Group (40-49 yellow and 60-69 blue)
and Decade of Birth using 1972 to 2004 General Social Surveys
74%76%
82% 82%84%
52%
57.00%
63%
74%
82%
50.00%
60.00%
70.00%
80.00%
90.00%
1900's 1910's 1920's 1930's 1940's 1950's 1960's
Age40-49
Age60-69
Adapted from: Robert Warren and Elaine Hernandez (In Press) Journal of Health and Social Behavior,Table 2
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Something is Driving these Dramatic Improvements in Health
X ?
Shouldn’t whatever “x” is be an important part of our explanations of health disparities?
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Do Key Explanatory Variables in Theories of Disparities Account for Trends Toward
Improvement in Health Over Time?
• How about genetic factors?
• Stress?
• Social involvement and participation?
• How about income inequality?
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Of course, X is not any one thing but many things
• The discovery of the germ theory is a strong candidate for declines in rates of infectious diseases in the first half of the 20th century.
• Recent declines in age adjusted rates of death from lung cancer are probably influenced by the lagged effects of declines in smoking rates in earlier decades.
• The rapid decline in HIV/AIDS mortality is probably related to the new anti-retroviral drugs that were developed and disseminated in the late 1990’s
• And then screening for disease, public health efforts to increase the consumption of fruits and vegetables, promote exercise, eradicate smoking, and smog control, flu shots, seat belts, angioplasty, screening for early detection of cancer, etc. etc.
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• So X is clearly not just one thing and is likely different things for different diseases…and probably different things at different times….But the confluence of all of these things has clearly had an enormously positive impact on population health.
• Clearly human beings have dramatically increased their capacity to control disease and death.
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Fundamental Cause Reasoning Concerning the Sources of Disparities: The Core Proposition
• Our enormous capacity to control disease and death combined withsocial and economic inequality creates health disparities.
• It does so because of a very basic principle – When we develop the ability to control disease and death, the benefits of this new found capacity are not distributed equally throughout the population, but are instead harnessed more securely by individuals and groups who are less likely to be exposed to discrimination and who have more knowledge, money, power, prestige and beneficial social connections.
• People who are more advantaged with respect to resources such asthese and who are less likely to be held back by discrimination benefit more and have lower death rates as a consequence. Disparities are the result.
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How Does Happen -- Examples
• When Bad things happen --– Titanic, WTC, Katrina– All the quotidian tragedies of life
• When Good things happen --– Discovery that smoking is harmful to health– New technology -- cancer screens
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1954 Percent Answering that they had Recently Read or Heard Anything Saying that Cigarette Smoking May be a Cause of Cancer
81
90
95.5 95.1
70
75
80
85
90
95
100
1954
< 12 years12 years13-1516+
Nationwide Gallup Surveys Jan and June 1954
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Percent Responding “Yes” to a Question asking whether Smoking is a Cause of Lung
Cancer by Education 1954
41 41.947.5 46.3
0102030405060708090
100
1954
< 12 years12 years13-1516+
Nationwide Gallup Surveys Jan and June 1954
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Percent Responding “Yes” to a Question asking whether Smoking is a Cause of
Lung Cancer
41 42.8
70.1 71.1 71.181.6 84 82.8
94.4 92.9
0102030405060708090
1001954 Jan1954 June19691971197219771981198519901999
Multiple National Public Opinion Surveys
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Percent Responding “Yes” to a Question asking whether Smoking is a Cause of Lung
Cancer by Education 1954 thru 1999
4146.3
62.8
84.7
72.1
92.486.6
96.8
30
40
50
60
70
80
90
100
1954 1969-1972 1977-1985 1990-1999
< 12 years12 years13-1516+
Nationwide Surveys 1954 -1999
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Percent Current Smokers1954-1999
47.243.4
40.9 42 42.138.3
34.629.5
24.822.3
05
101520253035404550
1954 Jan1954 June19691971197219771981198519901999
Multiple National Public Opinion Surveys
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Percent Current Smokers by Education 1954 thru 1999
43.245.5
40.5
34.438
22.5
32.2
14.6
05
101520253035404550
1954 1969-1972 1977-1985 1990-1999
< 12 years12 years13-1516+
Nationwide Surveys 1954 -1999
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Age Adjusted Lung Cancer Mortality (Men 25-64) 1950-1998 by SES of County of
Residence
0
10
20
30
40
50
60
70
80
90
50 56 62 68 74 80 86 92 98
Low SES
High SES
Middle SES
From Singh et al. 2002 Journal of the National Cancer Institute
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Points to be Made From the Very Familiar Smoking Story
• It exemplifies the process specified by the fundamental causes theory –there is a social shaping of new knowledge and this social shaping creates health disparities by socioeconomic status.
• The story sensitizes us to the fact that many other forms of health knowledge and technology are shaped in this way – e.g. the same states in the US that were quick to adopt the use of beta blockers had been rapid in their deployment of hybrid corn 30 to 50 years earlier.
• The length of time it takes for knowledge and behavior change tospread is instructive. It is not simply a matter of being smart enough to know the evidence and act. It is again likely deeply social. And this tells me an important story about disparities.
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Percent Responding “Yes” to a Question asking whether Smoking is a Cause of Lung
Cancer by Education 1954 thru 1999
4146.3
62.8
84.7
72.1
92.486.6
96.8
30
40
50
60
70
80
90
100
1954 1969-1972 1977-1985 1990-1999
< 12 years12 years13-1516+
Nationwide Surveys 1954 -1999
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Percent Current Smokers by Education 1954 thru 1999
43.245.5
40.5
34.438
22.5
32.2
14.6
05
101520253035404550
1954 1969-1972 1977-1985 1990-1999
< 12 years12 years13-1516+
Nationwide Surveys 1954 -1999
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Percent Believing that Sun Goes Around Earth and that Sound Travels Faster than
Light – US Population 1999
24.522.6
0
5
10
15
20
25
30
% Sun Goes Around Earth % Sound Faster than Light
NSF Survey of Public Understanding of Science and Technology 1999
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Among People Who Believe that Sun Goes Around Earth and that Sound Travels Faster than Light -- %
Who Think Smoking Causes Cancer
91.1 92
0102030405060708090
100
Sun - Earth Sound - Light
NSF Survey of Public Understanding of Science and Technology 1999
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Test #1 --SES Associations with More and Less Preventable Causes of
Death
• We say that SES differences arise because people of higher SES use flexible resources to avoid risks and adopt protective strategies
• it follows that the SES gradient should be more pronounced for diseases that we can do something about… for which there are known and modifiable risk and protective factors…
• Our first test involves ratings of the preventability of death from specific causes
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US National Longitudinal Mortality Survey
• Very large study of a nationwide sample of over 350,000 people.
• Interviewed as part of the US Current Population Survey (assesses unemployment etc.) and followed for 9 years with National Death Index for mortality and cause of death
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Relative Risks of Death by Income -- NationalLongitudinal Mortality Study
Income (1980 $) Men 45-64Women 45-64
< 5000 2.32 3.13
5000-9999 1.79 2.63
10000-14999 1.56 2.03
15000-19999 1.35 1.69
20000-24999 1.21 1.47
25000-49999 1.09 1.28
50000+ (reference category) 1.00 1.00
Sorlie et al. AJPH 1995
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The Rating Task
• Thinking of both our ability to prevent a disease from occurring and to treat it once it occurs, to what degree was it possible, in the early 1990’s to prevent death from this disease?
• Rated on a 5 point scale from “virtually impossible to prevent death” to “virtually all deaths preventable”
• Inter-rater reliability .85. Correlation with Rutstein independent ratings .57.
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Examples of Hi and Lo Preventability Diseases
• Low Preventability:brain cancer, ovarian cancer, gallbladder
cancer, multiple sclerosis, pancreatic cancer,
• High Preventability:lung cancer, ischemic heart disease,
colon cancer, pneumonia
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National Longitudinal Mortality Study Percent Dying During 9 Year Follow-Up:
Men and Women 25-44
0.5
1
1.8
0.20.3
0.4
00.20.40.60.8
11.21.41.61.8
Hi Preventability Lo Preventability
16+ Years12 -15 years< 12 Years
Phelan, Link, Diez-Roux, Kawachi and Levin. 2004 JHSB
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National Longitudinal Mortality Study Percent Dying During 9 Year Follow-Up:
Men and Women 45-64
4.15
8.2
1.8 1.8 2.1
0123456789
Hi Preventability Lo Preventability
16+ Years12 -15 years< 12 Years
Phelan, Link, Diez-Roux, Kawachi and Levin. 2004 JHSB
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Test # 2 Evidence Bearing on the Hypothesis Trends Over Time
• If the core proposition is true we should find that disparities by SES and race emerge when new health enhancing information or technology is obtained: – E.g. Heart disease, Hodgkins Disease, Colon Cancer
• If death from a disease remains unpreventable – disparities will not change dramatically with time– E.G. Brian cancer, Ovarian Cancer, Pancreatic Cancer
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Trends by Race
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Brain Cancer -- Age-adjusted Death Rates Per 100,000 1950-1999 (Males)
2.843.21
2.91 3.1 3.08
3.864.18
4.54.81 4.97 5.17 5.04 5.26 5.47
0
1
2
3
4
5
6
50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99
White Males
Black Males
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Ovarian Cancer -- Age-adjusted Death Rates Per 100,000 1950-1999 (Females)
7.216.66 6.56 6.43 6.72
8.358.91 8.9 9.03 8.88 8.58
8.11 8.08 8.13
0123456789
10
50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-99
White Females
Black Females
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Pancreatic Cancer -- Age-adjusted Death Rates Per 100,000 1981-2002
1112.3
11.712.3 12.1
11.5 11.3 11
8.4 8.3 8.2 8.2 8.2 8 8.2 8.2
0
2
4
6
8
10
12
14
1981 1984 1987 1990 1993 1996 1999 2002
White
Black
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Heart Disease -- Age-adjusted Death Rates Per 100,000 1950-2000
586.7548.3
512
455.3
391.5
324.8
584.8559
492.2
409.4
317
253.4
200
250
300
350
400
450
500
550
600
1950 1960 1970 1980 1990 2000
White
Black
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All Cancers Combined-- Age-adjusted Death Rates Per 100,000 1950-2000
176.4199.1
225.3
256.4279.5
248.5
194.6 193.1 196.7 204.2 211.6197.2
0
50
100
150
200
250
300
1950 1960 1970 1980 1990 2000
White
Black
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Breast Cancer-- Age-adjusted Death Rates Per 100,000 1950-2000
25.327.9 28.9
31.7
38.134.5
32.232.4 32 32.5 32.1 33.2
26.323.9
0
5
10
15
20
25
30
35
40
45
1950 1960 1970 1980 1990 2000 2004
White
Black
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Colon, Rectum and Anus -- Age-adjusted Death Rates Per 100,000 1960-2000
22.8
26.1
28.3
30.6
28.2
30.9
29.2
27.4
24.1
20.320
22
24
26
28
30
32
34
1960 1970 1980 1990 2000
White
Black
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Age Adjusted Cancer Mortality (All Types) 1950-1998 by SES of County of Residence
100
120
140
160
180
200
220
240
260
50 54 58 62 66 70 74 78 82 86 90 94 98
Low SES
High SES
Middle SES
From Singh et al. 2002 Journal of the National Cancer Institute
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Age Adjusted Colon Cancer Mortality (Men 25-64) 1950-1998 by SES of County of
Residence
0
5
10
15
20
25
50 56 62 68 74 80 86 92 98
Low SES
High SES
Middle SES
From Singh et al. 2002 Journal of the National Cancer Institute
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Percent with Total Cholesterol Above 240 mg/dL -- Age-adjusted
24.423.5
19.3 18.9
28.9
26.5
19.4
17.5
28.9 29
19.6
1615
17
19
21
23
25
27
29
1971-1974 1976-1980 1988-1994 2001-2004
< 100% Pov Level
> 200% Pov Level >100% Pov <200%
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Conclusions
• When we examine Race and SES disparities in mortality by particular diseases we find dramatic evidence that such disparities are created over time.
• Groups with more resources and who face less discrimination benefit more greatly from our new found capacity and disparities emerge
• This means that explanations that propose relatively unchanging causes of disparities like genes, relative deprivation, social participation etc. cannot be the main reasons for health disparities.
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Colon, Rectum and Anus -- Age-adjusted Death Rates Per 100,000 1950-2000
22.8
26.1
28.3
30.629.3
28.2
30.929.2
27.4
24.1
2220.320
22
24
26
28
30
32
34
1950 1960 1970 1980 1990 1995 2000
White
Black
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Age Adjusted Lung Cancer Mortality (Men 25-64) 1950-1998 by SES of County of
Residence
0
10
20
30
40
50
60
70
80
90
50 56 62 68 74 80 86 92 98
Low SES
High SES
Middle SES
From Singh et al. 2002 Journal of the National Cancer Institute
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Policy Issues
• Social policies that provide resources to the resource poor
• Population health policy that focuses on changing contextual factors that affect everyone in a context regardless of resources
• Population health policies that “contextualize” individual risk
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Social Policies that Provide Resources to the Resource Poor
Probabilityof
DiseaseAnd Death
Hi
Lo
SESLo Hi
Lop off low end of SES distribution
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Policies That Affect How Steep the SES Gradient Becomes
Current Situation
More of a Gradient
Less of a Gradient
Probabilityof
DiseaseAnd Death
Hi
Lo
SESLo Hi
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• Create interventions that affect entire contexts rather than interventions that require individual action– Fluoridation versus flossing– Air bags versus seat belts– Cleaning up lead paint versus instructing parents how
to keep their children from ingesting paint chips– Meat inspection versus information to carefully wash
cutting boards
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• If interventions require individual action “contextualize” risk factors – that is find out what puts people at risk of risk – then intervene broadly and comprehensively to remove existing barriers to individual action directed towards health.
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• If interventions require individual action “contextualize” risk factors – that is find out what puts people at risk of risk – then intervene broadly and comprehensively to remove existing barriers to individual action directed towards health.
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Thank you for your Attention!