Transcript Social Determinants of Health as a Social Justice

SOCIAL DETERMINANTS
OF HEALTH in HIV/AIDS
RESEARCH
Dr. John Cairney
McMaster Family Medicine Professor of Child Health Research
Senior Scientist, Centre for Addiction & Mental Health
OVERVIEW
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Overview of the population health &
social determinants perspective
Brief survey of the field & previous
research
Social justice – HIV/AIDS
POPULATION HEALTH
Focuses on the health of an entire population,
rather than on individuals
 Involves consideration of a very broad range
of factors, including economic and social forces
 Focus on intervention is populations, not
individuals
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INFLUENCES ON HEALTH
INFLUENCES ON HEALTH
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Income and wealth:
Absolute and relative
deprivation
Social status: Education,
occupational prestige
Social support
Education: Influence on
behaviour
Employment and
working conditions
Physical environment: air
and water quality,
housing, community safety
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Biology and genetics
Health behaviours and
practices
Child Development:
Prenatal and early
childhood experiences
Health Services:
Availability and use of
preventive and primary
health care services)
From: Hamilton and Bhatti, Public Health Agency
of Canada (http://www.phac-aspc.gc.ca/phsp/phdd/php/php.htm)
POPULATION HEALTH
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Collective health
Influenced by everything that affects an individual’s
health
Some influences are difficult to trace at the
individual level but are very important to the
population as a whole
Social determinants of health and biopsychosocial
model of health
SOCIAL DETERMINANTS PERSPECTIVE
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CORE ASSUMPTIONS:
 Virtually
every aspect of life is determined by the
place people occupy in the social order (Mills, 1959;
Pearlin, 1989; 1999)
 An
individual’s location in the social structure has an
important influence on their health & well-being
SOCIAL DETERMINANTS PERSPECTIVE
What is social location?
 Usual suspects:
Gender
 Socioeconomic status (income, education, occupation)
 Ethnicity
 Marital Status
 Age
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Others?
Gender identity
 Housing status
 Employment status
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PREVIOUS RESEARCH
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Decades of research confirm that social
location is a powerful determinant of mental
health, physical health, and mortality (Black
Report, 1980; Link and Phelan, 1995; Wilkinson,
2003)
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True at all stages of life (Cairney and Krause,
2005)
PREVIOUS RESEARCH
There is a SES gradient in health outcomes: As
social advantages (wealth, status) accrue,
health improves. Like rungs on a ladder, health
is better at each successive level.
 Material (Lynch) versus psychosocial
explanations (Kawachi)
 Pervasive association, detectable at different
levels of social organization (e.g., Whitehall
studies to Wilkinson’s work on Nation-states)
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PREVIOUS RESEARCH
Income gradient in mood disorder in Canadians ages 15 and
over. Source: CCHS 1.2
PREVIOUS RESEARCH
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Interpretive Issues – Social Causation versus Social
Selection
 Does low social or economic status cause disorder
(social causation)…
 Or,
does disorder cause low social or economic
status (social selection)?
SOCIAL CAUSATION AND SELECTION:
EITHER/OR?
Social causation and social selection are not
mutually exclusive processes
 Current research often assumes that both are
operative
 Focus is on measuring relative importance of
selection and causation for specific outcomes
and exploring the mechanisms through which
they operate
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Link & Phelan (2005)
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Distal versus proximal risk factor
Social conditions are “distal” - therefore,
fundamental
Why? Start with the “persistence” in SES
relationships over time
Proximal risk factors have changed (poor sanitation)
– fundamental causes remain – position in the social
structure conditions exposure
Link & Phelan (2005)
Why do social conditions remain constant, but
proximal risk factors change?
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“new mechanisms arise because persons
higher in socioeconomic status enjoy a wide
range of resources including money,
knowledge, prestige, power, and beneficial
social connections that they can utilize to their
health advantage (Link and Phelan 1995)”
Social Policy Implications
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“First, social inequality produces health inequality, and
thus policies that reduce social and economic
inequality will reduce health inequality.”
“Second, policies that benefit people irrespective of
individual resources or initiative (for example,
fluoridating water versus brushing with fluoride
toothpaste) will be more effective in reducing health
disparities than policies that require individuals to
marshal resources to obtain health benefits.”
Social Policy Implications
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“Third, we hold that policies that attend to the
social distribution of knowledge about risk and
protective factors— and the ability to act on
that knowledge—are essential.
SOCIAL CAUSATION
A conceptual framework for understanding social inequalities in health and aging (from: House, 2001)
SOCIAL CAUSATION & SELECTION
Biological
Factors, Social
Conditions in
the Context of
Life Course
Development:
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“Specific genes are known to alter the likelihood of
specific behaviors. For example, a gene might be
associated with the likelihood to engage in impulsive
behaviors. Clearly, a totally impulsive person would
function poorly in most modern social settings … But
genetic influences on behaviors like impulsivity depend on
social circumstances. Imagine two people who have an
equally high genetic propensity for impulsive behavior. Yet
perhaps one person grows up in a permissive family and
the other person grows up in an authoritative family.
These two people may well differ in their levels of
impulsive behavior and, ultimately, how well they function
in adult settings. Of course, life is more than family; the
difficulty is capturing the multidimensional, temporal
complexities of people’s experiences.”
~ Michael Shanahan, UNC Sociology
Health People 2010 Report: US Department of
Health and Human Services, 2000.
Gene – Environment Interactions
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Relatively new model for child health &
development
Diathesis-stress model: the right environmental
stressor triggers genetic vulnerability
Another way of explaining why some children
are affected by environment, others not
Maltreatment (Abuse) and Conduct Disorder
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Conduct disorder – antecedent to anti-social
personality disorder
Abuse is a risk factor – especially in boys
Genetic component – violent behaviour
Interaction?
Source: Jaffee et al. (2005) Developmental and Psychopathology
INTERLOCKING SYSTEMS APPROACH
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Typical approach: Examine outcomes by income or sex
or ethnicity and controls for other “risk factors”
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E.g., is female sex a risk factor for depression independent
of SES, ethnicity, etc.”?
Sex, SES, ethnicity, etc., all influence social location and
access to resources…
…but also combine to produce complex social roles that
cannot be treated as simply the sum of their parts
Multiple-jeopardy hypothesis
HEALTH AS A SOCIAL JUSTICE ISSUE
HIV/AIDS as a special case
 Social inclusion/exclusion
 OHTN Cohort Study
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DEVELOPING A POPULATION HEALTH
PROMOTION MODEL
Hamilton and Bhatti, Public Health Agency of Canada (http://www.phac-aspc.gc.ca/ph-sp/phdd/php/php.htm)