Transcript Schulz et al (2005)

SOCIAL DETERMINANTS: A
LEADING INDICATOR FOR THE
HEALTH OF THE PEOPLE
PERSPECTIVES OF A SOCIOLOGIST
Katherine Clegg Smith, PhD
Associate Professor
Johns 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-toeffectiveness 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: 10991104
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/pove
rty.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
Overall
African American Men
Rate of CVD death (per
100,000)
251.2
405.9
White Men
African American Women
White Women
294.0
286.1
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 care
Racial Trends in the Use of Major
Procedures among the Elderly
Jha 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.or
g/diabetesatlas/5
e/the-socialdeterminants-ofdiabetes-andthe-challenge-ofprevention
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.
Pathways to patterned differences
in diabetes
 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?
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

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?