Social Epidemiology/Social

Determinants of Health
Session 4
KNES 400
Instructor: Dr. Shannon Jette

Learning Objectives
Identify limitations (critiques) of chronic disease
epidemiology
Define the concept Social Determinants of
Health (SDoH)
Define the difference between upstream and
downstream determinants of health

Discuss hypothesized pathways of health/ill health

CRITIQUES OF and ISSUES WITH

CHRONIC DISEASE
EPIDEMIOLOGY?

h"p://www.youtube.com/watch?v=h4MhbkWJzKk;;

Critiques/Issues with Chronic Disease

Epidemiology?;
A finding of association between presence
of a risk factor (exposure) and a disease
(outcome) does not prove causation
Just because the RR does not equal 1,
does not mean that a particular exposure
CAUSED the disease (or is protective)
Thurston,;2014,;Causality;

Association does not mean

causation
An association could be non-causal
It could merely be a one-time observation
due to random error OR due to errors in
methods/procedures used (systematic bias)

Association does not mean

causation ;
If, after controlling for bias/error, association
seems to hold, one still should not infer
causality
Best to think of exposure of interest as a risk
factor for outcome b/c association is statistical
(as opposed to biological)
Must work through # of principles used to infer
causality
E.g., Temporality, Strength of association,
Consistency, Dose-response, Biological Plausibility

Critiques/Issues with Chronic Disease

Epidemiology?
Loss of attention to wider social factors that
play role in development of chronic disease
Excessive focus on lifestyle factors; individual
risk factors decontextualized from social and
historical context (Pearce, 1996)
Why?

Easy to measure

Social Factors

Health
Issue

Determining
factors

Obesity/
overweight

Cardiovascular
disease

Direct
contributing
factors

Indirect
contributing
factors

Stress?

Low Self
Efficacy

Inactivity

Lack Access

Poor diet

Lack Time

Poor diet (high

sodium)
Hypertension

Inactivity
Stress

Structural Factors

Social Determinants of Health: Social and

economic conditions under which people live
which determine their health. These conditions
are shaped by the distribution of money, power,
and resources at global, national and local
levels
(WHO definition cited in Thurston, 2014, p. 38)

 Upstream Determinants of Health: influences more

remote in time or position (i.e., distal) to outcome of
concern and more difficult to link together
Downstream Determinants of Health: individual
lifestyle factors (health related knowledge, beliefs,
behaviors) that are closer in time and distance (i.e.,
proximal) to health outcome making it easier to
trace links b/n them
Influenced by upstream factors
Downstream: putting solutions on the individual

Example: Concentrated Animal Feeding

Operations (CAFOs)
d;

Downstream
solution?
Upstream
solution?
Clean Water Act: reg. to prevent
dumping waste in the water
-no regulation for waste from
field waste going into the water.
-ppl are getting sick
Downstream: people are getting
sick
Upstream: policy to make water
safe

Downstream: filtration of water

Upstream: policy to stop practice of
allowing the spraying of waste
h"p://www.circleoJlue.org/waternews/2012/world/cleanLwaterLactLturnsL40LpartLiiLaLharvestLofLcleanLwaterLexempOonsLonLtheLfarm/;;

SocioLecological;model;(health);

Dahlgren;&;Whitehead,;1991;

Unnatural Causes
Why is name appropriate? How does it
capture main message of film?

Working conditions and health?

Physical (material) aspects
Repetitive movements;
heavy workload
Desk job
Exposure to chemical hazards

Psychosocial aspects
Demand-control model (Karasek, 1979)
Effort-reward imbalance (Siegrist, 1996)

Hard work should be awarded; otherwise there is a lack of satisfaction and happiness

Work-related opportunities/resources
how much paid? sick days? retirement?

EducaOon;and;health?;;

built networks.

81.1%

72%%

75%%

83.1%

72.7%

48%%
11%%
62.9%

Education & Health?

Red: Life Expectancy (yrs)
Blue: % residents w/ bachelors
degree or more

h"p://balOmorehealth.org/neighborhoodmap.html;;

Income, wealth, and health?

income: $$ in bank account
wealth: capital that is passed down family

Economic resources for

Is economic INEQUALITY bad for our health?

More money does not necessarily mean a healthier
society?
Element of social comparison that impacts well-being?
http://www.ted.com/talks/richard_wilkinson.html
disparity causes a breakdown of social trust.

states with most social inequality has the worst health

Wilkinson;&;Picke",;2009;

income alone does not have profound eects on health problems

Wilkinson;&;Picke",;2009;

Wilkinson;&;Picke",;2009;

Wilkinson;&;Picke",;2009;

Proposed pathways
Material
Factors
Psycho-social

Health
Behaviors

1. Material factors
People who suffer from material deprivation have
greater exposure to negative events like hunger,
lack of good food, poor housing, poor work
conditions; less exposure to positive resources like
books, access to rec/leisure activities
Accumulate over life-course and are determined in
large part by income (wealth) available to them

2. Psycho-Social

Wilkinson;&;Picke",;2009;

what is the wider social context?

3. Health Behaviors
Behavioral risk factors for chronic disease are well known
(poor diet, smoking, sedentary lifestyle)
Associated with lower income and social status
Patterns of health behaviors are strongly shaped by social
and economic environments; stress produces behaviors
aimed at easing tension (fatty food, smoking, alcohol);
Planning healthy meals and exercising difficult when
worried about meeting basic needs of food, housing,
clothing
Standing still (Messing et al., 2005)

Evolution of SDoH
For many years, even when social
determinants of health were acknowledged,
the focus was on downstream determinants
(health beliefs/behaviors) instead of upstream
determinants; give downstream solutions
(individual change)
Contaminated drinking water example

Braveman,;2011;

 Downstream Question: How can we promote healthy

behaviors?
Upstream Question: How can we target dangerous conditions
and ensure healthy spaces and places?
Downstream: How can individuals protect themselves against
health threats?
Upstream: How can community organizing and alliance
building help create policies that protect the public good?
Downstream: Which populations have the worst health?
Upstream: What causes the unequal production and
distribution of the conditions that promote and harm health?