1. Nancy Krieger Clarice Amorim
“Proximal, Distal, and the Politics of Causation: What’s Level Got to Do With It?”
Nancy Krieger
Clarice Amorim

2. Levels of Causation in Public Health
Proximal vs. Distal
Downstream vs. Upstream
Risk factors and Determinants
Levels / Multilevel

3. “Although notions of proximal, distal, and level all matter for elucidating causal pathways, clear thinking […] is distorted by conflating measures of space, time, level, and causal strength. When it comes to causation, it is one thing to think about near and far in relation to space and time; it is another matter entirely to do so for levels.”

4. Spatiotemporal Scales
The terms “proximal” and “distal” were originally used to describe anatomical location and distance, as measured on a spatial scale.
These terms primed to develop new meanings the moment time entered the picture; temporal events are described in spatial terms.
It was a short step to equate distance (in time or space) with causal strength.
In causal hierarchies, “closeness” and “distance” can only be measured conceptually.

5. Mutually Exclusive Causes?
“In the instant of a muscle contraction, both proximal and distal causes were at play.”
HOW muscles contract
WHY muscles contract
Explanations exist across levels and involve the distant past and the immediate present

7. Web of Causation
Proximal factors operate directly on or within the body.
These are also “easier” to address.
All exposures are on a single plane.
Where are “power” and “injustice?
Distal factors exert their influence through proximal factors.
These require societal change.

8. Social Determinants of Health
Cumulative exposures
Disease triggers
Where are “power” and “injustice?

9. Levels coexist simultaneously!
Ecosocial Approach
Combustible mass of tobacco leaves and additives whose burning transports nicotine and carcinogens into one’s body, increasing the risk for cancer and other chronic diseases.
Highly profitable product whose production, distribution, advertisement, and consumption involves relentless corporate marketing, government regulation and taxation, famers and farmworkers, trade agreements and international treaties.
Levels coexist simultaneously!

10. Ecosocial Approach
Economic, political, and social relationships affect how people live; therefore, the social distribution of health cannot be divorced from political economy and political ecology.
Power drives inequities in health; it does not directly translate into “proximal” or “distal” and does not neatly partition across “levels”.

11. Ecosocial Approach

12. Core Constructs
Embodiment: people incorporate biologically the material and social world in which they live.
Pathways of embodiment: involve exposure, susceptibility, and resistance structured by societal arrangements of power and constraints in our biology.
Cumulative interplay: exposure, susceptibility, and resistance interplay on multiple levels and domains, across time and space.
Accountability and agency: who and what are responsible for social inequities in health.
Analytic implications and predictions: determinants of disease distribution are not reducible to mechanisms of disease causation.

13. THE THEORY OF TRIADIC INFLUENCE
Distal
Influences
Proximal
Predictors
Levels of
Causation
Ultimate
Causes
Social/
Personal
Nexus
Expectancies
& Evaluations
Affect and
Cognitions
Decisions
Experiences
Intrapersonal Stream
Social/Normative Stream
Cultural/Attitudinal Stream
Biological/Nature
Nurture/Cultural
BIOLOGY/
PERSONALITY
SOCIAL
SITUATION
CULTURAL
ENVIRONMENT
Values/
Evaluations
Knowledge/
Expectancies
Perceived
Norms
Information/
Opportunities
Interpersonal
Bonding
Social
Competence
Interactions w/
Social Instit’s
Others’
Beh & Atts
Motivation
to Comply
Skills:
Social+General
Sense of
Self/Control
Self
Determination 1 2 3 7 8 9 10 11 12 13 14 15 16 17 18 l 4 5 6 a b c d e f C F I B E H A D G g h i j k m n o p q r s t u v w x
SELF-EFFICACY
BEHAVIORAL
CONTROL
SOCIAL
NORMATIVE
BELIEFS
ATTITUDES
TOWARD THE
BEHAVIOR 19 20 21 22 23
DECISIONS/INTENTIONS
Trial Behavior
EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological
Related Behaviors J K 13

14. Discussion
Should researchers in the field of health promotion stop using the terms “proximal” and “distal”?
In what ways can we make the role of power in driving health inequities more explicit?