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Katherine Clegg Smith, PhD Associate Professor Johns Hopkins Bloomberg School of Public Health.

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Presentation on theme: "Katherine Clegg Smith, PhD Associate Professor Johns Hopkins Bloomberg School of Public Health."— Presentation transcript:

1 Katherine Clegg Smith, PhD Associate Professor Johns Hopkins Bloomberg School of Public Health

2 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

3 What does a sociologist have to say about health?

4 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

5 Stand back and go upstream

6 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

7 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

8 Levels of influence on health Image of Bronfenbrenner’s (1979) Ecological Model taken from:

9 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-to- effectiveness transition. American Journal of Public Health. 93:

10 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)

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

12 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

13 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)

14 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:

15 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

16 Dahlgren and Whitehead's model of the social determinants of health. Bambra C et al. J Epidemiol Community Health 2010;64: ©2010 by BMJ Publishing Group Ltd

17 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

18 Percentage of persons with fair or poor perceived health status by household income, United States, (Healthy People 2010)

19 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: rty.html

20 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.

21 Differences in Diabetes Rates

22 Race and health: CVD deaths (2007 data) PopulationRate of CVD death (per 100,000) Overall251.2 African American Men405.9 White Men294.0 African American Women286.1 White Women205.7 American Health Association. Heart disease and stroke statistics – 2011 update. Dallas, Texas: American Heart Association 2011

23 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

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)

25 Death rates by gender & education level

26 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

27 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: NEJMsa050672

28 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

29 Social determinants & diabetes Social determinants of racial disparities in diabetes risk in Detroit. Schulz et al (2005) doi: /AJPH

30 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

31 Figure from: g/diabetesatlas/5 e/the-social- determinants-of- diabetes-and- the-challenge-of- prevention g/diabetesatlas/5 e/the-social- determinants-of- diabetes-and- the-challenge-of- prevention Whiting et al. Diabetes: equity and social determinants. In Blas E, Kurup A, editors. Equity, social determinants and public health programmes. World Health Organization; p77-94.

32  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? Pathways to patterned differences in diabetes

33 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):

34 A social disparities approach to tackling diabetes: Healthy Eating and Exercising to Reduce Diabetes (HEED) Schulz et al (2005)  Overall goalReduce the risk, or delay the onset, of diabetes by encouraging moderate physical activity and healthy eating among residents of Detroit’s East Side Objective 1Increase 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 2Increase 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 3Identify and create opportunities for safe, enjoyable, low-impact physical activities for community members of Detroit’s East Side Objective 4Strengthen 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 TABLE 3— Objective 3 Objective 4

35 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

36 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

37 Thank you! Questions?


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