1. 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

2. OVERVIEW (1) Overview of the population health & social determinants perspective (2) Brief survey of the field & previous research (3) Social justice – HIV/AIDS

3. 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

4. INFLUENCES ON HEALTH

5.  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  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/ph- sp/phdd/php/php.htm)

6. POPULATION HEALTH  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

7. SOCIAL DETERMINANTS PERSPECTIVE  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

8. SOCIAL DETERMINANTS PERSPECTIVE What is social location?  Usual suspects:  Gender  Socioeconomic status (income, education, occupation)  Ethnicity  Marital Status  Age  Others?  Gender identity  Housing status  Employment status

9. PREVIOUS RESEARCH  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)  True at all stages of life (Cairney and Krause, 2005)

10. 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)

11. PREVIOUS RESEARCH Income gradient in mood disorder in Canadians ages 15 and over. Source: CCHS 1.2

12. PREVIOUS RESEARCH  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)?

13. 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

14. Link & Phelan (2005)  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

15. Link & Phelan (2005) Why do social conditions remain constant, but proximal risk factors change?  “ 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) ”

16. Social Policy Implications  “ 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. ”

17. Social Policy Implications  “ 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.

18. SOCIAL CAUSATION A conceptual framework for understanding social inequalities in health and aging (from: House, 2001)

19. SOCIAL CAUSATION & SELECTION Biological Factors, Social Conditions in the Context of Life Course Development:  “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

20. Health People 2010 Report: US Department of Health and Human Services, 2000.

21. Gene – Environment Interactions  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

22. Maltreatment (Abuse) and Conduct Disorder  Conduct disorder – antecedent to anti-social personality disorder  Abuse is a risk factor – especially in boys  Genetic component – violent behaviour  Interaction? Developmental and Psychopathology Source: Jaffee et al. (2005) Developmental and Psychopathology

26. INTERLOCKING SYSTEMS APPROACH  Typical approach: Examine outcomes by income or sex or ethnicity and controls for other “risk factors”  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

27. HEALTH AS A SOCIAL JUSTICE ISSUE  HIV/AIDS as a special case  Social inclusion/exclusion  OHTN Cohort Study

28. 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)