Social epidemiology

Branch of epidemiology that studies the social distribution and

social determinants of health (Berkman and Kawachi 2000).

All epidemiology is social epidemiology (Kaufman and Cooper 1999) with the analysis of the social determinants of Health .

Builds and expands by posing new research questions, utilising

new research methods and influencing government policy agenda.

Definition

I1674 john Graunut : who was dying during outbreaks .

1763 Loius rene villerme : social class & work condition as the crucial determinants of health & diseases.

1800 physician & other argued that bad air & emanation from decaying matter cause outbreak of illness , observing that death were commonly clustered among poor .

1830 john snow who methodically covered the street of London collecting statistics documenting the location of outbreak. Snow identified that contaminated water from communal pumps is the source of cholera

History:

1844 Freidrich Engels : the horrible working condition &

identified the relationship between these condition & disease.

1860 Germ theory identifies single causal agent such as Salmonella Typhi as the cause of disease.

By the 1950 -60 : clinician & epidemiologist monitoring these condition to understand the chronic disease caused by combination of biological social behaviour patterns.

History cond….

1960- the health impact of social condition & social class as the key

determinants of morbidity & mortality .

By the end of 20th century the concept of social causation of disease gained traction

DIFFERENCE BETWEEN MODERN & SOCIAL EPIDEMIOLOGY

MODERN EPIDEMIOLOGY Biological paradigm

All diseases are biological phenomena can be described in fully biological paradigm.

Disease is reflection of individual risk factor

SOCIAL EPIDEMIOLOGY Bio psychosocial paradigm

Biology of organism is determined in multilevel interactive environment

Disease are assumed to be product of mutual interaction among social factor,individual factor & biological factor

is to conceptualize, operationalize and test the associations between aspects of the social environment (families, workplaces, residential neighbourhoods, the political economy) and population health

The range of problems studied by social epidemiologist : whether neighbourhood contexts , or workplace organization, or income inequality and social cohesion affect the health

Goals of Social epidemiology

What are the social determinants of health?

"The poor health of the poor, the social gradient in health within countries, and the health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives –their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, –and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a natural phenomenon….Together, the structural determinants and conditions of daily life constitute the social determinants of health."

(WHO Commission on Social Determinants of Health, 2008)

What are the social determinants of health?

Pathway underlying Social determinant Marmot & Wilkinson

Why emphasize social determinants?

Have a direct impact on health.

Predict the greatest proportion of health status inequity.

Social determinants of health structure health behaviours.

Interact with each other to produce health.

Under 5 mortality (per 1000 live births) by wealth group

Mortality over 25 years according to level in the occupational hierarchy: Whitehall

(Marmot & shipley , BMJ 1996)

40-64 65-69 70-890

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50

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Admin Prof/Exec clercial others

Infant mortality in Brazil by race and mother's education, 1990

In social epidemiology the three main theoretical framework for

explaining disease distribution are

(1) Psychosocial

(2) Social production of disesase /political economy of health

(3) Ecosocial & other emerging multi level frameworks

Theories of Social Epidemiology in the 21st century Ecosocial prospective

The commissioner overreaching recommendation:

1. 1. Improve daily living condition 2. 2. Tackle the inequitable distribution of power money &

resources

3. Measure & understand , assesses the impact of action

Commission on social determinant of health: closing the gap in generation

What must be done

Commit & implement a comprehensive approach to early life building on existing child survival programms & extending intervention in early life to include social emotional & language /cognitive development

Expand the provision & scope of education to include the principal of early child development (physical social emotional & language).

Improve daily living condition 1.1 Equity from start

What must be done Place health & health equity at the heart of urban governance &

planning

Promote health equity between rural & urban areas through sustained investment in rural development

Ensure that economic & social policy responses to climate change & other environmental degradation take into account health equity.

1.2 Healthy places healthy people

What must be done Make full & fair employment & decent work a central goal of national

& international social & economic policy.

Achieving health equity requires safe ,secure & fairly paid work year round work opportunities & healthy work balance for all

Improve the working condition for all worker to reduce their exposure to material hazard , work related stress & health damaging behaviour

1.3 Fair employment decent work

What must be done Establish & strengthen universal comprehensive social protection

policies that supports a level of Income sufficient for healthy living.

Ensure social protection to those normally excluded .

1.4 Social protection across life course

What must be done Build health care system based on principles of equity , disease

prevention & health promotion

Ensure that health care system financing is equitable .

Build & strengthen the health workforce & expand capabilities to act on the social determinant of health

1.5 Universal health care

2.1 Health equity in all policy system programmes

what must be done

Place responsibility for action on health & health equity at the highest level of goverance & ensure its coherent consideration across all policies.

Adopt a social determinant framework across the policy & programmatic function of the ministry of health & strengthen in supporting a social determinants approach across government.

2. Tackle the inequitable distribution of power money & resources the structural drivers of the conditions of daily life

globally, nationally, and locally

What must be done Strengthen public finance for action on the social determinants of

health.

Increase international finance for heath equity & coordinate increased finance through social determinants of health action framework.

Fairly allocate government resources for action on the social determinant of health

2.2 Fair financing

Address gender biases in the structures of society –in laws & their

inforcement in the way organisation are run & intervention designed.

Develop finance policies & programme that closes gaps in education & skills & that support female economic participation.

Increase investment in sexual & reproductive health services & programme building to universal coverage & right.

2.3 Gender equity What must be done

Empower all group of society through fair representation in decision

making & how society operates particularly in relation to its effect on health equity .

Enable civil society to organise & act in a manner that promotes & realize the political & social right affecting health equity

2.4 Political empowerment- inclusion of voiceWhat must be done

Make health equity global development goal & adopt a social determinant of health framework to strengthen multilateral action for development .

Strengthen WHO leadership in global action on the social determinant of health institutionalizing social determinants of health as a guideline principle across WHO department

2.5 Good global governanceWhat must be done

3.1 The Social Determinants of Health: Monitoring, Research, and Training Ensure that routine monitoring systems for health equity and the social

determinants of health are in place, locally, nationally, and internationally. Invest in generating and sharing new evidence on the ways in which social

determinants influence population health and health equity and on the effectiveness of measures to reduce health inequities through action on social determinants.

Provide training on the social determinants of health to policy actors,

stakeholders, and practitioners and invest in raising public awareness

3. Measure and Understand the Problem and Assess the Impact of Action

Examples of action

Sweden

–National health policy with a focus on decreasing health inequity based on population interventions defined with a social determinants approach .

Cuba

–Intersectoral approach to child health between health and education sectors resulting in strong interaction between health staff in polyclinics and other sectors, along with emphasis on early child development with almost all children (99.8%) attending early child services.

Cuba has very low child mortality across all groups and high educational attainment despite significant economic difficulties

Examples action

New Zealand

–Whole-of-government national policy to reduce inequities led by health sector with primary health care reform, now showing reduction in major health inequity (between health status of indigenous and non-indigenous New Zealanders)

Thailand –Implementation of universal health care coverage without fee-for-

service, using a capitation based system with a primary health care approach

Brazil

–Implementation of Family Health Programme to improve coverage of health care using a health team approach, building in intersectoral action, which is already showing impressive improvements in infant mortality

Indira Aawas yojna MNREGA Public distribution system Rajiv gandhi swasthya guarantee yojna ICDS VHNSC Vridha Pension Yojna

Government of India

Social Determinants of Health and Primary Health Care

Advance holistic view of health, with primary value of health equity The Declaration of Alma implicitly referred to the social

determinants Primary health care starts with the health sector and reaches out to

other sectors Social determinants discourse sees health sector as one of the social

determinants –Report of the Commission and the upcoming World Health Report

thus complement each other, and the Commission's findings will inform WHO's revitalisation of primary health care

Progress can be achieved in short time periods

The social determinants of health: Health behaviours Material, economic and political determinants of health: Life course Social biology Ecological prospective General susceptibility of disease Social support Social disorganisation Work stress Depression & affective disorder

How society affect health: area of research

 

Chanola Tarani, Marmot Micheal :social epidemiology , Dept of

Epidemiology & public health , University college London Kriger Nancy International journal of epidemiology 2001:30: 668-667 Commission on social determinant of health 2008: final Report World

Health Organisation Candace Miller , Chapter 2 , social epidemiology Jones & Bartlett

Publisher Equity, Social Determinant & Public Health Programme: World Health

Organisation 2010 Eric Blas , Social Determinants Approach to Public Health , from

concept to practice 

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