SocialandBehavioralFactorsinPublicHealth

DrSamanWaqarAlShifaSchoolofPublicHealth

IntroductiontotheCourse:

• Thiscourseisdesignedtohelpthestudentsinunderstandingbasicsocialconceptsandprocessesthatinfluencehealthstatusandpublichealthinterventions.• Thiscourseintendstopromoteinterestinfurtherstudyofthesocialandbehavioraldeterminantsofhealth.

LearningGoal:

• Theapplicationofsocialandbehavioralsciencetheoriestopublichealthisoneoftheimportantgoalsofthiscourse.• Thefocusofthiscourseonholisticviewbykeepingsocial,cultural,ecological,politicalandeconomicreasonsandtheirsharedinteractionthatinfluencestheoccurrenceofdiseaseanditsmanagementatindividual,communityandnationallevel.

LearningObjectives:

Byendofthecoursetheparticipantsshouldbeableto:• Explainkeyconceptsinthesocialandbehavioralaspectsofpublichealth,culture,race/ethnicity,gender,poverty/disparities.• Describethefactorsrelatedtobehaviorchange,community,organizationalclimateandfamilystructure.• Demonstrateunderstandingofthesocialdeterminantsofhealth.• Describehowsocialdeterminantsinfluencepopulationhealth.• Criticallyassesstherelevanceofethics,equityandpoliticsinpublichealth.

Contents:Thefollowingareaswillbecoveredduringthecourse:• RoleofSocialandbehavioralfactorsinPublicHealth• SocialDeterminantsofHealth• ConceptsofDisease,IllnessandSickness• EconomicChange&itsImpactonHealth• RoleofCivilSocietyinHealthCare• CommunityParticipationinHealthCare• GenderandHealth• EquityinHealthCare• PoliticsofHealth• EthicsinPublicHealth• SocialPolicyandHealth• SocialChangeandDevelopment• Stressandsocialsupport• Socialtheories

Healthisastateofcompletephysical,mentalandsocialwell-beingandnotmerelytheabsenceofdiseaseorinfirmity.Publichealthisthescienceofprotectingandimprovingthehealthoffamiliesandcommunitiesthroughpromotionofhealthylifestyles,researchfordiseaseandinjurypreventionanddetectionandcontrolofinfectiousdiseases.Overall,publichealthisconcernedwithprotectingthehealthofentirepopulations.Thesepopulationscanbeassmallasalocalneighborhood,orasbigasanentirecountryorregionoftheworld.

TheDeterminantsofHealth

IntroductionManyfactorscombinetogethertoaffectthehealthofindividualsandcommunities.Whetherpeoplearehealthyornot,isdeterminedbytheircircumstancesandenvironment.Thefactorssuchaswherewelive,thestateofourenvironment,genetics,ourincomeandeducationlevel,andourrelationshipswithfriendsandfamilyallhaveconsiderableimpactonhealth.

Thedeterminantsofhealthinclude:

• Thesocialandeconomicenvironment,• Thephysicalenvironment,and• Theperson’sindividualcharacteristicsandbehaviors.

Thesedeterminants—orthingsthatmakepeoplehealthyornot—includetheabovefactors,andmanyothers:• Incomeandsocialstatus- higherincomeandsocialstatusarelinkedtobetterhealth.Thegreaterthegapbetweentherichestandpoorestpeople,thegreaterthedifferencesinhealth.• Education– loweducationlevelsarelinkedwithpoorhealth,morestressandlowerself-confidence.• Physicalenvironment– safewaterandcleanair,healthyworkplaces,safehouses,communitiesandroadsallcontributetogoodhealth.• Employmentandworkingconditions– peopleinemploymentarehealthier,particularlythosewhohavemorecontrolovertheirworkingconditions.• Politicalenvironmentofasocietyhasastrongimpactonthehealthofasociety.

• ReligiousBeliefshaveastronginfluence• Socialsupportnetworks– greatersupportfromfamilies,friendsandcommunitiesislinkedtobetterhealth.Culture,customs,traditions,andbeliefsofthefamilyandcommunityallaffecthealth.• Healthservices- accessanduseofservicesthatpreventandtreatdiseaseinfluenceshealth• Genetics - inheritanceplaysapartindetermininglifespan,healthinessandthelikelihoodofdevelopingcertainillnesses.• Personalbehaviorandcopingskills- balancedeating,keepingactive,smoking,drinking,andhowwedealwithlife’sstressesandchallengesallaffecthealth.• Gender - Menandwomensufferfromdifferenttypesofdiseasesatdifferentages.

Introduction

• Socialandbehavioralsciencesareamongthenewerdisciplinestobeintegratedintopublichealth.• Publichealthhasalwaysbeenconcernedwiththewaysinwhichsocialconditionsinfluencethehealthandwell-beingofcommunitiesandhumanpopulations.• Thedisciplinesofpublichealthandsocialsciencebothemergedinthelatterpartofthe19thcenturyalongwiththerecognitionoftheneedsofthepoorandmarginalizedgroupsandtheassociationbetweenlivingconditionsandhealth.

• Inmid-20thcenturyprofessionallytrainedsocialscientistsbecameactivelyinvolvedinpublichealthprograms,andbythe1980s,accreditedschoolsofpublichealthwereestablishedtoprovideformaltraininginthesocialandbehavioralsciences.• Themostimportantchallengesforimprovinghealthinthe21stcenturyinvolvesocial,cultural,andbehavioralchange.• Makingeffectivechangesintheindividual’slivesandsocietytoachievepublichealthgoalsisnoeasytask.Politicalandeconomicbarriersdeeplyrootedinthesocialorderconstrainwhatispracticallyfeasible.

Period Event Significance

19thcentury

Europeansocialtheoristsdefinemedicine/publichealthas“socialscience”

Socialdeterminantsidentifiedasfundamentalcausesofhealthandillness:politicaladvocacyforsocialreform

19thcentury SnowandFarrinBritain,PanusinDenmark,andothers

Useofsocialsciencemethodsforepidemiologicalinvestigation

Late19thcentury SanitaryMovement

Organizedeffortstoimprovelifestyle,livingandworkingconditionsofurbanpoorwithinindustrializingnations

1948 WHOdefineshealthtoincludementalandsocialwell-being

Setstageforaddressingpsychosocialfactorsinhealthandillness

1950s Anthropologicalresearchoncommunityhealth

Recognitionofculturalfactorsasbarrierstopublichealthinterventions;firstplannedculturechangeprojectstoimprovehealth

ImportantMilestonesintheHistoryofSocialSciencesinPublicHealth

Period Event Significance

1978 AlmaAtaConferenceonPrimaryHealthCare

Setlong-termglobalagendatodevelopcomprehensive,community-basedapproachestopromotebasichealth

1980sBehavioralandSocialScienceCounciloftheU.S.AssociationofSchoolsofPublicHealthestablished

Formalizationofsocialandbehavioralsciencesasintegralcomponentofpublichealthtrainingprograms

1986 OttawaCharterforHealthPromotionIdentifiedfundamentalsocialprerequisitesforensuringhealthandwell-being

2005 BangkokCharterforHealthPromotion

Reaffirmedsocialprerequisitesandhighlightedroleofeconomicdevelopmentinhealthpromotion

The1950s:SeminalDevelopments• Focusonpopulation-basedscreeningformedicalconditions.• Itwasaneraofgreatoptimismaboutthepotentialforsocialengineeringofhealthdevelopmentandtheapplicationofsocialsciencemethodstounderstandingandimprovingthehealthofpopulations.• Anthropologistsbeganworkingonprojectsaimedatimprovingthehealthanddietoftraditionalpopulations.• Anumberofanthropologistswereappointedtokeypositionsininternationalhealthorganizations e.g.WHO,RockefellerFoundationetc.• Anthropologistsdefinedcultureasabarriertodesirablehealthpracticeandintroducedtheroleofthesocialscientistasaculturebrokerwhoseexpertisecanbeappliedtofacilitatedirectedchange

ShiftFromInfectioustoChronicDisease

• Overthecourseofthe20thcentury,publichealthunderwentsignificanttransformationasaresultofaradicalshiftinfocusfrominfectiousdiseasestochronicconditionsasthemajorchallengestopopulationhealthinindustrializedsocieties.• Tiedtodemographic,environmental,andsocialchange,thistransformation,alsoknownastheepidemiologictransition,requiredprofoundalterationsinhowpublichealthproblemswereaddressed.• Chronicconditionssuchasheartdisease,cancer,diabetes,mentalillness,andhealthproblemsofolderpersonsreplacedTB,pneumonia,childhooddiarrhea,andotherinfectionsastheleadingcausesofmorbidityandmortalityinindustrialcountries.

Primary,Secondary,andTertiaryPrevention• Publichealthfocusesonpreventionofdiseaseanddisability,whilemedicalpracticeemphasizesthetreatmentofhealthproblemsaftertheyoccur.• Inprimaryprevention,thefocusisonactivitiesthatpreventthedevelopmentofpathologicalconditions.Forexample,preventingtheonsetofheartdiseasethroughhealthylifestylebehavior.• Secondarypreventionreferstodetectionofdiseaseoritsprecursorsatanearlystagetotakeameliorativeactionthatcanthwartfulldevelopmentorenablemeasurestokeeptheproblemincheck.Regularscreeningfordetectableconditionssuchashypertension,breastandcolorectalcancer,diabetes,andsexuallytransmittedinfectionsfallsinthiscategory.• Finally,tertiarypreventionincludesinterventionsatlaterstagesofdiseasetopreventsecondarycomplications,sustainoptimaldiseasemanagement,andensurethebestqualityoflife.

• Treatmentforhypertension,diabetes,depression,osteoporosis,andotherchronicconditionsillustratesthethirdcategoryofprevention.• Socialandbehavioralfactorsfigureimportantlyinallthreetypesofprevention;however,overthedecades,interesthasgrownparticularlyintheirpotentialcontributiontoprimaryprevention.• Ofallthepublichealthdisciplines,thesocialandbehavioralsciencescanmakeuniquecontributionstoprimaryprevention.• Influencinglifestylepatternsandthesocialcontextinwhichpeopleliveisfundamentaltopreventionofthemajorhealthconditionsfacedbysocietytoday.

• Itisfareasiertomodifythemoreproximatedeterminantsofhealth,suchasindividualfoodchoices,thanitistoaltertheintermediateanddistalforcesthataffectthosechoices.• Changingtheorganizationofsocietyandthecorecomponentsofcul-tureposesanenormouschallenge,yetthereisgrowingrecognitionthatonlythroughalterationofthefundamentalcausesofdisease(e.g.,inadequateincomeandaccesstohealthcare,unemployment,racialandgenderdiscrimination,lackofsocialsupport,stressfulworksettings,failuretoprovideeducationalopportunities)cantrueprimarypreventionberealized.

• Inthepast,thegermtheoryofdiseasedominatedmedicalresearchandpractice,nowindividualhealthisviewedasshapedbycomplexinteractingsystemsofbiological,social,andenvironmentalfactors.• Whiletremendousadvancesinbiomedicaltechnologyhavedramaticallyimprovedourabilitytotreatillnessandprolonglifethroughtheuseofsophisticateddiagnostictesting,powerfuldrugs,andadvancedsurgery,medicinehasincreasinglyrecognizedtheimportanceofculturalcontext,socialorganization,andlifestylechoicesforindividualhealth.• Variouslylabeled"socialmedicine,”“behavioralmedicine,”and“medicalecology,”isamedicalmodelsharedwithpublichealthasabroadenedframeworkforanalyzinghealthproblemsintermsofcomplexbiosocialsystems.

• Preventionandtreatmentofchronicdiseasesdependsheavilyonbehavioralpracticessuchasdiet,exercise,substanceuse,andstressreduction.Likewise,behaviorandsocialconditionsarethecentralcomponentsofpreventiveapproachesforotherleadingpublichealthproblems.• Nearlyalldiseasesandhealthconditionsarenowknowntohavemultifactorialetiologiesinvolvingcomplexinteractionsofprocesseslocatedinsideandoutsidepeople’sbodies.

• Asweknow,thatstressisanunderlyingcomponentofallillness,includingbothacuteinfectionsandchronicdisorders,andthatphysicalandpsychologicalstresscanaffectone’sabilitytofightdiseaseandrestorehealth.• Illnessisincreasinglyviewedasabreakdowninthebody’snaturaldefensesystem,whichishighlysensitivetointernalemotionsandexternalstressorsinthesocialenvironment.Thenegativeimpactofsocialdiscord,whetherfromfamilyrelationships,theworksetting,orschoolpressure,canplayanimportantpart.

• Researchandstudiesonsocialsupporthasshownthatthewayinwhichweareconnectedtootherpeoplehasaprotectiveeffectonourwell-being.• Ithasbeenshown,forinstance,thatpeoplewhointeractwithalargenetworkoffriendsandfamilymembersgetsicklessoftenandrecoverfromillnessfasterthanthosewhodonot.• Similarly,peoplewholivealonehavehigherratesofdeathandsuicidethanthosewholivewithothers.Thesetrendsillustrateonekindofmechanismthroughwhichthesocialenvironmentcanaffecthealthstatus.

• Thesocialenvironmentcanalsoinfluencehealththroughsocialstructuralarrangements,whichpositionpeopleatdifferentplacesinsocietyandmediateaccesstoresourcessuchaseducation,income,medicalservices,status,andprestige.• Becausepeopleoccupydifferentpositionsinthesocioeconomicstructure,sodiseaseandmortalityarenotevenlydistributedwithinapopulation• Differentculturalfactorsinfluencehealth—forexample,thewaysinwhichpeoplethinkaboutandbehaveregardingfood,therelativevaluetheyplaceonworkandleisure,howhealthandillnessareperceivedandmanaged,andtheroleofethnicidentityinshapingdiseasepatterns.

• Anumberofformulationsofthesocialecologicalmodelhavebeendeveloped.Theyallhaveincommonthenotionofmultilevelsystemsofmutualinfluenceandinteraction,movingfromtheindividuallevelthroughlinkagestolargersocialnetworksincludingthefamily,com-munity,socialinstitutions,thestate,andglobalsystems.• Keyconceptsincludesystemintegration,change,andadaptationovertime

SOCIALECOLOGYOFHEALTHMODEL

Thismodelisorganizedaroundfivehierarchicallevelsofinfluence:• Intrapersonalfactors,• Interpersonalprocessesandrelationswithprimarysocialgroups,• Institutionalfactors,• Communityfactors,and• Publicpolicy.

• Factorsinfluencinghealthattheintrapersonallevelincludebiologicalandpsychologicalfactorssuchasgenetics,cognition,andpersonality.• Attheinterpersonallevel,weidentifyhome,family,andpeergroupinfluences,• Whiletheorganizationallevelmightincludeworkandschoolsettings,civicassociations,andhealthcareorganizations.• Atthelevelofcommunity,wecanidentifyfactorssuchasethnicity,socialclass,socialcapital,publicfacilities,andthebuiltenvironment.• Themoremacrolevelsocietalfactorsincludepolicyissues,nationalethosandculturalvalues,infrastructure,economics,and education.

Thismodelalsoincorporatesthenotionofproximate,intermediate,anddistaldeterminantsofhealth:• Withthemoreproximatefactorslocatednearthetipofthepyramid,theindividuallevel;• Intermediatefactorscorrespondingwithinterpersonalandorganizationallevels;• Anddistalfactorscorrespondingwithcommunityandsocietalinfluences• Althoughsystemsstrivetowardequilibrium,perfectbalanceisneverachievedbecausesystemsareopentointernalandexternalchangesandthusconstantlyrequireadjustmentoradaptation.• Becausealllevelsofanecosystemareintegrated,changeatanylevelofthesystemmayrequireadjustmentatotherlevels.

• Theprocessofadaptationinresponsetochangeisonewayofconceptualizingstress,andagainitcanoccuratdifferentlevels,includingpsychologicaldistress,familydysfunction,communitydisruption,rapidculturechange,andenvironmentaldegradation.• Socioculturalorenvironmentalchangecanhaverepercussionsthateventuallyaffectcommunities,families,andindividuals:• Forexample,aneconomicrecessionoftenleadstohighunemploymentrates;withinfamilies,aprovidermaylosehisorherjob,leadingtolossofmedicalbenefitsandreducedincome,whichaffectsaccesstohealthcare.• Socialsupportcanbufferthenegativeeffectsofstressatdifferentlevelsofthesystem,suchasthroughclosefriendships,strongfamilies,communityresources,andone’sintegrationwith(oralienationfrom)thelargersociety.

• Thesocialecologyofhealthmodelalsoincorporatesaspectsofthephysicalenvironment:• Atthehouseholdlevel:wecanconsiderhousingconditionsandhazardsinthehome;• Atthecommunitylevel:wemusttakeintoaccountphysicalaspectssuchasthebuiltenvironment,waterquality,airpollution,toxicwaste,noise,crowding,andotherfeatures;• Atthesocietallevel: examplesofphysicalenvironmentalconcernsmightincludeatmosphericchange(e.g.,globalwarming),changesinfloraandfauna(e.g.,deforestation,vectorhabitat),climaticstress(e.g.,heatwaves,coldspells),andnaturaldisasters(floods,tornadoes,hurricanes).

SOURCE:Hansonetal.(2005).