Social Epidemiology: Questionable answers or answerable

84 Pages·2012·7.65 MB·English

Social Epidemiology: Questionable answers or answerable
questions?
S.Harper
UniversityofWashington
17 Oct 2012
S.Harper (McGill) UWSeminar 17Oct2012 1/57
Why “Social” Determinants of Health?
What merits consideration as “social”?
1 Not genetic.
2 Not medical care.
“The term social determinant of health is often used to refer
broadly to any nonmedical factors influencing health, including
health-related knowledge, attitudes, beliefs, or behaviors (such as
smoking). These factors, however, represent only the most
downstream determinants in the causal pathways influencing
health; they are shaped by more upstream determinants.”
-Braveman et al. Ann Rev Pub Health (2011)
S.Harper (McGill) UWSeminar 17Oct2012 2/57
What is Social Epidemiology?
Social epidemiology is the study of relations betwen social
factors and disease in human populations. It may be broadly
interpreted to subsume differential occurrence of any “risk factor”
or health outcome across groups categorized according to any of
a number of socially defined dimensions. Primary among the axes
of social distinction in contemporary Western societies are
race/ethnicity, gender, and socioeconomic class/position.
-JS Kaufman, “Modern Epidemiology” (2008)
S.Harper (McGill) UWSeminar 17Oct2012 3/57
General Focus of Social Epidemiology
1 Existence of social differences in health (Descriptive)
Who gets what, which groups have a greater disease burden,
monitoring of inequalities, etc...
2 Causes of observed social differences in health (Etiologic)
Overall effect of social group categories (total “effects”)
Direct/Indirect effects (causal mediation)
3 Policies to address causes and/or remediate social differences in
health. (Policy/Intervention)
S.Harper (McGill) UWSeminar 17Oct2012 4/57
S.Harper (McGill) UWSeminar 17Oct2012 5/57
Obligatory slide showing growing impact of my research field
(ignoretheabsenceofcomparisontoanyotherfield)
Source: WebofScience,12Apr2012
S.Harper (McGill) UWSeminar 17Oct2012 5/57

Anarchy in the UK?
3 major reviews of health inequalities in England:
Black (1980)
Acheson (1998)
Marmot (2010)...and yet:
“The main conclusion therefore is that reducing health
inequalities is currently beyond our means. That is the sad but
inevitable conclusion from the story of the English strategy to
reduce health inequalities.”
Mackenbach, “Has the English Strategy to Reduce Health
Inequalities Failed?” (2010)
S.Harper (McGill) UWSeminar 17Oct2012 7/57
What happend in England?
“England has been the first European country to enter the stage of
systematic government action to reduce health inequalities”
“It seems that the strategy has been unsuccessful in harnessing the
underlying forces to help to reduce, instead of widen, the gap.”
Why?
1 Wrong entry-points: it spent resources on entry-points which were
irrelevant for life expectancy or infant mortality.
2 It did not use effective policies: it had to rely on policies of unproven
effectiveness, reflecting the almost complete lack of scientific evidence
on differential effectiveness.
3 Wrong scale: the scale required for achieving population-wide impacts
was not determined in advance, and proved to be insufficient.
S.Harper (McGill) UWSeminar 17Oct2012 8/57
What happend in England?
“England has been the first European country to enter the stage of
systematic government action to reduce health inequalities”
“It seems that the strategy has been unsuccessful in harnessing the
underlying forces to help to reduce, instead of widen, the gap.”
Why?
1 Wrong entry-points: it spent resources on entry-points which were
irrelevant for life expectancy or infant mortality.
2 It did not use effective policies: it had to rely on policies of unproven
effectiveness, reflecting the almost complete lack of scientific evidence
on differential effectiveness.
3 Wrong scale: the scale required for achieving population-wide impacts
was not determined in advance, and proved to be insufficient.
S.Harper (McGill) UWSeminar 17Oct2012 8/57