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SOCIAL DETERMINANTS OF HEALTH in HIVAIDS RESEARCH Dr' John Cairney

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Title: SOCIAL DETERMINANTS OF HEALTH in HIVAIDS RESEARCH Dr' John Cairney


1
SOCIAL DETERMINANTS OF HEALTH in HIV/AIDS
RESEARCHDr. John Cairney
  • McMaster Family Medicine Professor of Child
    Health Research
  • Senior Scientist, Centre for Addiction Mental
    Health

2
OVERVIEW
  • Overview of the population health social
    determinants perspective
  • Brief survey of the field previous research
  • 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
INFLUENCES ON HEALTH
  • 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/p
hp/php.htm)
6
POPULATION HEALTH
  • Collective health
  • Influenced by everything that affects an
    individuals 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 individuals 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 Wilkinsons 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 knowledgeare 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
    peoples 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?

Source Jaffee et al. (2005) Developmental and
Psychopathology
23
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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)
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