Explaining Social Change and Health

Explaining Social Change and Health

Introduction

The challenge we face in trying to understand the rapid changes in health and mortality illustrated in the case studies you read in unit 1 is that all of these mortality changes cannot be explained simply by examining individual behaviours. For example, why did alcohol and drug abuse by men steadily increase in the case studies? Why are women more at risk of HIV than men in South Africa? This unit introduces ways of explaining these changes in health behaviour and mortality by examining changes at a social or population level.

There are three study sessions in this unit.

Study session 1:Influence of societal factors on individual phenomena

Study session 2:Adopting a population perspective in prevention

Study session 3:How society influences individual health

Intended Learning Outcomes

By the end of this Unit you should be able to:

• Justify the need to undertake a more societal analysis to explain changes in mortality.
• Describe the public health importance of a more population based approach.
• Outline the implications a broader approach to understanding social change and health has for epidemiology.

Unit 2 - Session 1

Influence of Societal Factors on Individual Phenomena

Introduction

This session will provide you with an overview of the insights that can be gained when using a societal or population perspective in examining individual phenomena such as mortality or ill health.

In later sessions we will see how taking a broader population perspective has important implications for prevention strategies and the kind of epidemiological studies we conduct.

Session contents

1.Learning Outcomes of this session

2.Readings

3.Explaining suicide rates in different societies

4.Explaining changes in the health of societies

Timing

There are three tasks in this session, and four readings.

1LEARNING OUTCOMES OF THIS SESSION

By the end of this session you should be able to:

• Describe how Durkheim uses routine data at a population level to describe the relationship between social conditions and suicide.
• Outline how this might assist in explaining changes in mortality at times of intensive social change.

2READINGS

Author/s /

Reference details

Durkheim, E. / (1979). Ch 5 – Anomic Suicide. In Suicide: A Study In Sociology. London:Routledge & Kegan Paul: 241-259.
Susser, M. / (May 1996). Choosing a future for epidemiology. Eras and Paradigms. Am J Pub Health; 86 (5): 668-673.
Chopra M. / (September 2000). A New Epidemiology for a New South Africa. South African Medical Journal: 875-876.
Wilkinson, R. / (1996). Ch 2 - Health Becomes a Social Science. In Unhealthy Societies: The afflictions of inequality: 13-29.

3EXPLAINING SUICIDE RATES IN DIFFERENT SOCIETIES

In order to formulate effective public health interventions, it is very important to try and explain the underlying reasons for the widespread changes in health behaviours and the maintenance of those health behaviours. To achieve this requires a search for collective characteristics that shape individual and group outcomes. In identifying these collective characteristics, we will also be able to answer questions such as why some communities and countries weather the storm of social transition so much better than others.

We will now consider the work of Emile Durkheim, as a foundation for beginning to answer these questions.

Emile Durkheim was a French social scientist who is also considered one of the founding fathers of modern sociology. He was acutely aware that society is not just the sum of individuals: “The group thinks, feels and acts entirely differently from the way its members would if they were isolated. If we therefore begin by studying these members separately, we will understand nothing about what is taking place in the group.” In other words, we cannot merely add up the individual risk factors for mortality to inform ourselves of what keeps a population healthy or makes it sick. To illustrate this principle, Durkheim chose to investigate one of the most individualistic acts imaginable – suicide.

Durkheim makes the observation that the suicide rates remained fairly constant across time in different communities despite the fact that these communities were made up of very different people over time.

“Individuals making up a society change from year to year, yet the number of suicides itself does not change…the population of Paris renews itself very rapidly, yet the share of Paris towards the total number of French suicides remains practically the same. Likewise, regardless of the diversity of individual temperaments, the relation between aptitude for suicide of married persons and that of widowers and widows is exactly the same in wide different social groups.”

Instead of trying to understand this by investigating each individual suicide Durkheim compares the rates of suicide in various communities against their characteristics.

He identifies three categories of suicide:

Egoistic Suicide: This results from the lack of integration of the individual into society. The stronger the forces throwing the individual onto his own resources, the greater the suicide rate in that society. So for example, the suicide rate in Catholic communities is low because of its strong integrative current whereas in Protestant communities, where the emphasis is much more on individual achievement, the rate of suicide is higher.

Altruistic Suicide: This is the opposite of egoistic suicide. Whereas egoistic suicide occurs because an individual is not sufficently integrated into a community or family, altruistic suicide occurs where an individual’s life is rigorously governed by custom and habit. In this case, the individual may take his/her own life because of higher commandments, either those of religious sacrifice or unthinking political allegiance (for example in the army).

The third category Durkheim calls anomic suicide. This category of suicide is particularly relevant in perhaps explaining some of the trends we have found in the case studies. The next reading is taken from Durkheim’s original manuscript; not only does it describe this category of suicide, it also illustrates his sociological methods.

READING

Durkheim, E. (1979). Ch 5 - Anomic Suicide. In Suicide: A Study in Sociology. London: Routledge & Kegan Paul Ltd: 241-259. See pp 107-118 in the reader.

TASK 1 – Apply Durkheim’s theory of anomie to a different context

a)What are the different types of anomie that Durkheim describes? Give a brief description of each.

b)How well does Durkheim´s description of anomie relate to the societies in South Africa today and in 19th Century Sweden?

In summary, Durkheim shows how the power of social forces can influence even the most private of acts – suicide. Only through studying the incidence of suicides at a societal level could we possibly identify underlying explanations, from categorising individual suicides according to the identified categories.

4EXPLAINING CHANGES IN THE HEALTH OF SOCIETIES

The insight that Durkheim has given us – that there might be forces that impact on individuals at a societal or population level and that these forces are more than just the sum of individual factors – is one that health scientists and epidemiologist once understood and accepted. However, with the rise of the ‘germ theory’, this perspective became displaced. This is illustrated in the next reading by Mervyn Susser who describes the early development of epidemiology.

Read the article by Susser, then respond to the task.

READING

Susser, M. (May 1996). Choosing A Future For Epidemiology. Eras and Paradigms.Am J Pub Health; 86 (5): 668-673. See pp 373-380 in the reader.

TASK 2 - Contrast ‘black box’ and population epidemiological approaches

a)Compare and contrast the features of a population epidemiological approach with those of the ‘black box’ approach.

b)In what way can a perspective that places more emphasis on the population give insights to the HIV epidemic?

FEEDBACK

There is a growing debate in epidemiological research about the need to understand more fully the context in which people live, and the impact of social and cultural influences on health. Chopra makes this point.

Read the following article by Chopra and complete the task.

READING

Chopra, M. (September 2000). A New Epidemiology for a New South Africa. South African Medical Journal: 875-876. See pp 83-86 in the reader.

TASK– Assess argument for broadening approach adopted in epidemiological research

a)To what extent do you agree with the recommendations put forwards by this paper?

b)Give three issues raised by the paper that concern the importance of and need for epidemiological research?

FEEDBACK

One of the things that become clear in this article is that health problems exist not only in terms of their physical manifestation as diagnoses, diseases and disabilities, but also as social and cultural entities. Moreover, it is now well recognised that social and cultural determinants - gender, social class, cultural beliefs - have a powerful influence on health. This broader approach is also reflected in recent WHO statements about research priorities as well as in national public health programmes such as that for Sweden. But has epidemiological research been able to address these issues? And if not, why not?

This final reading reinforces the points made above but focuses on how a population perspective could assist in explaining differences in mortality between different groups within and between societies.

READING

Wilkinson, R. (1996). Ch 2 - Health Becomes a Social Science. In Unhealthy Societies: The Afflictions of Inequality: 13-29. See pp 437-448 in the reader.

In summary, there is convincing epidemiological evidence that explanations for health outcomes are not only to be found at the individual level but also at a more societal level. The next session will outline two other reasons why it is important to take a population perspective when trying to explain such mortality changes as described in the case studies, and in recommending effective interventions.

Unit 2 - Session 2

Adopting a Population Perspective in Prevention

Introduction

This session will provide you with an overview of the importance of a population perspective in designing and prioritising prevention activities.

Session contents

1.Learning outcomes of this session

2.Readings

3.A population perspective on differences in risk factors

4.Explaining changes in the health of societies

5.Summary

Timing

There are three tasks and three readings in this session.

1LEARNING OUTCOMES OF THIS SESSION

By the end of this session you should be able to:

• Describe the importance of the distribution of risk factors across whole populations.
• Describe evidence that many individual behaviours are greatly shaped by the social contexts in which they occur.
• Outline the implications this has for public health interventions.

2READINGS

Author/s /

Reference details

Rose, G. / (1992). Ch 5 - Individuals and Populations. In The Strategy of Preventive Medicine. Oxford: Oxford University Press: 53-64.
Berkman, C. F. & Kawachi, I. (eds). / (2000). Ch 11 - Health Behaviours in a Social Context In Social Epidemiology. Oxford: Oxford University Press: 242-266.
Evans, M., Sinclair, R.C., Fusimalohi, C. & Liava’a, V. / (2001). Globalisation, Diet and Health: An Example from Tonga. Bulletin of the World Health Organisation, 79 (9): 856-862.

3A POPULATION PERSPECTIVE ON DIFFERENCES IN RISK FACTORS

Another reason for taking a population perspective when analysing changes in health status is provided by the work of Geoffrey Rose, one of the most prominent figures in epidemiology. In his influential book, ‘The Strategy of Preventive Medicine’, Rose points out that risk factors are rarely binary in nature. In traditional clinical medicine the emphasis is upon identifying whether a risk factor or illness is present or not. For example, whether somebody has hypertension or not. However, risks and illness are mostly distributed along a continuum. Therefore, making small shifts in the distribution of risk throughout the population can make a large difference in the health status of that population. This is illustrated in the following reading.

When you have read the Rose reading, complete the task that follows.

READING

Rose, G. (1992). Ch 5 - Individuals and Populations. In The Strategy of Preventive Medicine. Oxford: Oxford University Press: 53-64. See pp 313-322 in the reader.

TASK 1 – Describe the implications of Rose’s population perspective

a)What are the implications of Rose´s argument for understanding the importance of individual versus population level risk factors?

b)What implications does Rose´s argument have for prevention strategies - for example, reducing the mortality associated with cardiovascular disease?

FEEDBACK

Rose suggests that the individual´s risk of illness cannot be considered in isolation from the disease risk of the population to which he or she belongs. A level of blood pressure that is considered ´normal´ in one society may be considered very ´abnormal´ in another depending upon the distribution of the whole population (Rose uses the example of the cholesterol levels in Japan and Finland).

This brings us to a second important insight from this work. Factors that might be important risk factors at an individual level may not explain much of the disease rate in the whole population. Consider an example in which population A has a higher rate of cardiovascular disease (CVD) than does population B. Within each population, individuals who smoke have twice the CVD risk than those who do not. However, the prevalence of smoking is similar in the two populations and hence cannot account for the difference in CVD rates. But population A has a higher consumption of saturated fat than population B. So the difference between the two populations is explained by the difference in diet and not smoking even though smoking is a much more dominant risk factor at the individual level.

The implications of Rose´s argument are also very important for prevention efforts. By just focusing at one end of the distribution curve, ie those at ´high risk´, as prevention interventions traditionally have, Rose is suggesting that most of the death caused by CVD is missed. This is because most of the people who die from CVD do so without warning, and only a small fraction of deaths from CVD occur amongst those classified as at ´high risk´. Rather than trying to screen and identify these few individuals it would, therefore, be more effective and efficient to change the distribution of the risk factors for the whole population. For example, it has been calculated that a 2% reduction in mean blood pressure across the population has the potential to prevent 1.2 million deaths from stroke (about 15% of all deaths from stroke) and 0.6 million from coronary heart disease every year by 2020 in the Asia Pacific region alone and could be readily achieved in many populations by reducing the salt content of manufactured food.

4EXPLAINING CHANGES IN THE HEALTH OF SOCIETIES

An understanding of the collective characteristics that shape individual and group behaviours is required to explain the underlying reasons for widespread changes in health behaviour. Formulating effective public health interventions is dependent on this understanding of what leads to maintenance or change in health behaviour.

The following reading provides a useful summary of the need to incorporate social and policy level factors when designing behaviour change interventions.

READING

Berkman, C. F. & Kawachi, I. (eds). (2000). Ch 11 - Health Behaviours in a Social Context. In Social Epidemiology. Oxford: Oxford University Press: 242-266.

TASK 2 - Analyse the consequences of a theory for practice

a)If we accept that the social context is very important in shaping behaviours, what consequences does this have for behaviour interventions?

The importance of considering the broader societal factors that can influence health behaviours is neatly highlighted in the following study.

READING

Evans, M., Sinclair, R.C., Fusimalohi, C. & Liava’a, V. (2001). Globalisation, Diet and Health: An Example from Tonga. Bulletin of the World Health Organisation, 79 (9): 856-862.

The following task is based on the reading.

TASK 3 – Summarise the text and show practical implications of the main ideas

a)What are the main reasons for the rise in obesity levels in Tonga?

b)What hints or insights do these reasons offer us about interventions to reduce obesity?

5SUMMARY

In this session, the focus has been on the uses of a “population perspective” in understanding, examining and dealing with health behaviours and risk factors.

The value of adopting a “population” perspective in examining health behaviours and designing prevention strategies has been emphasised. At the same time, you had an opportunity to contrast an individual with a population approach to risk factors.

We hope that you are familiar with the main elements or characteristics of a “population perspective”, and could describe various ways to understand this approach, and apply the insights gained to the design of particularly preventive interventions.

Unit 2 - Session 3

How Society Influences Individual Health

Introduction

This session will summarise the concepts that have been discussed in the preceding two sessions and show how these concepts are being adopted by epidemiologists in new paradigms of analysis.

Session contents

1. Learning outcomes of this session
2. Readings
3. Population level determinants that influence health outcomes
4. Integrating population level determinants into epidemiological models
5. Summary

Timing

There are two tasks and two readings in this session.

1LEARNING OUTCOMES OF THIS SESSION

By the end of this session you should be able to,

• List the possible mechanisms through which population effects may influence individual health outcomes.
• Describe how epidemiologists are trying to incorporate population level analysis with individual level analysis in explaining changes in health status.

2READINGS

Author/s /

Reference details

Cassel, J. / (1995). The Contribution of the Social Environment to Host Resistance. American Journal of Epidemiology, 141 (9): 798-813.
Pearce, N. / (May 1996). Traditional epidemiology, modern epidemiology and public health American Journal of Public Health, 86 (5): 678-683.

3POPULATION LEVEL DETERMINANTS THAT INFLUENCE HEALTH OUTCOMES

John Cassel was a South African epidemiologist who moved to the United States and became a leading thinker in the field. In a seminal lecture he gave in 1976 (reprinted in the reading below), he stated that “the question facing epidemiological inquiry is, are there categories or classes of environmental factors that are capable of changing human resistance in important ways and making sub-sets of people more or less susceptible to ubiquitous agents in our environment?”.