+ Social Determinants of Health Lan Doan H671 Advance d Theories of Health Behavior January 28, 2016

+ Outline  Translating Social Ecologic Theory (Stokols)  Social Ecological Theory Guidelines  Wiist example  Promise Neighborhood Initiative (Komro et al.)  Summary of the framework  Summary of the key outcomes  Activity: How it relates to the TTI  Social determinants (Marmot)  Future Steps towards Health Equity  Iconography

+ Approaches to Community Health Promotion  Health Protection  Health Promotion  Community Health Promotion

+ Behavioral Change Strategies  Interventions can focus on modifying single patterns or replacement of unhealthy lifestyles with healthier ones  Social Influence = guiding theory o Cognitive + mediated behavior change o Affective changes o Behavioral modification  Limitations o Economic, social and cultural constraints o Person is not motivated o Exposure to environmental and safety hazards

+ Environmental Change Strategies  Health-related functions of the environment: o Medium for disease transmission o Operate as a stressor o Function as a source of safety or danger o Serve as an enabler of health behavior o Serve as a provider of health resources  Strengths o Benefits everyone exposed in the environment o Passive interventions  Limitations o Only focused on one component of the environment o Analysis doesn’t include behavioral patterns or sociodemographics

+ Social Ecological Models of Health Promotion: Core Principles 1. Characterizes environments as having multiple physical, social, and cultural dimensions that influence health outcome 2. Human health is influenced by personal attributes 3. Systems theory used to understand dynamic relationships between people and environments. 4. Interdependence of environments within certain settings and interconnections between multiple settings and life domains 5. Interdisciplinary approaches

+ Social Ecological Models: Strengths & Limitations  Strengths: o Integrates behavioral and environmentally based health promotion strategies o Two or more analytic levels of health problems and interventions o Integrates problem theories and intervention theories o Use of passive and active interventions  Limitations:  Logistical complexities  Overly inclusive

+ Translation of Social Ecologic Theory into Practice 1. Examine the multifaceted nature of environmental influence on well-being. 2. Consider joint influence of intrapersonal and environmental conditions on individual and community well-being. 3. Develop programs that enhance the fit between people and their surroundings.

+ Translation of Social Ecologic Theory into Practice 4. Focus interventions on high-impact behavioral and organizational leverage points.  Personal vs. other-directed health behavior  High-impact roles in corporations and institutional settings 5. Design programs that address interdependencies between the physical and social environment and encompass multiple settings and life domains. 6. Integrate multidisciplinary perspectives in program design and use multiple methods to gauge scientific and social validity of interventions.

+ Movements where health promotion has been involved Anticorporate movement Green movement Organic movement

+ Epi + demos + cracy Transition to capitalism Neoliberal restructuring Welfare state Political incorporation of subordinated groups

+ Policy Development and Advocacy What is the role of policy in public health? How are political systems important? What is their role? Is there a role for public health practitioners in advocacy?

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+ Promoting Child Health & Development within High-Poverty Neighborhoods (Komro et al.) Promise Neighborhoods Initiative Promise Neighborhoods Research Consortium Purpose was to present (1) a framework defining child and adolescent developmental outcomes and (2) an intervention template to increase nurturing environments

The Harlem Children's Zone

+ Harlem Children’s Zone Network and Strategies: n Parenting classes n Pre-kindergarten programs n Charter schools n Afterschool programs n Transition to college n Tenant and block associations (Komro, Flay, & Biglan, 2011)

+ Harlem Children’s Zone

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+ Promise Neighborhoods HCZ funded these neighborhoods and communities working to improve the outcomes of children living within distressed neighborhoods will benefit from assistance in framing, selecting, and implementing evidence-based and efficient strategies. (Komro, Flay, & Biglan, 2011)

+ Creating Nurturing Environments Framework

+ Key Development Outcomes

+ Six Domains of Influence Proximal (Immediate) Influences Family School Peers Distal (Background) Influences Income and resources Social cohesion Physical environment

+ Group Activity Please divide into 3 groups Group 1: family influences and school influences Group 2: peer influences and income and resources Group 3: social cohesion and physical environment How do the various aspects of the proximal and distal influences relate to the TTI? Keep note of the path numbers from the model

24 DECISIONS/INTENTIONS SOCIAL S ITUATION BIOLOGY/ P ERSONALITY THE THEORY OF TRIADIC INFLUENCE ATTITUDES TOWARD THE BEHAVIOR CULTURAL E NVIRONMENT SOCIAL NORMATIVE BELIEFS Trial Behavior EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological SELF-EFFICACY BEHAVIORAL CONTROL Nurture/CulturalBiological/Nature Intrapersonal StreamSocial/Normative StreamCultural/Attitudinal Stream Values/ Evaluations Knowledge/ Expectancies Perceived Norms Information/ Opportunities Interpersonal Bonding Social Competence Interactions w/ Social Instit’s Others’ Beh & Atts Motivation to Comply Skills: Social+General Sense of Self/Control Self Determination Distal Influences Proximal Predictors Levels of Causation Ultimate Causes Social/ Personal Nexus Expectancies & Evaluations Affect and Cognitions Decisions Experiences

Social Determinants

+ (Beckfield and Krieger, 2009) “Contextual factors such as political systems and government policies drive population health and health inequities.”

+ Social Determinants In addition to political systems: Economic systems Social institutions (public schooling, Medicare) Physical Environment (built environment) Social Environment (culture, war, racism)

+ Social Determinants And of course, these can work in tandem. Hurricane Katrina, 2005

+ Health Inequity Also called health disparity Social determinants create inequities because populations are effected differently We can see this both on a local and global scale

+ Health Inequity on a Global Scale

+ Food Deserts Source: USDA Food Atlas, 2012

+ Poverty Source: USDA Food Atlas, 2012

+ Food Assistance Source: USDA Food Atlas, 2012

+ Activity Level Source: USDA Food Atlas, 2012

+ Health Outcomes Source: USDA Food Atlas, 2012

+ Closing the Gap – the move toward health equity Population level interventions Challenge: Where is our focus?

+ Closing the health gap in a generation (Marmot et el.) Problem: Unequal distribution of power, income, goods, services, globally and nationally resulting in health inequities Three principles of action: Improve the conditions of daily life Tackle the inequitable distribution of power, money, and resources Understand the problem and evaluate action

+ Improving Daily Life Conditions Equity from the start Urban governance and planning Employment conditions and nature of work Social protection throughout life Universal health care

+ Tackle Inequity of Power, Money, and Resources Coordinated action across government (policies, systems, programs) towards health equity Publicly financed infrastructure Market responsibility Gender equity Political empowerment System of global governance

+ Understand the problem and evaluate action International cooperation on health-equity surveillance systems Routine on-going monitoring of health inequities On-going tracking of social determinants Evaluation of interventions Use of evidence-based interventions Assess health-equity impact of policy changes and interventions

+ Creating the organizational space and capacity to act effectively on health inequity requires: Investment in training of policy makers and health practitioners, Public understanding of social determinants of health, and A stronger focus on social determinants in public health research.

+ Are these realistic goals???

(A) Pyramid of capitalist system. N Krieger J Epidemiol Community Health 2008;62: ©2008 by BMJ Publishing Group Ltd

N Krieger J Epidemiol Community Health 2008;62: ©2008 by BMJ Publishing Group Ltd

N Krieger J Epidemiol Community Health 2008;62: ©2008 by BMJ Publishing Group Ltd

N Krieger J Epidemiol Community Health 2008;62: ©2008 by BMJ Publishing Group Ltd

Levels of Causation for Health Interventions from McKinlay & Marceau (2000). Public health matters. Am J Pub Hlth, 90, 25-33, p. 29. Levels of Causation Organization & Community Interventions Environmental Influences Social Position Social & Cultural Processes Psychological Processes Biological & Genetic Factors Primary & Secondary Prevention Primary & Secondary Prevention / Treatment Healthy Public Policy

+ Any Questions?