Nancy Krieger Clarice Amorim “Proximal, Distal, and the Politics of Causation: What’s Level Got to Do With It?” Nancy Krieger Clarice Amorim

Levels of Causation in Public Health Proximal vs. Distal Downstream vs. Upstream Risk factors and Determinants Levels / Multilevel

“Although notions of proximal, distal, and level all matter for elucidating causal pathways, clear thinking […] is distorted by conflating measures of space, time, level, and causal strength. When it comes to causation, it is one thing to think about near and far in relation to space and time; it is another matter entirely to do so for levels.”

Spatiotemporal Scales The terms “proximal” and “distal” were originally used to describe anatomical location and distance, as measured on a spatial scale. These terms primed to develop new meanings the moment time entered the picture; temporal events are described in spatial terms. It was a short step to equate distance (in time or space) with causal strength. In causal hierarchies, “closeness” and “distance” can only be measured conceptually.

Mutually Exclusive Causes? “In the instant of a muscle contraction, both proximal and distal causes were at play.” HOW muscles contract WHY muscles contract Explanations exist across levels and involve the distant past and the immediate present

Web of Causation Proximal factors operate directly on or within the body. These are also “easier” to address. All exposures are on a single plane. Where are “power” and “injustice? Distal factors exert their influence through proximal factors. These require societal change.

Social Determinants of Health Cumulative exposures Disease triggers Where are “power” and “injustice?

Levels coexist simultaneously! Ecosocial Approach Combustible mass of tobacco leaves and additives whose burning transports nicotine and carcinogens into one’s body, increasing the risk for cancer and other chronic diseases. Highly profitable product whose production, distribution, advertisement, and consumption involves relentless corporate marketing, government regulation and taxation, famers and farmworkers, trade agreements and international treaties. Levels coexist simultaneously!

Ecosocial Approach Economic, political, and social relationships affect how people live; therefore, the social distribution of health cannot be divorced from political economy and political ecology. Power drives inequities in health; it does not directly translate into “proximal” or “distal” and does not neatly partition across “levels”.

Ecosocial Approach

Core Constructs Embodiment: people incorporate biologically the material and social world in which they live. Pathways of embodiment: involve exposure, susceptibility, and resistance structured by societal arrangements of power and constraints in our biology. Cumulative interplay: exposure, susceptibility, and resistance interplay on multiple levels and domains, across time and space. Accountability and agency: who and what are responsible for social inequities in health. Analytic implications and predictions: determinants of disease distribution are not reducible to mechanisms of disease causation.

THE THEORY OF TRIADIC INFLUENCE Distal Influences Proximal Predictors Levels of Causation Ultimate Causes Social/ Personal Nexus Expectancies & Evaluations Affect and Cognitions Decisions Experiences Intrapersonal Stream Social/Normative Stream Cultural/Attitudinal Stream Biological/Nature Nurture/Cultural BIOLOGY/ PERSONALITY SOCIAL SITUATION CULTURAL ENVIRONMENT 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 1 2 3 7 8 9 10 11 12 13 14 15 16 17 18 l 4 5 6 a b c d e f C F I B E H A D G g h i j k m n o p q r s t u v w x SELF-EFFICACY BEHAVIORAL CONTROL SOCIAL NORMATIVE BELIEFS ATTITUDES TOWARD THE BEHAVIOR 19 20 21 22 23 DECISIONS/INTENTIONS Trial Behavior EXPERIENCES: Expectancies -- Social Reinforcements -- Psychological/Physiological Related Behaviors J K 13

Discussion Should researchers in the field of health promotion stop using the terms “proximal” and “distal”? In what ways can we make the role of power in driving health inequities more explicit?