1. Research Topics in Social Epidemiology Laura Rudkin, Ph.D. Division of Sociomedical Sciences Department of Preventive Medicine & Community Health

2. General Purposes of Epidemiology To describe To explain To predict To control

3. General Purposes of Social Epidemiology To describe social differentials in health outcomes. To explain the observed social differentials by identifying causal mechanisms. To predict how policy changes and psychosocial interventions might reduce the differentials. To control and improve population health.

4. Identifying, Investigating Social Differentials in Health Outcomes Social Factors SES Race/Ethnicity Gender Age, Life Course Place, Environment Health Outcomes Mortality Morbidity Disability Well-being

5. Identifying, Investigating Social Differentials in Health Outcomes Social Factors SES Race/Ethnicity Gender Age, Life Course Place, Environment Health Outcomes Mortality Morbidity Disability Well-being Health Behaviors Psychosocial Stressors and Resources Physical Environmental Stressors Health Care Access, Utilization, and Quality

6. Social Factors Socioeconomic status Education, income, occupation Wealth Childhood SES Community SES Social relationships Social support Social networks Social isolation Social engagement

7. Social Factors Occupational factors Demand-control Effort-reward imbalance Social inequalities Race, ethnicity Nativity status Gender Sexual orientation Religious belief, affiliation

8. Sources of Heterogeneity Reverse causality Selective drift Differential susceptibility Spurious relationship, third variable is causal Individual lifestyle Health-related behaviors

9. Sources of Heterogeneity Physical environment Harmful exposures to physical, chemical, biological agents Social environment & psychological response Stressors, social & coping resources Health care services Differential access, quality, utilization

10. Williams, 1997

11. Basic v. surface causes Basic causes Distal causes, also called fundamental causes Work through multiple pathways, affect multiple outcomes What puts people at risk for risk? Surface causes Proximal causes, traditional risk factors

12. FIGURE 1. Conceptual framework for the relation between socioeconomic position and health among persons with diabetes mellitus. Numbers and letters refer to pathways mentioned in the text. From: Brown: Epidemiol Rev, Volume 26(1).July 2004.63-77

13. FIGURE 2. Distal mediators and moderators of the relation between socioeconomic position and health behaviors, access to care, processes of care, and health among persons with diabetes mellitus. From: Brown: Epidemiol Rev, Volume 26(1).July 2004.63-77

14. Direct & Buffering Effects of Social Support STRESSOR APPRAISALCOPING HEALTH OUTCOMES SOCIAL SUPPORT Instrumental Emotional Informational Appraisal Stressors may activate social support Social support may reduce stressors Buffering effects Direct effect

15. Social Position Social Environment Social Interaction Perceptions of Injustice Negative Emotional Response High Allostatic Load Poor Health Outcomes Genetic Endowment Development Daily Life Personal Productive Societal  Social Structure

16. FIGURE 2. Upstream and downstream determinants of population health. Reprinted with permission from Promoting Health: Intervention Strategies from Social and Behavioral Research, by the National Academy of Sciences. Courtesy of the National Academies Press, Washington, DC. From: Kaplan: Epidemiol Rev, Volume 26(1).July 2004.124-135

17. Underlying Assumptions Biological, behavioral, social factors interact through multiple feedback mechanisms to influence individual health over time. Interactions often bidirectional, so cause-and- effect models, used alone, likely to misrepresent actual relationships.

18. Underlying Assumptions Because health is a function of biological, psychological, social variables, many events, interventions traditionally considered irrelevant actually are quite important for health status of individuals, populations.