Definition
Social Epidemiology has been defined as the branch of epidemiology that studies the social
distribution and social determinants of health (Berkman and Kawachi 2000).
In this broad sense, all epidemiology is social epidemiology (Kaufman and Cooper 1999) with
perhaps the latter discipline making explicit the analysis of the social determinants of
Health .
Social epidemiology builds and expands by posing new research questions, utilising new
research methods and influencing government policy agenda.
History:
In 1674 john Graunut set out to understand who was dying during outbreaks
1863 Loius rene villerme recognise elevated level of illness that appeared work related ,
thus identifying social class & work condition as the crucial determinants of of health &
diseases.
1800 physician & other argued that bad air & emanation from decaying matter cause
outbreak of cholera , observing that death were commonly clustered among poor
1830 john snow ,who methodically covered the street of London collecting statistics
documenting the location of outbreak. Snow identified that contaminated water from
communal pumps s the source of cholera.
1844 Freidrich engels a german social scientist further described the working condition of
factory worker in England , Engles witnessed the horrible working condition & identified the
relationship between these condition & disease.
1860 Germ theory identifies single causal agent such as salmonella typhi as the cause of
disease.
By the 1950 -60 chronic disease were more frequent particularly in developed country
where infectious diseases are controlled , now clinician & epidemiologist monitoring these
condition to understand the chronic disease caused by combination of biological social
behaviour patterns.
This new branch of epidemiology focussed on the health impact of social condition & social
status as the key determinants of morbidity & mortality emerged in the 1960 -70.
By the end of 20th century the concept of social causation of disease gained traction
The range of problems studied by social epidemiologists includes such questions as whether
neighbourhood contexts can affect health, or workplace organization, or income inequality
and social cohesion .
Goal of social epidemiology
is to conceptualize, operationalize and test the associations between aspects of the social
environment (families, workplaces, residential neighbourhoods, the political economy) and
population
health.
Various factor at different levels that interact to influence health status
Various factor at different levels that interact to influence health status
Structural
social
individual
Legal structure
Social capital
Individual characteristics
Laws , law enforcement
Trust , norms
Age
Policy environment
Community
sex
Economic policy
Access to health care ,
race
Health & education policy
community group school &
disability
Agriculture ,transportation
work place instiution
psychosocial
Demographic changes
Cultural context
biolgy
Urbanisation ,
Belief , pattern of behaviour heredity
migration.aging
Tradition
Behavior
Institution
Social network
Hygine
Government legislative
Social influence engagement Sexual activity
&judicial system
a
Diet & exercise
Access to resources
Care practices
Support
Socioeconomic position
Physical environment
Income
Weather natural resources
Education
hazzards
occupation
Theories of social epidemiology in the 21st century ecosocial prospective
In social epidemiology the three main theoretical framework for explaining disease
distribution are
(1) psychosocial
(2) social production of disesase/political economy of health
(3) ecosocial & other emerging multi level frameworks.
A psychosocial framework direct attention to endogenous biological response to human
interaction.
a social production of disease / political economy of health framework explicitly address
economic & political determinants of health & disease but leave biology opaqae;
ecosocial & other emerging multi level frameworks seek to integrate social biological
reasoning & a dynamic, historical & ecological prospective to develop new insight into
determinants of population distribution of disease & social ineqilities in health.
To gain clarity on causes & barrier to reducing social ineqilities in health , social
epidemiologist will need to generate improved theoretical framework & necessary data to
test & refine them
Commission on social determinant of health : closing the gap in generation
The commissioner overreaching recommendation:
1. Improve daily living condition- the circumstances in which people are born, grow, live,
work, and age
2. Tackle the inequitable distribution of power money & resources : the structural
drivers of the conditions of daily life globally, nationally, and locally
3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that
is trained in the social determinants of health, and raise public awareness about the social
determinants of health
1. Improve daily living condition
Improve the well-being of girls and women and the circumstances in which their children
are born, put majoremphasis on early child development and education for girls and boys,
improve living and working conditions and create social protection policy supportive of all,
and create conditions for a flourishing older life. Policies to achieve these goals will involve
civil society, governments, and global institutions
1.1 Equity from start


What must be done
Commit & implement a comprehensive approach to early life building on existing
child survival programms & extending intervention in early life to include social
emotional & language /cognitive development
Expand the provision & scope of education to nclude the principl of early child
development (physical social emotional & language.
1.2 Healthy places healthy people
What must be done



Place health & health equity at the heart of urban governance & planning
Promote health equity between rural & urban areas through sustained investment in
rural development
Ensure that economic & social policy responses to climate change & other
environmental degradation take into account health equity.
1.3 Fair employment decent work
What must be done
 Make full & fair employment & decent work a central goal of national &
international social & economic policy.
 Achieving health equity requires safe ,secure & fairly paid work year round work
opportunities & healthy work balance for all
 Improve the working condition for all worker to reduce their exposure to material
hazard , work related stress & health damaging behaviour
1.4 Social protection across life course
What must be done
 Establish & strengthen universal comprehensive social protection policies that
supports a level of Income sufficient for healthy living.
 Ensure social protection to those normally excluded .
1.5 Universal health care
What must be done
 Build health care system based on principles of equity , disease prevention & health
promotion
 Ensure that health care system financing is equitable .
 Build & strengthen the health workforce & expand capabilities to act on the social
determinant of health
2. Tackle the inequitable distribution of power money & resources the structural drivers of
the conditions of daily life globally, nationally, and locally
In order to address health inequities, and inequitable conditions of daily living, it is
necessary to address inequities – such as those between men and women – in the way
society is organized. This requires a strong public sector that is committed, capable, and
adequately financed. To achieve that requires more than strengthened government – it
requires strengthened governance: legitimacy, space, and support for civil society, for an
accountable private sector, and for people across society to agree public interests and
reinvest in the value of collective action. In a globalized world, the need for governance
dedicated to equity applies equally from the community level to global institutions
2.1 Health equity in all policy system programmes
What must be done?
Place responsibility for action on health & health equity at the highest level of goverance &
ensure its coherent consideration across all policies
Adopt a social determinant framework across the policy & programmatic function of the
ministry of health & strengthen in stewardship role in supporting a social determinants
approach across government
2.2 Fair financing
What must be done
Strengthen public finance for action on the social determinants of health
Increase international finance for heath equity & coordinate increased finance through
social determinants of health action framework.
Fairly allocate government resources for action on the social determinant of health.
2.3 Gender equity
What must be done
Address gender biases in the structures of society –in laws & their inforcement in the way
organisation are run & intervention designed .
Develop finance policies & programme that closes gaps in education & skills & that support
female economic participation .
Increase investment in sexual & reproductive health services & programme building to
universal coverage & right .
2.4 Political empowerment- inclusion of voice
What must be done
Empower all group of society through fair representation in decision making & how society
operates particularly in relation to its effect on health equity .
Enable civil society to organise & act in a mathat promotes & realize the political & social
right affectin g health equity .
2.5 Good global governance
What must be done
Make health equity global development goal & adopt a social determinant of health
framework to strengthen multilateral action for development .
Strengthen WHO leadership in global action on the social determinant of health
institutionalizing social determinants of health as a guideline principle across WHO
department
Measure and Understand the Problem and Assess the Impact of Action
Acknowledging that there is a problem, and ensuring that health inequity is measured –
within countries and globally – is a vital platform for action. National governments and
international organizations, supported by WHO, should set up national and global health
equity surveillance systems for routine monitoring of health inequity and the social
determinants of health and should evaluate the health equity impact of policy and action.
Creating the organizational space and capacity to act effectively on health inequity requires
investment in training of policy-makers and health practitioners and public understanding of
social determinants of health. It also requires a stronger focus on social determinants in
public health research
3.1 The Social Determinants of Health: Monitoring, Research, and Training
Ensure that routine monitoring systems for health equity and the social determinants of
health are in place, locally, nationally, and internationally.
Invest in generating and sharing new evidence on the ways in which social determinants
influence
population health and health equity and on the effectiveness of measures to reduce health
inequities through action on social determinants.
Provide training on the social determinants of health to policy actors, stakeholders, and
practitioners and invest in raising public awareness .
How society affect health: area of research
The social determinants of health:
Health behaviours
Material, economic and political determinants of health:
Life course
Social biology
General susceptibility of disease
Social support
Social disorganisation
Work stress
Depression & affective disorder
The social determinants of health:
People from better social environments with greater access to socio-economic resources
are likely to have better health.
Supporting this view, social inequalities in health have been documented for most countries.
The influences of the social structure operate via three main pathways- material factors,
work and the social environment
Health behaviours
People from lower socio-economic groups are more likely to smoke, drink alcohol
excessively, have less physical exercise and unhealthier diets. It is likely that such
unhealthy behaviours form part of the pathways underlying social inequalities in health.
Material, economic and political determinants of health:
Chadwick (Flinn 1965) wrote about how overcrowding, damp and filthy living conditions
contributed to the lower life expectancy of working class men. In 1848, partly through fear
of cholera
and partly through pressure from Chadwick, the British parliament passed the first Public
Health Act. This, in addition to the pioneering work of the epidemiologist John
Snow (Snow 1855), set in motion the public health movement in 19th century Britain which
saw improvements in housing, sewage and drainage, water supply and
contagious diseases and provided Britain with the most extensive public health system in
the world .
Life course :
The study of long term effects of physical and social exposures during gestation, childhood,
adolescence, young adulthood and later adult life on the risk of chronic disease has been
defined as a life course approach to chronic disease epidemiology (Ben-Shlomo and Kuh
2002). The first is a latency model of early life experiences which hypothesises that
experiences in utero and early life affect cardiovascular disease in adulthood (Barker 1991,
Barker 1997). Barker found evidence that birthweight and other indicators of fetal growth in
the newborn are related to fibrinogen and insulin resistance fifty years later. He also found
that birthweight is related to functioning of the hypothalamic-pituitary-adrenal axis. Low
birthweight is associated with poorer childhood health which some researchers have linked
to lower social position in adulthood (Illsley 1986). This evidence suggests that
a short term exposure in utero can have a long latency period with adverse health and social
consequences in adulthood.
Social biology :
Psychosocial factors may affect health in two distinct ways- they may directly cause
biological changes which predispose to disease, or they may, indirectly, influence
behaviours such as smoking and diet, which in turn affects health (Brunner 2000).
General susceptibility to disease:
research from social biology shows that some stressful experiences activate multiple
hormones, affecting multiple systems and potentially producing wide-ranging organ
damage. The cumulative experience of stress may affect a variety of chronic and infectious
diseases through neuroendocrine-mediated biological pathways.
Social support :
Durkheim investigated the links between social integration and suicide. He explained suicide
in terms of social dynamics, arguing that suicide is not an isolated individual tragedy but a
reflection of social conditions such as the lack of attachment and regulation in society .
Bowlby (Bowlby 1969) who argued that marriage is the adult equivalent of childhood
attachment between mother and child. Secure attachment, whether interms of parent-child
or marital relationships, provides for successful and healthydevelopment. Men who have
never married or have recently divorced have a significantly greater risk of dying from both
cardiovascular and non-cardiovasculardiseases than married men (Ebrahim et al 1995)
Social disorganisation: Social scientists have puzzled over why some societies seem to
prosper, possess effective political institutions and have better health outcomes compared
to other societies. A cohesive society has greater amounts of social capital (higher levels of
interpersonal trust, reciprocity and mutual aid) than a disorganised society.
Work stress: There are two dominant models of work stress . The first, the job strain model
is based on the concepts of job control and demands (Karasek et al 1981).
Workers with low levels of job control and high levels of demand are said to have high levels
of job strain (or work stress). Job control (or decision latitude) consists of
whether or not workers are able to utilise and develop skills (skill discretion) and their
authority over decisions. Job demands consist of qualitative emotional demands as
well as quantitative demands specifying output per unit of time. Prolonged and repeated
exposure to job strain is hypothesised to increase sympathadrenal arousal anddecrease the
body’s ability to restore and repair tissues which in turn affects health.
Depression and affective states:
Another set of psychological pathways by which social conditions may affect health is
through emotions and the physiological, cognitive and behavioural responses they
evoke.. Emotions can be considered as products of stress as well as mediators of its effects
thus representing acrucial link in the chain of causation from social stressors to individual
biological responses .
Research Method in social epidemiology
1. Applying a population perspective Applying the population perspective into
epidemiological research means asking “why does this population have this
particular distribution of risk factors”, in addition to asking “why did a particular
individual get sick?
2. Better measures of exposures In attempting to understand the social determinants
of health, research into social epidemiology has pioneered the use of better
measures of the social structure.
3. Better measure of health : Research in social epidemiology does not just focus on
clinically measured disease outcomes because the absence of disease is not
sufficient for health. Rather, one of the main focuses of social epidemiological
research is the use of health related quality of life measures as valid measures of
health outcomes
4. Better measures of the association between the social Structure and health : As
different measures of the social structure may have different pathways to different
health outcomes, the reduction of such differences into a single regression model
may obscure rather than elucidate the pathways underlying the social determinants
of health.
5. Analysing population surveys, birth cohorts : One of the defining characteristics of
research methods in social epidemiology is the use of population representative
sample surveys in analysing the social determinants of health. Research in social
epidemiology tends to use non-experimental observational studies, both cross
sectional and longitudinal.
References:
1. Chanola Tarani, Marmot Micheal :social epidemiology , Dept of Epidemiology &
public health , University college London
2. Kriger Nancy International journal of epidemiology 2001:30: 668-667
3. Commission on social determinant of health 2008: final Report World Health
Organisation
4. Candace Miller , Chapter 2 , social epidemiology Jones & Bartlett Publisher
5. Equity Social Determinant & Public Health Programme: World Health Organisation
2010
6. Eric Blas , Social Determinants Approach to Public Health , from concept to practice