Managerial Epidemiology
Helpm31990
51589_PPTx_CH15.pptxChapter 15
Social, Behavioral, and Pychosocial Epidemiology
Learning Objectives
Define the terms social epidemiology, behavioral epidemiology, and psychosocial epidemiology
State the role of psychological, behavioral, and social factors in health and disease
Discuss the stress concept as a hypothesized determinant of disease
Define social incongruity, person-environment fit, and stressful life events
Learning Objectives (cont’d)
Discuss moderators of the stress-illness relationship
State outcomes of exposure to stress
Introduction
This chapter explores a rich tradition of epidemiologic theory and research: the role of psychological, behavioral, and social determinants of health and illness.
These determinants includes aspects of the individual’s personality, social factors enmeshed in the fabric of society, and cultural influences.
Social Epidemiology: Definitions
Concerned with the influence of a person’s position in the social structure upon the development of disease (Syme, 1974)
“ . . . the branch of epidemiology that studies the social distribution and social determinants of states of health.” (Berkman, Kawachi, 2000)
Behavioral Epidemiology
Studies the role of behavioral factors in health
Examples of behavioral factors are tobacco use, physical activity, risky sexual behavior, and consumption of unhealthful foods.
Behavioral Medicine
Related to behavioral epidemiology
Emphasizes the application of behavioral factors to specific clinical interventions, e.g., biobehavioral approaches to management of hypertension
Biobehavioral approaches include nonpharmacologic treatment methods, e.g., exercise, maintenance of desirable weight, changes in diet, and meditation.
Psychosocial Epidemiology
Defined as “of relating to the interrelation of social factors and individual thought and behavior.” (Oxford College Dictionary)
Broadly conceptualized term that examines the influence of psychosocial influences on health.
Psychosocial epidemiology often is used as a synonym for social epidemiology.
Topics Covered in the Field
Stress and stressful life events
Personality factors
Culture
Personal behavior
Social support
Mental and physical health status (linked to psychological, social, and behavioral factors)
Guide to Psychosocial Epidemiology
Types of Variables
Independent variables (also referred to as exposure or risk factor variables) — a hypothesized causal factor in a model
Moderating (Intervening) variables —intermediate variables in the causal process between independent and outcome variables
Dependent variables — outcome variables in a model; independent variables affect or influence dependent variables (via the pathway of moderating variables)
Multiple Causation
This concept is defined as “. . . a given health state or health-related process may have more than once cause. A combination of causes or alternative combination of diseases is often required to produce the health outcome.” (Porta, 2008)
Research Designs
Studies used in this field of investigation:
Case-control
Cohort
Cross-sectional
Needed are more:
Longitudinal, prospective studies
Studies of women and minority groups
Valid and operationalized measures
Example of Longitudinal, Prospective Study
The Early Stages of Psychopathology Study followed 3,021 adolescent and young adult residents of Munich, Germany.
Begun in 1994-95, subjects were followed up on average after a 42-month interval.
Incidence of mental disorders was examined.
Community-Based Participatory Research (CBPR)
A method relevant to psychological and social epidemiologic studies
Viewed as an alliance between community organizations and research units in order to investigate health-related issues of interest to the community
Results in the eventual training and empowerment of community organizations to conduct their own independent research projects that address their unique needs
Social Context of Health
The social environment contributes to the regulation of psychosocial influences upon health.
Example:
Scotland has higher mortality than England and other European countries.
Scottish effect
Glasgow effect
Social Context of Health and International Comparisons
The social environment impacts the health of residents of both the less developed and more developed worlds.
Example: In less-developed areas, overcrowding, poor living conditions, and lack of preventive health care promote spread of infectious diseases.
Global Burden of Disease Study
Assesses the worldwide consequences of disease.
The disability-adjusted life year (DALY) combines information on mortality with information on morbidity for specific causes.
Lower respiratory infections: leading cause of global DALYs.
The Whitehall Study
First Whitehall Study
Initiated in 1967, and included18,000 men in the British Civil Services
Discovered a higher likelihood of premature death among the lowest employment grades
Whitehall II Study
Began in 1985, and included 10,308 nonindustrial civil servants from 35 to 55 years of age
Contributed significantly to “. . .the importance of psychosocial factors such as work stress, unfairness, and work-family conflict to socio-economic inequalities.”
Independent Variables
General concepts of stress
Social incongruity theory
Person-environment fit
Stressful life events
Stress process model
General Concepts of Stress
Psychological stress is “…a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being.” (Lazarus, 1984)
Societal structures, interpersonal processes, and the individual’s physiological, cognitive, and other responses relate to the distribution of stress.
Homeostatic Regulatory Mechanisms
Homeostasis--tendency toward stable equilibrium among physiological processes
Allostasis--“...how the organism achieves stability (or homeostasis) through continual change.”
Allostatic load—“the consequences of sustained activation of primary regulatory mechanisms serving allostasis over time”
General Concepts of Stress: Walter Canon
Canon studied changes in gastrointestinal function accompanying stressful events.
General Concepts: Selye
Selye proposed that stress is a change in the environment of the organism.
General adaptation syndrome specified three stages of response to stress:
alarm reaction
stage of resistance
stage of exhaustion
General adaptation syndrome is associated with corticoid secretion.
General Concepts: Crider
Crider proposed that adverse environmental events produce stress. Examples:
noxious stimuli
removal of reinforcement
conflict situation
The executive monkey experiments demonstrated physiological effects (e.g., gastric ulcers) associated with stress.
Social Incongruity Theory
The guiding hypothesis is that either social mobility or status incongruity may be associated with morbidity.
Themes of research are correlates of changes in residence; intragenerational mobility; husband-wife discrepancy in status.
Social Incongruity Theory (cont’d)
Cobb, et al. (1969) examined discrepancy between husband and wife in social and educational status as associated with rheumatoid arthritis.
Syme, et al. (1966) studied the association between cultural mobility and coronary heart disease.
Person-Environment Fit Model
“conceives of adjustment as the goodness of fit between the characteristics of the person and the properties of [his or her] environment.” (French, et al., 1974)
Lack of adjustment occurs when there are discrepancies between demands from the environment and supplies (resources) to meet those demands.
Stressful Life Events
Theory postulates that there is a relationship between the happenings in one’s life and the development of illness.
Two crucial issues of life events research are to:
determine which attributes distinguish more stressful from less stressful life events, and
refine the knowledge base regarding the pathologic effects of stressful life events.
Social Readjustment Rating Scale
Holmes and Rahe (1967) developed 43-item Social Readjustment Rating Scale.
Each item represented a life event.
The more severe the life change event and the higher the frequency of the event, the greater the chance that severe disease will occur.
Ten Leading Life Change Events
death of a spouse
divorce
marital separation
jail term
death of a close
family member
personal injury or
illness
marriage
being fired from a job
marital reconciliation
retirement
Pearlin’s Stress Process Model
Used as a guide for stress research
Stress: a process occurring over time.
Events chain from one another with interconnectedness among various factors:
Social and economic status
Life events and chronic strains
Moderating resources, e.g., coping skills
Stress outcomes, e.g., mental disorders
Moderating Factors in the Stress-Illness Relationship
Type A behavior pattern
Personal behavior, lifestyle, and health
Social support
Type A (Coronary-Prone) Behavior Pattern
Found to be associated with CHD
Characteristics include aggressiveness, ambition, drive, competitiveness, and time urgency.
Interview measure and self-administered measure of Type A are used.
Social Support
Refers to perceived emotional support that one receives from social relationships
Operates as mediator--buffers against stress
May enhance immune status
Lack of social support may contribute to onset and severity of psychological stress.
Social Networks
Quantitative concept that refers to the number (and patterns) of ties that one has with other people and organizations
May serve to lessen the adverse psychological consequences of stress and reduce levels of depression
Social network websites, such as Facebook
The Buffering Model of Social Support
Marital status is important in the social support process.
Increased social contact is associated with increased emotional support and perceptions of support availability.
Interpersonal relationships provide a stress-buffering effect when there is concordance between coping requirements demanded by a particular stressor and specific types of support provided.
Personal Behavior, Lifestyle, and Health
Risk taking
Dietary practices and exercise levels
Smoking
Alcohol consumption
The Alameda County Study (Breslow)
Seven healthful habits:
moderate food intake
eating regularly
eating breakfast
not smoking cigarettes
moderate or no use of alcohol
moderate exercise
7 to 8 hours of sleep daily
Healthy People 2020
“… a comprehensive set of disease prevention and health promotion objectives for the Nation…”
Related in part to lifestyle and health
Topic areas include nutrition, physical activity, obesity, substance abuse, and tobacco use.
Healthy People 2020
Four major overarching goals:
“Attain high quality, longer lives free of preventable disease, disability, injury, and premature death.”
“Achieve health equity, eliminate disparities, and improve the health of all groups.”
“Create social and physical environment that promote good health for all.”
“Promote quality of life, healthy development, and health behaviors across all life stages.”
Smoking and Health Surgeon General’s Report of 1964
Overall there is 70% excess morbidity among smokers compared with nonsmokers.
Mortality from smoking increases with quantity of cigarettes smoked.
Association between smoking and cardiovascular diseases, cancer, pulmonary diseases, peptic ulcer disease
Smoking and Health The 2004 Surgeon General’s Report
Identified an increased number of diseases associated with smoking
Alcohol Consumption
Over-consumption is a leading cause of preventable death.
Excessive consumption is a risk factor for cirrhosis, peptic ulcers, gastritis.
Leading cause of death in 12-20 age group:
Unintentional injury
Homicide
suicide
Deterioration of family environment and job loss
Fetal alcohol syndrome
Dietary Practices
Consumption of refined carbohydrate foods is associated with obesity and diabetes.
Lack of dietary fiber related to diseases of the bowel.
Consumption of saturated fats and cholesterol associated with arteriosclerosis and heart disease.
Sedentary Lifestyle
Risk factor for CHD and other conditions.
Morris, et al. (1973) found vigorous exercise, not light exercise, reduced incidence of CHD.
Paffenbarger, et al. (1978) corroborated findings for vigorous exercise.
Sociocultural Influences on Health
Culture is defined as the set of values to which a group of people subscribes, as the way of life of a group of people, or as the totality of what is learned and shared through interaction of the members of a society.
CHD in Japanese Men: Marmot, et al. (1975)
Compared CHD rates among men of Japanese ancestry living in Japan, Honolulu, and San Francisco.
Rates lowest in Japan, highest in San Francisco, intermediate in Honolulu.
Possibly due to variations between the two countries in terms of diet, occupation, and the social and cultural milieu.
Utilization of Health Services
Preference for health care services varies according to cultural background.
Persons from traditional cultures may prefer folk medicine and family care.
Persons from more developed societies may prefer technologically advanced medical services.
Dependent (Outcome) Variables
These include physical health, mental health, and affective states.
Some topics covered are:
Life and job dissatisfaction
Mental health and stressors
Premorbid psychological factors and cancer
Personality and smoking
Psychosocial aspects of employment
Life and Job Dissatisfaction
“The hypothesis that life dissatisfaction is a risk factor for coronary disease is a promising one and deserved careful examination in prospective studies.” (Jenkins, 1971)
Sales and House (1971) demonstrated a strong negative correlation between job satisfaction and coronary disease death rates.
Life and Job Dissatisfaction (cont’d)
Tedious work, feeling ill at ease at work, lack of recognition, difficulties with coworkers, demotion, and prolonged emotional strain associated with work overload have been shown to be related to coronary disease.
Mental Health and Stressors
Epidemiologic research has examined psychological disorders and affective states as outcomes of stress-illness paradigm.
Psychological disorders: posttraumatic stress disorder and major depression
Affective states: depressive symptoms
Depression: Frerichs, et al. (1982)
Prevalence of depression in a representative sample of adults in Los Angeles County was 19%.
Rates of depression among women higher than men (23.5% vs. 12.9%).
Depressed persons reported more physical illness than nondepressed.
Premorbid Psychological Factors and Cancer
Fox (1978)--two major personality types at increased risk of cancer:
Yielding, compliant, eager to please.
Extroverted, nonneurotic individuals who tend toward heaviness.
Fox’s 1995 review showed contradictory findings regarding psychologic variables and cancer.
Effects of Major Diseases on Personality
Severe illness may bring about personality changes in the individual, spouse, children, and coworkers.
Wives of heart attack victims experience depression, fear, anxiety, and guilt.
Heart attack victims may experience similar feelings.
Personality and Smoking: Surgeon General’s Report (1979)
Personality factors related to smoking behavior may include extroversion, neuroticism, antisocial tendencies, and belief that one is externally controlled.
Smokers may show greater risk-taking, impulsiveness, and interest in sex.
Habitual Mental Outlook and Health Status
Habitual mental outlook includes mental health, adult adjustment, cheerfulness, and sense of humor.
Valliant (1979) demonstrated association between good mental health and physical health.
Results of other studies inconsistent.
Psychosocial Aspects of Employment and Health
Stresses and other psychological aspects of the work environment represent an important area of investigation for occupation health epidemiologists.
Examples of topics examined in research include CHD, job stresses and absenteeism due to infectious and chronic diseases, shift work and physical and mental health, and health effects of physical activity at work.
