Social epidemiology is a multidisciplinary area of research that incorporates aspects of sociology, psychology, biology, health, medicine, economics, and political science into the study of the health of individuals and populations. A variety of conceptual frameworks inform the study of social epidemiology including psychosocial, social production of disease, political economy, eco-epidemiology, social ecological, and ecosocial. While social epidemiologists initially used a stress adaptation or risk factor approach to identify characteristics that defined the health of individuals, researchers are now taking a broader look at the evolutionary, social, socioeconomic, political, and institutional policies that create inequalities in health within and among populations.
Keywords Eco-Epidemiology; Ecosocial Theory; Medical Sociology; Population Health; Psychosocial Theory; Social Epidemiology; Social Production of Disease; Social Ecological Systems
Social epidemiology explores the social phenomena that impact public health. According to Burris (2002), there is a clear distinction between social epidemiologists and others. He explains, "Whereas traditional epidemiologists are trained to ask the question, 'Why are some individuals healthy and others not?' the social epidemiologist is concerned with the question, 'Why are some societies healthy, while others are not?'" (p. 510). Indeed, the development of social epidemiology over the last half of the twentieth century marked a movement from a broad effort to understand social factors related to health toward a more focused study of the social inequalities in health, as they provide a framework for the improvement of population health (House, 2002). In studying the causes of health issues, Krieger (2001) suggests that it "raises not only complex philosophical issues but also…issues of accountability and agency…the central question becomes: who and what is responsible for population patterns of health, disease, and well-being as manifested in present, past and changing social inequalities in health?" (p. 668).
Research into social patterns that impact health, both positively and negatively, has led social epidemiologists to think outside the box of the biomedical establishment toward macroeconomic indicators such as economic development, poverty, unemployment, and the distribution of resources as well as social indicators such as social cohesion, social exhaustion, gender and racial/ethnic identity. These indicators are determinants of the conditions under which people live and work in order to maintain their health and that impact both daily life and health outcomes (Burris, 2002). Burris, Kawachi, and Sarat (2002) offer economic inequality as an example, stating it "can be seen as a characteristic of social groups at all levels of social organization, from the nation to the neighborhood, and at any level will owe a considerable proportion of its effect to the way it shapes the mundane details of individual interaction in everyday life" (p. 511).
For example, social epidemiology attempts to explain why populations with the same genetic background, lifestyle habits, and access to medical care have widespread variations in overall health. The NiHonSan Study of Japanese immigrants indicated that the subjects were more similar in their health to the people in the US than their Japanese counterparts in Japan (Marmot, Adelstein & Bulusu, 1984 as cited in Burris, Kawachi, and Sarat, 2002). Genetics played only a minor role, and lifestyle factors alone could not account for the differences. Burris, Kawachi, and Sarat (2002) state "one is forced to look toward societal factors to explain why Japanese have better health than Americans, despite smoking more and spending roughly half of what the United States does on medical care" (p. 510).
In the 1950s and early 1960s, critics, the medical community, and the general public regarded with skepticism the idea that social, psychological, and environmental factors played a key role in overall health. According to House (2002), "though not largely a product of social science research, the US Surgeon General's (1964) report on Smoking and Health gave great impetus to the idea that health and illness were products of individual and social behavior as well as biological processes" (p. 127). For the first time, a lifestyle choice such as smoking was identified as a major risk factor for disease and death. Over time, lifestyle choices such as smoking, drinking, exercising, and eating in moderation, to name a few, were accepted as risk factors for disease by the biomedical and scientific communities and by the public, and they have led to major public policy initiatives supporting health behaviors (DHHS, 1990 as cited in House, 2002). It is now widely accepted that poor health behaviors, lack of social relationships and supports, poor management of chronic stress, and a variety of psychological conditions are major risk factors for individual health (House, 2002).
More recently, researchers in the area of social epidemiology have turned their attention away from individual and toward population health issues. Kindig and Stoddart (2003) define population health as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group" (p. 380) and assert that the idea includes not only the health outcomes, but also the patterns of health determinants (risk factors) and the economic and social policies and interventions that impact them. According to Burris, Kawachi, and Sarat (2002), "social epidemiology has made a powerful case that health is determined…by social conditions, including the economy, law and culture. Indeed, at the level of populations, evidence suggests that these ‘structural’ factors are the predominant influences on health" (p. 510). House (2002) concurs, "the rediscovery over the past two decades of social inequalities…in health, especially by socioeconomic status and race/ethnicity…is important…because it provides, conceptually and empirically, a basis for a more integrated, parsimonious, and practically effective science of social factors in health (House, p. 133).
The field of social epidemiology and medical sociology developed rapidly during the second half the twentieth century. Physical health and illness during the 1950s were viewed simply as biological processes by the medical establishment. They were later understood as much more complex functions of social, psychological, and behavioral factors (House, 2002, p. 125). Contemporary social epidemiology is founded upon three theories. Krieger (2001) identifies them as:
• Social production of disease and/or political economy of health, and
• Ecosocial theory and related multi-level frameworks (p. 669).
Each attempts to explain the social inequalities in health; they differ in the emphasis each places on the myriad social and biological factors that shape the health of a population, in the integration of the social and biological factors present, and in their recommendations for further study and action (Krieger, p. 669).
The psychosocial conceptual framework with which social epidemiology is studied is based upon a model of stress and adaptation that emerged in the 1960s. The framework allowed for the study of the ways in which social and environmental conditions are perceived as stressful and how they then generate behavioral, psychological, and physiological responses. If they exist over a period of time, these responses may lead to chronic health behaviors that negatively impact health such as smoking, drinking, and substance abuse as well as mental and physical illness and, in extreme cases, death (French, Kahn, & Mann, 1962; Lazarus, 1966; McGrath, 1970; Levine & Scotch, 1970 as cited in House, 2002). The extent to which the stressor is viewed as stressful and the ways in which the stressor is responded to are moderated by existing social, psychological, and biological characteristics.
There are a number of identified psychosocial risk factors for health. According to House (2002), these are
• Social relationships and support;
• Acute or event-based stress;
• Chronic stress in work and life; and
• Psychological dispositions such as anger/hostility, lack of self-efficacy/control, and negative affect/hopelessness/pessimism, with new risk factors continuing to be identified (p. 125).
The presence of risk factors is considered within the context of the relationships among them, their causes, and consequences.
One area of application has been the persistent socioeconomic and racial/ethnic disparities in health. A person's socioeconomic position and ethnicity impact the individual's level of exposure to and experiencing of all of the psychosocial risk factors, as well as many of the environmental, biomedical, and genetic risk factors. According to House (2002), the exposure to these combined risk factors offers an explanation of the social disparities in health (p. 125). House posits that if the socioeconomic level of a wide array of disadvantaged members were improved, so would be their health. "This in turn requires better understanding of the macrosocial forces that influence the socioeconomic position of individuals" (House, 2002, p. 125).
In sum, a psychosocial framework focuses upon biological responses to human interactions, or on stress and stressed people in need of psychosocial resources. The framework accords less importance to the origin of the psychosocial risk factors and how their distribution is impacted by social, political, and economic policies, and it leaves open the question of whether the increase in stress levels alone serve as explanation of secular trends in disease and death (Krieger, 2002, p. 670).
Social Production of Disease/Political Economy Framework
The social production of disease and/or political economy of health framework is based upon a risk factor approach to the study of public health. It arose in response to the many theories correlating health with lifestyle choices and asserting that it was the responsibility of individuals to choose to lead lifestyles conducive to good health...
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