Public health chapter 4

Complex relationship between social systems and individuals helps us look at the 3 key components of the social system and their relationship to health.

socioeconomic status, culture, and religion

downstream factors

are those that directly involve an individual and can potentially be altered by individual interventions, such as an addiction to nicotine.

Mainstream factors

are those that result from the relationship of an individual with a larger group or population, such as peer pressure to smoke or the level of taxation on cigarettes. These factors require attention at the group or population level

Social justice

implies a society that provides fair share of the rewards of society to individuals and groups. early public health reformers advocated for social justice and saw public health as an integral aspect of it

Key concept theory the social cognitive theory is reciprocal determinism

the dynamic interplay among personal factors, the environment, and behavior. The theory proposes that changing one of these factors will change them all

How can individual behavior be changed

The behavior of individuals is often the common pathway through which disease, disability, and death can be prevented. The forces at work to mold individual behaviors are sometimes referred to as *downstream factors* *mainstream factors* , and *upstream factors*. Changes in behavior often require more than individual motivation and determination to change. They require encouragement and support from groups ranging from friends and families to work and peer groups. Behavioral change may also require social policies and expectations that reinforce individual efforts.

How does socioeconomic status affect Culture

-defines what is good and what is bad/ what is healthy and what is not -help people make judgments about the world/behaviors -lifestyle patterns, beliefs about risk, and beliefs about body type-large body type in cultures may be healthy, but other culture may be seen as unhealthy -Culture directly affects the daily habits of life. Food choice and methods of food preparation and preservation are all affected by culture, as well as socioeconomic status. Ex: The Mediterranean diet, which includes olive oil, seafood, vegetables, nuts, and fruits, has been shown to have benefits for the heart. -negatives/positive impacts on disability related to cultural traditions: diverse as feet binding in China and female genital mutilation in some parts of Africa Culture is also related to an individual's response to symptoms and acceptance of interventions. -Many traditional cultures have developed sophisticated systems of self-care and self-medication supported by family and traditional healers. -Many cultures allow and even encourage the use of traditional approaches alongside Western medical and public health approaches. -traditional healers are considered appropriate for health problems related to spiritual and other phenomena. -cultural differences should not be viewed as problems but to be addressed and understood.

How does socioeconomic status affect religion

-religious practices like: we now know that male circumcision reduces susceptibility to HIV/AIDS. -Religious attitudes that condone or condemn the use of condoms, alcohol, and tobacco have direct and indirect impacts on health as well. -Some religions prohibit specific healing practices, such as blood transfusions or abortion, or totally reject medical interventions altogether, as is practiced by Christian Scientists. -Religious individuals may see medical and public health interventions as complementary to religious practice or may substitute prayer for medical interventions in response to symptoms of disease.

Mental health can impact physical health

Depression may limit an individual's desire and motivation to exercise and seek out nutritious food, contributing to chronic conditions such as cardiovascular disease and diabetes. Therefore, understanding the factors, both internal and external to the individual, contributing to emotional, psychological, and social well-being is critical in addressing population health.

Place matters when it comes to Gini index:

Place matters. Some Americans will die 20 years earlier than others who live just a short distance away because of differences in education, income, race, ethnicity, and where and how they live racial or ethnic differences were also considered. For example, black men in the county with the shortest life expectancy for blacks lived approximately 60 years, while white men in the county with the longest life expectancy for whites could expect to live two decades longer.

more on diffusion innovation

The theory proposes that the diffusion and adoption, or rejection, of an innovation is affected by perceived attributes of the innovation, including relative advantage (Is the innovation better than what it will replace?), compatibility (Does the innovation fit with the values and needs of the intended audience?), complexity (Is the innovation easy to understand and use?), trialability (Can the innovation be tried before making a decision to adopt?), and observability (Are the results of the innovation observable and easily measureable?).

How do social determinants affect health?

They contribute to a wide variety of diseases rooted in lifestyle, environmental, and social factors Connected with *health disparities* , a type of difference in health closely linked with social or economic disadvantages -Health disparities negatively affect groups of people who have systematically experienced greater social or economic obstacles to health -These obstacles stem from characteristics historically linked to discrimination or exclusion, such as race or ethnicity, religion, socioeconomic status, gender, disability, mental health, sexual orientation, and geographic location can occur in noncommunicable and communicable diseases and environmental health and safety

diffusion of innovation theory: community

This theory focuses on how a new idea, product, or social practice (an innovation) is disseminated and adopted in a population. The theoretical constructs include the innovation itself, the time it takes to adopt the innovation, the communication channels used to transmit the innovation, and the social system in which diffusion of the innovation takes place. has contributed the concept of different types of adopters, including early adopters (those who seek to experiment with innovative ideas), early majority adopters (often opinion leaders whose social status frequently influences others to adopt the behavior), and late adopters (or laggards—those who need support and encouragement to make adoption as easy as possible).

Theory of Planned Behavior: intrapersonal

This theory is based on the idea that intention is the main predictor of behavior. The theory proposes that behavioral intention is influenced by an individual's attitude toward performing a behavior, his or her beliefs about whether people important to him or her approve or disapprove of the behavior, and his or her beliefs about their control over performing the behavior. intention determines whether someone will engage in a behavior; therefore, interventions based on the Theory of Planned Behavior set out to affect individuals' intention to perform a behavior.

How are social systems related to health?

complex interactions influencing behavior

What are the social determinants of health?

conditions in which people are born, grow, live, work, worship and age -as well as the systems put in place to deal with illnesses that affect health and quality of life. -the World Health Organization encompass many key social determinants that affect health. Each individual has his or her unique combination of influences

How is public health related to the social and behavioral sciences?

development of social and behavioral sciences in the 1800s and 1900s is closely connected to the development of public health. fundamental belief, understanding the organization, and Motivations behind social forces include understand the behavior of individuals that can be used to improve the life of individuals The 19th-century development of social and behavioral sciences, as well as public health, grew out of the Industrial Revolution in Europe, and later in the United States. It was grounded in efforts to address the social and economic inequalities that developed during this period and provided an intellectual and institutional structure

complex interactions

interactions we have with other people, institutions, communities, and policies -The relationship between individuals and social systems is reciprocal(meaning we influence our social systems and our social systems influence us). ~Due to our constant interaction with our surroundings, efforts aimed at improving population health require an understanding of the *complex relationship* between *social systems* and *health*.

health belief model (1950s): intrapersonal theory

is an intrapersonal theory, as it focuses on individuals' characteristics, including their perceptions and thought processes prior to taking health-related action. -The model proposes that people will be more likely to take action if they believe they are susceptible to the condition; they believe the condition has serious consequences; they believe taking action would benefit them, with the benefits outweighing the harms;

The precede-proceed

planning framework provides a structure to design and evaluate health education and health promotion programs through a diagnostic planning process followed by an implementation and evaluation process There are nine steps of the framework, divided into two phases: PRECEDE and PROCEED.2

social science models: levels of influence

~to gain understanding of various social influences on health as well as to assist in identifying points at which to intervene.~ -Individual lifestyle factors: Characteristics of the individual, including knowledge, attitudes, beliefs, and personality traits, as well as age, sex, and hereditary factors. -Social and community networks: Points at which interaction with other individuals occurs. Divided further into: *Interpersonal: Family, friends, and peers who shape social identity, support, and roles. *Institutional/organizational: Rules and regulations of institutions, such as schools and places of employment, which may limit or promote healthy behavior. *Community: Comprises informal and formal social networks and norms formed among individuals, groups, and organizations, including cultural and religious practices. General socioeconomic, cultural, and environmental conditions: individuals that comprise living and working conditions, such as education, housing, work environment, and healthcare services. ~These conditions are shaped by public policy and laws at the local, state, and federal levels.~

Social determinants can affect mental health as well

*mental health* is a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with challenges. mental illness: refers to all diagnosable mental disorders, which are health conditions characterized by alterations in thinking, mood, and/or behavior associated with distress and/or impaired functioning ex: depression, anxiety, bipolar disorder, schizophrenia, and dementia.

10 key categories of social determinants of health

1. social status 2. social support or alienation 3. food *food desert- to describe geographic areas that lack grocery stores and other establishments in which low-income individuals are able to purchase nutritious food due to high prices or inaccessibility 4. housing 5. education 6. work 7. stress 8. transportation 9. place 10. access to health services

Influencing behavior: complex relationship between social systems and individuals

1.) Shaping norms: certain behaviors that are accepted in society ex:An attitude of "everyone else is doing it" can have a strong influence on an individual's decision to partake in the activity. 2.)Enforcing patterns of social control: ex:Having rules and regulations in place creates structure for society, which can affect health. having curfew for teenagers to be off the streets by midnight or accompanied by an adult can prevent violence. 3.) Providing opportunities to engage in healthy behaviors: The opportunities, or lack thereof, in our surroundings can have a strong influence on our health. ex: having access to a community pool= physical exercises/prevents drowning-learning how to swim. and social cohesion. 4.) Encouraging selection of healthy behaviors as a coping strategy: ex:college students often go through stressful periods throughout their academic career, around exam time.Some students may cope with stress by binge drinking to going for a run, each selection having a different effect on health.

How do socioeconomic status affect health?

1800s, social scientists developed the concept of socioeconomic status. They also developed elaborate systems to operationalize the definition of "socioeconomic status" and classify individuals. -family income -educational level or parents' educational level -professional status or parents' professional status -in developed countries like the U.S., health status measured by life expectancy is strongly associate with socioeconomic status. greater longevity=high social status *socioeconomic gradient* : modest level of income disparities. This gradient can be viewed as a ladder in that moving down the socioeconomic ladder, more ill health and shorter life expectancy are experienced at each rung. ~Therefore, socioeconomic determinants of health do not solely affect the very poorest or those in the lowest socioeconomic levels but are rather an issue throughout all income levels.

socioeconomic factors that affect health- continued

An argument has been made that poorer health leads to lower income and not the other way around. There is little evidence that this phenomenon explains the socioeconomic factors that affect health. -Education level is an even stronger predictor of life expectancy than income, and education levels are usually well established before poor health develops. ~Therefore, it may be more accurate to say that disparities in socioeconomic status are associated with poorer population health status *Gini Index* : a measure that has been adapted to calculate economic inequity across populations also known as the Gini coefficient. -commonly used measure of income distribution, with an index ranging from 0 to 1, with higher values indicating greater inequality. -0 indicates complete income equality (everyone has the same income), and 1 indicates complete inequality in income (one individual receives all the income). Oftentimes, for ease of reporting and drawing comparisons, the index is multiplied by 100 so that the values range from 0 to 100. The index measures the extent of deviation between an economy's distribution of income among individuals or households and that of perfectly equal distribution.

How Can Health Behavior Be Explained and Predicted?

But what tools do we have to understand these behaviors? A *theory* is a set of interrelated concepts that presents a systematic view of relationships among variables in order to explain and predict events and situations. -present a systematic way to understand events or situations, linking various factors and elements together, they provide a useful framework to study health problems, develop appropriate interventions, and evaluate the impact of the interventions. -answers the "why" "what" and "how" of health issues and their solutions accordance with evidence based practice(EBP) principles, interventions developed based on theory and supported by evidence using these theories are more likely to succeed than those that were not. Similarly, a *model* is a combination of ideas and concepts taken from multiple theories and applied to specific problems in particular settings. Theories and models are tools commonly used by health researchers and health practitioners to gain insight into why people behave in healthy or unhealthy ways and to guide the development and evaluation of interventions aimed at changing behavior to improve health.

Can health behavior be changed?

Consider all the behaviors related to health. Some are intentional health behaviors, while others are not necessarily motivated by health concerns(unintentional) Example of intentional health: Getting a mammogram because it is a behavior most likely undertaken for health benefits—in this case, screening for breast cancer. However, driving the speed limit may be a behavior that has an effect on health but is undertaken not because the individual is concerned about the health benefits of doing so (avoiding injury)from a motor vehicle crash) but because he or she wants to avoid getting a ticket. Therefore, in order to have an impact on health, a wide range of behavioral motivations and factors needs to be addressed (pg.86) The potential to change behavior can make health worse as well. (pg.86)

Some ways socioeconomic factors affect health (but do not explain the entire observed difference in life expectancy among individuals of different socioeconomic status)

Greater economic wealth usually implies access to healthier living conditions. Improved sanitation, less crowding, greater access to health care, and safer methods for cooking and eating are all strongly associated with higher economic status in developed, as well as developing, countries. Education is also strongly associated with better health. It may change health outcomes and increase longevity by encouraging behaviors that provide protection against disease and also reduce exposure to behaviors that put individuals at risk of disease. (also wealth has access to good education)greater wealth can provide, may increase access to better medical care Individuals of lower socioeconomic status are more likely to be exposed to health hazards at work and in the physical environment through toxic exposure in the air they breathe, the water they drink, and the food they eat.

intrapersonal level

Health promotion and health education efforts set out to raise awareness of health issues among individuals; therefore, a number of intrapersonal theories and models exist, focusing on factors within the individual - *Health belief model* , *stages of change model* , *theory of planned behavior*

Choosing a theory/model

Identify the health issue or problem and the population affected. ■■ Gather information about the issue, population, or both. ■■ Identify possible reasons or causes for the problem. ■■ Identify the level of interaction (intrapersonal, interpersonal, or community) under which the reasons or causes most logically fit. ■■ Identify the theory or theories that best match the level of interaction and the reasons or causes.

Planning frameworks

In recent years, public health has begun to apply marketing approaches to try to better understand and change the health behaviors of groups of people—especially those who are at high risk for the health impacts of their behavior, such as cigarette smokers. *social marketing* : -a use and extension of traditional product marketing, has become a key component of a public health approach to behavioral change. Social marketing campaigns were first successfully used in the developing world for promoting a range of products and behaviors, including family planning and pediatric rehydration therapy. In recent years, social marketing efforts have been widely and successfully use

Interpersonal level

Interpersonal theories and models take into consideration the influences of other people on an individual's behavior. include family members, peers, coworkers, healthcare providers, etc., and they can influence behavior by sharing their advice,feelings, and opinions and through the support and assistance they provide.

What Are Some Key Theories and Models Used to Address Health Behavior?

Many theories and models are used in health behavior research and practice. Theories and models are categorized according to three levels of influence: ~Intrapersonal: Focusing on characteristics of the individual, including knowledge, attitudes, beliefs, motivation, self-concept, past experiences, and skills ~Interpersonal: Focusing on relationships between people, acknowledging that other people influence behavior by sharing their thoughts, advice, feelings, emotional support, and other assistance ~Population and community: Focusing on factors within social structures, such as norms, rules, regulations,policies, and laws

Research to understand other effects of socioeconomic status

One theory suggests that social control and social participation may help explain these substantial differences in health. It contends that control over individual and group decision-making is much greater among individuals of higher socioeconomic status. The theory holds that the ability to control one's life may be associated with biological changes that affect health and disease. Additional research is needed to confirm or reject this idea and/or provide an adequate explanation

Why are some individual health behaviors easier to change than others?

Some behaviors are relatively easy to change, while others are extremely difficult. Being able to recognize the difference is an important place to start when trying to alter behavior. It is relatively easy when one behavior can be substituted for a similar one and results in a potentially large payoff. Along with knowledge, incentives—such as reduced cost, increased availability, or improvements in ease of use—can encourage rapid acceptance and motivate behavioral change. The most difficult behaviors to change are those that have a physiological component, such as obesity, or an addictive element, such as cigarette smoking. In addition, physical, social, and economic barriers can stand in the way of behavior change, even if individuals themselves are motivated. If health care is not accessible, or if survival needs require individuals to engage in risks they might not take otherwise, change in behavior may be impeded. Successful behavioral change requires that we understand as much as we can about how behavior can be changed and what we can do to help.

the 9 steps of the planning framework: divided into 2 phases(procede and proceed)

The diagnostic phase of PRECEDE consists of collecting data and information to understand societal needs (step 1: social assessment), prioritizing community needs (step 2: epidemiological assessment), identifying factors contributing to the health issue (step 3: behavioral and environmental assessment), identifying factors that must be in place to initiate and sustain behavioral change (step 4: educational and ecological assessment), and identifying policies, resources and other circumstances that may assist or hinder efforts (step 5: administrative and policy assessment The implementation and evaluation phase of PROCEED begins with implementation of the strategies developed based on the findings from the PRECEDE (phase in step 6. Knowing what works and what does not work is important across all public health interventions; therefore, evaluation is a critical component embedded within this planning model. (In step 7, evaluation of the intervention components takes place to determine if the program is functioning the way it was intended, reaching the target population, Step 8 evaluates the impact the intervention has on the factors being targeted. In step 9, outcomes of the intervention are evaluated to determine whether the intervention has affected the overall public health issue it set out to address.

Population and Community level

Theories and models on the community level are typically viewed as change theories guiding strategies that change aspects within the social systems, such as norms, rules, regulations, policies, and laws This is in contrast to theories and models on the intrapersonal and interpersonal levels, which are viewed as explanatory theories because they primarily identify and describe reasons for a problem. ~commonly used community level theory is *diffusion of innovation*

Stages of change model: intraperonal

also known as Transtheoretical model 1.) precontemplation 2.)contemplation 3.)preparation 4.)action 5.)maintenance 6.) relapse 7.) upward spiral

social cognititve theory: interpersonal

originally known as the Social Learning Theory -focuses on the interaction between individuals and their social systems. change in behaviors require an understanding of: ■ Individual characteristics, such as knowledge, skills, and beliefs ■ Influences in the social and physical environment, such as peer influence, level of family support, characteristics of the neighborhood, and work and school environments that help or hinder opportunities for health ■ Interaction among all these factors ~can be applied to a wide variety of public health issues that encompass the complex interactions between individual characteristics, influences in the social system, and individual behavior such as drug addiction

behavioral economics (pg.97)

seeks to utilize new understandings about human behavior to change the behavior of clinicians and patients. These new understandings include

upstream factors

upstream factors are often grounded in social structures and policies, such as government-sponsored programs that encourage tobacco production. These require us to look beyond traditional healthcare and public health interventions to the broader social and economic forces that affect health.

Social marketing incorporates the "4 Ps," which are widely used to structure traditional marketing efforts. These are:

■■ Product: Identifying the behavior or innovation that is being marketed ■■ Price: Identifying the benefits, the barriers, and the financial costs ■■ Place: Identifying the target audiences and how to reach them ■■ Promotion: Organizing a campaign or program to reach the target audience(s) Social marketing, like product marketing, often relies on what marketers call branding. *Branding* includes words and symbols that help the target audience identify with the service

branding goes deeper than just symbols. It can be seen as a method of implementing the fourth "P," or promotion. It also builds upon the first three "Ps":

■■Branding requires a clear understanding of the product or the behavior to be changed (product). ■■ Successful branding puts forth strategies for reducing the financial and psychological costs (price). ■■ Branding identifies the audience and segments of the audience and ~Branding is the public face of social marketing, but it also needs to be integrated into the core of the marketing plan.