Social Conditions as Fundamental Causes of Disease

Over the last several decades, epidemiological studies have been enormously successful in identifying risk factors for major diseases. However, most of this research has focused attention on risk factors that are relatively proximal causes of disease such as diet, cholesterol level, exercise and the like. We question the emphasis on such individually-based risk factors and argue that greater attention must be paid to basic social conditions if health reform is to have its maximum effect in the time ahead. There are two reasons for this claim. First we argue that individually-based risk factors must be contextualized, by examining what puts people at risk of risks, if we are to craft effective interventions and improve the nation's health. Second, we argue that social factors such as socioeconomic status and social support are likely 'fundamental causes" of disease that, because they embody access to important resources, affect multiple disease outcomes throughmultiple mechanisms, and consequently maintain an association with disease even when intervening mechanisms change. Without careful attention to these possibilities, we run the risk of imposing individually-based intervention strategies that are ineffective and of missing opportunities to adopt broad-based societal interventions that could produce substantial health benefits for our citizen

Smoking and the emergence of a stigmatized social status

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/60953/1/stuber_smoking and stigma_2008.pd

Fundamental causes" of social inequalities in mortality: a test of the theory

Medicine and epidemiology currently dominate the study of the strong association between socioeconomic status and mortality. Socioeconomic status typically is viewed as a causally irrelevant "confounding variable" or as a less critical variable marking only the beginning of a causal chain in which intervening risk factors are given prominence. Yet the association between socioeconomic status and mortality has persisted despite radical changes in the diseases and risk factors that are presumed to explain it. This suggests that the effect of socioeconomic status on mortality essentially cannot be understood by reductive explanations that focus on current mechanisms. Accordingly, Link and Phelan (1995) proposed that socioeconomic status is a "fundamental cause" of mortality disparities-that socioeconomic disparities endure despite changing mechanisms because socioeconomic status embodies an array of resources, such as money, knowledge, prestige, power, and beneficial social connections, that protect health no matter what mechanisms are relevant at any given time. We identified a situation in which resources should be less helpful in prolonging life, and derived the following prediction from the theory: For less preventable causes of death (for which we know little about prevention or treatment), socioeconomic status will be less strongly associated with mortality than for more preventable causes. We tested this hypothesis with the National Longitudinal Mortality Study, which followed Current Population Survey respondents (N = 370,930) for mortality for nine years. Our hypothesis was supported, lending support to the theory of fundamental causes and more generally to the importance of a sociological approach to the study of socioeconomic disparities in mortality.http://deepblue.lib.umich.edu/bitstream/2027.42/57746/1/Fundamental Causes of Social Inequalities in Mortality A Test of the Theory .pd

Reliability of Self-reported Neighborhood Characteristics

The majority of studies examining the relation between neighborhood environments and health have used census-based indicators to characterize neighborhoods. These studies have shown that neighborhood socieconomic characteristics are associated with a range of health outcomes. Establishing if these associations reflect causal relations requires testing hypotheses regarding how specific features of neighborhoods are related to specific health outcomes. However, there is little information on the reliability of neighborhood measures. The purpose of this study was to estimate the reliability of a questionnaire measuring various self-reported measures of the neighborhood environment of possible relevance to cardiovascular disease. The study consisted of a faceto-face and telephone interview administered twice to 48 participants over a 2-week period. The face-to-face and telephone portions of the interview lasted an average of 5 and 11 minutes, respectively. The questionnaire was piloted among a largely Latino and African American study sample recruited from a public hospital setting in New York City. Scales were used to assess six neighborhood domains: aesthetic quality, walking/ exercise environment, safety from crime, violence, access to healthy foods, and social cohesion. Cronbach’s α’s ranged from. 77 to. 94 for the scales corresponding to these domains, with test-retest correlations ranging from 0.78 to 0.91. In addition neighborhood indices for presence of recreational facilities, quality of recreational facilities, neighborhood participation, and neighborhood problems were examined. Test-retest reliability measures for these indices ranged from 0.73 to 0.91. The results from this study suggested that self-reported neighborhood characteristics can be reliably measuredhttp://deepblue.lib.umich.edu/bitstream/2027.42/57744/1/Reliability of Self reported neighborhood characteristics.pd

A multilevel analysis of income inequality and cardiovascular disease risk factors.

Recent research has suggested that inequality in the distribution of income is associated with increased mortality, even after accounting for average income levels. Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we investigated whether inequality in the distribution of income within US states is related to the prevalence of four cardiovascular disease risk factors (body mass index (BMI), history of hypertension, sedentarism, and smoking). Multilevel models (including both state-level and individual-level variables) were used to examine associations of state inequality with risk factor levels before and after adjustment for individual-level income. For three of the four risk factors investigated (BMI, hypertension, and sedentarism), state inequality was associated with increased risk factor levels, particularly at low income levels (annual household incomes <$25,000), with associations persisting after adjustment for individual-level income. Inequality was also positively associated with smoking, but associations were either stronger or only present at higher income levels. Associations of inequality with the outcomes were statistically significant in women but not in men. Although not conclusive, findings for three of the four risk factors are suggestive of a contextual effect of income inequality, particularly among persons with lower incomes.http://deepblue.lib.umich.edu/bitstream/2027.42/78997/1/DiezRouxLink2000_SocSciMed.pd

Income inequality and cardiovascular disease risk factors

http://deepblue.lib.umich.edu/bitstream/2027.42/56181/1/Diez Roux Av, Income inequality and cardiovascular disease risk factors, 2000.pd

The effects of US state income inequality and alcohol policies on symptoms of depression and alcohol dependence

Mental health is likely to be influenced by contextual variables that emerge only at the level of the group. We studied the effect of two such group-level variables, within-state income inequality and alcohol tax policy, on symptoms of current depression and alcohol dependence in a US national sample, controlling for state-level and individual characteristics. A cross-sectional US national probability sample provided the individual-level data. State income data were obtained from the 1990 US census. The Gini coefficient (raw and adjusted) indicated income inequality. Outcome measures included current symptoms of depression and alcohol dependence. Controlling for individual-level variables and state median income, the odds of depressive symptoms was not positively associated with state income inequality. Controlling for individual-level variables, state median income and alcohol distribution method, a weak negative association between Gini and alcohol dependence was observed in women, but this association disappeared after additional adjustment for beer tax. No association was observed in men. Higher state beer tax was significantly associated with lower prevalence of alcohol dependence symptoms for both men and women. The results suggest that state income inequality does not increase the experience of alcohol dependence or depression symptoms. However, evidence was found for a protective effect of increased beer taxation against alcohol dependence symptoms, suggesting the need to further consider the impact of alcohol policies on alcohol use disorders.http://deepblue.lib.umich.edu/bitstream/2027.42/57742/1/The effects of US state income inequality and alcohol policies on symptoms of depression and alchohol dependence.pd

The relationship of multiple aspects of stigma and personal contact with someone hospitalized for mental illness, in a nationally representative sample

The stigma of mental illness has been shown to be affected by personal contact with mental illness and by a belief in the genetic heritability of mental illness. We use data from a nationally representative survey to test whether the relationship of stigma with contact remains after taking into account the effects of genetic beliefs and other background characteristics. Contact was defined as a history of psychiatric hospitalization among respondents themselves, their family members, or their friends. Respondents answered questions about a vignette character with a mental illness. We found that respondents with contact felt less anger and blame toward the character, thought that the character had a more serious problem, and would want less social distance from the character, including both casual and intimate aspects of social distance. Respondents with contact were not significantly different from the general population in the degree to which they expressed sympathy, thought the problem would last a lifetime, or wanted to restrict reproduction. Thus, contact is associated with having a less ostracizing, critical attitude toward a stranger with mental illness. The results underscore the importance of this experienced group as a resource in fighting stigma in society. Since many people who have had a psychiatric hospitalization have not told their friends or family members about it, this lower-stigma group could be enlarged

Association between an Internet-Based Measure of Area Racism and Black Mortality

Racial disparities in health are well-documented and represent a significant public health concern in the US. Racism-related factors contribute to poorer health and higher mortality rates among Blacks compared to other racial groups. However, methods to measure racism and monitor its associations with health at the population-level have remained elusive. In this study, we investigated the utility of a previously developed Internet search-based proxy of area racism as a predictor of Black mortality rates. Area racism was the proportion of Google searches containing the “N-word” in 196 designated market areas (DMAs). Negative binomial regression models were specified taking into account individual age, sex, year of death, and Census region and adjusted to the 2000 US standard population to examine the association between area racism and Black mortality rates, which were derived from death certificates and mid-year population counts collated by the National Center for Health Statistics (2004–2009). DMAs characterized by a one standard deviation greater level of area racism were associated with an 8.2% increase in the all-cause Black mortality rate, equivalent to over 30,000 deaths annually. The magnitude of this effect was attenuated to 5.7% after adjustment for DMA-level demographic and Black socioeconomic covariates. A model controlling for the White mortality rate was used to further adjust for unmeasured confounders that influence mortality overall in a geographic area, and to examine Black-White disparities in the mortality rate. Area racism remained significantly associated with the all-cause Black mortality rate (mortality rate ratio = 1.036; 95% confidence interval = 1.015, 1.057; p = 0.001). Models further examining cause-specific Black mortality rates revealed significant associations with heart disease, cancer, and stroke. These findings are congruent with studies documenting the deleterious impact of racism on health among Blacks. Our study contributes to evidence that racism shapes patterns in mortality and generates racial disparities in health

The Impact of Obesity on US Mortality Levels: The Importance of Age and Cohort Factors in Population Estimates

To estimate the percentage of excess death for US Black and White men and women associated with high body mass, we examined the combined effects of age variation in the obesity–mortality relationship and cohort variation in age-specific obesity prevalence