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

Caring for the older person with cognitive impairment in hospital: Qualitative analysis of nursing personnel reflections on fall events

Aims and objectives To explore nurse and nursing assistant reflections on the care of older patients with cognitive impairment who have experienced a fall. Background While there are evidence‐based clinical guidelines for the prevention and management of falls and for the care of older people with cognitive impairment, the falls rates for older people with cognitive impairment are three times as high as those without. Design Critical incident technique. Methods Eleven registered and two enrolled nurses and four assistants in nursing working in one subacute and two acute wards within two hospitals of a tertiary level health service in south‐east Queensland. Individual semistructured interviews focused on two past events when a patient with cognitive impairment had fallen in hospital: one when there was minimal harm and the second when there was significant harm. Thematic analysis was undertaken. The COREQ checklist was followed. Results Three themes emerged from 23 reflective accounts of fall events: “direct observation is confounded by multiple observers” and “knowing the person has cognitive impairment is not enough,” and “want to rely on the guideline but unsure how to enact it.” While participants were aware of the falls prevention policy and techniques available to prevent falls, the implementation of these was challenging due to the complexity of care required by the older person with cognitive impairment. Conclusions Falls prevention for older people with cognitive impairment is complex and belies the simple application of policy. Relevance to clinical practice To reduce falls, nurses can involve the family to support “knowing the patient” to enable prediction of impulsive actions; shift the focus of in‐service from lectures to specific case presentations, with collaborative analysis on person‐focused strategies to prevent falls in older people with cognitive impairment; and reconsider the sitter role from simple observer to assistant, focused on ambulation and supporting independence in activities of daily living.Full Tex

Inequities gone or enduring? Evaluating the effects of a school-based antistigma intervention on race/ethnic and gender intersectional disparities in mental illness stigma

While significant mental illness stigma disparities across race/ethnicity and gender exist, little is known about the efficacy of antistigma interventions in reducing these intersectional disparities. We examine the 2-year effects of school-based antistigma interventions on race/ethnic and gender intersectional stigma disparities among adolescents. An ethnically and socioeconomically diverse sixth-grade sample (N = 302) self-completed surveys assessing stigma before randomly receiving an antistigma curriculum and/or contact intervention versus no intervention. Surveys were also self-completed 2-year postintervention. Stigma measures assessed general mental illness knowledge/attitudes, awareness/action, and social distance. Stigma toward peers with specific mental illnesses was examined using vignettes—two adolescent characters were described as having bipolar (Julia) and social anxiety (David) disorder. Race/ethnicity and gender were cross-classified into six intersectional groups (Latina/o, non-Latina/o Black, and non-Latina/o White girls and boys). Linear regressions adjusting for poverty and mental illness familiarity examined antistigma intervention effects across intersectional groups in sixth and eighth grade. The school-based antistigma intervention reduced intersectional stigma disparities over the 2-year study period. While non-Latino Black boys and Latino boys/girls reported greater disparities in stigma at baseline compared to non-Latina White girls, these disparities (14 total) were predominantly eliminated in the 2-year follow-up following receipt of the curriculum and contact components to just one remaining disparity postintervention among non-Latino Black boys. By identifying differences in how school-based antistigma interventions reduce mental illness stigma for unique race/ethnic and gender intersectional groups, we can better understand how to shape future antistigma interventions for diverse intersectional populations

Adolescent views of mental illness stigma: An intersectional lens

Differences in mental illness (MI) stigma among adolescents were examined cross-sectionally across race, ethnicity, and gender to identify target populations and cultural considerations for future antistigma efforts. An ethnically and socioeconomically diverse sample of sixth graders (N = 667; mean age = 11.5) self-completed assessments of their MI-related knowledge, positive attitudes, and behaviors toward peers with MI and adolescent vignettes described as experiencing bipolar (Julia) and social anxiety (David) symptoms. Self-reported race, ethnicity, and gender were combined to generate 6 intersectional composite variables: Latino boys, Latina girls, non-Latina/o (NL) Black boys, NL-Black girls, NL-White boys, and NL-White girls—referent. Linear regression models adjusting for personal and family factors examined differences in stigma using separate and composite race, ethnicity, and gender variables. In main effects models, boys and Latina/o adolescents reported greater stigma for some outcomes than girls and NL-White adolescents, respectively. However, intersectional analyses revealed unique patterns. NL-Black boys reported less knowledge/positive attitudes than NL-Black and White girls. NL-Black and Latino boys reported greater avoidance/discomfort than NL-White girls. Moreover, NL-Black girls and boys and Latina/o girls and boys wanted more social separation from peers with mental illness than NL-White girls; NL-Black boys also reported more separation than NL-White boys, NL-Black girls, and Latina girls. Finally, NL-Black boys and Latina girls wanted more distance from David than NL-White and Black girls. Vital for informing future antistigma interventions, this study generates new knowledge about how differences in views about MI exist across racial and ethnic identity, and how gender intersects with these perceptions

“Me” versus “them”: How mental illness stigma influences adolescent help-seeking behaviors for oneself and recommendations for peers

Mental illness stigma is a significant barrier to utilizing mental health services for young populations. Few studies have evaluated how specific stigma dimensions relate to help-seeking and recommendations among adolescents. We examined how the stigma dimensions of labeling, stereotypes, and separation/discrimination influenced self-reported help-seeking behaviors of adolescents and recommendations for hypothetical peers with a mental health problem. Longitudinal data (four assessments) from a study evaluating the effectiveness of three antistigma interventions (curriculum, contact, materials, vs. control) among adolescents were analyzed (n = 396). Help-seeking outcomes comprised services in formal (e.g., doctor), informal (e.g., friend), or school-based (e.g., school counselor) settings. Generalized estimating equations tested associations of labeling, stereotypes, and separation/discrimination on help-seeking for a personal problem and recommendations for vignette characters described as having bipolar depression or social anxiety disorder. Adolescents were more likely to make help-seeking recommendations for peers with mental health problems than they were to seek help for a problem of their own. Labeling was a strong predictor of self-reported help-seeking and recommendations. Mental health literacy, an indicator for low negative stereotypes, was related to increased recommendations but not self-reported help-seeking. Positive stigma action and awareness—high cognizance of stigma and how to engage in proactive behaviors toward treating and destigmatizing mental illness—increased help-seeking in formal and informal settings for oneself. Finally, separation/discrimination did not prevent self-reported help-seeking, but it did increase peer recommendations in certain settings. Stigma did not always influence or interfere with help-seeking in the same way when the help-seeker was oneself versus a peer

Estimating School Race/Ethnic Enrollment Effects on Student Mental Health: Density and Diversity as a Risk or Protective Factor

Objective: To investigate effects of school race/ethnic enrollment on mental health in early adolescence by examining both race/ ethnic density (percent non-Latinx [NL] White enrollment) and diversity (range/size of all race/ethnic groups enrolled). Variation by student race/ethnic identity is examined as minority stressors are uniquely experienced by race/ethnic minority students. Methods: Generalized estimating equations tested main effects of density/diversity on depressive-anxious symptoms across student-reported race/ethnic identity, adjusting for student/school factors. Owing to statistically significant Latinx-group differences by acculturative stress, four unique identities were generated: NL-Black, low-stress Latinx, high-stress Latinx, and NL-White—referent. Points of convergence of student mental health profiles across density/diversity were explored. Results: A significant interaction between density and student race/ethnicity was found (P Conclusions: Greater NL-White density increases mental health risk for NL-Black and low-stress Latinx students, while school diversity lowers risk for high-stress Latinx students. These findings demonstrate how educational settings may produce or lessen minority stress

Understanding the Effects of the Neighbourhood Built Environment on Public Health with Open Data

The investigation of the effect of the built environment in a neighbourhood and how it impacts residents' health is of value to researchers from public health policy to social science. The traditional methods to assess this impact is through surveys which lead to temporally and spatially coarse grained data and are often not cost effective. Here we propose an approach to link the effects of neighbourhood services over citizen health using a technique that attempts to highlight the cause-effect aspects of these relationships. The method is based on the theory of {\em propensity score matching with multiple `doses'} and it leverages existing fine grained open web data. To demonstrate the method, we study the effect of sport venue presence on the prevalence of antidepressant prescriptions in over 600 neighbourhoods in London over a period of three years. We find the distribution of effects is approximately normal, centred on a small negative effect on prescriptions with increases in the availability of sporting facilities, on average. We assess the procedure through some standard quantitative metrics as well as matching on synthetic data generated by modelling the real data. This approach opens the door to fast and inexpensive alternatives to quantify and continuously monitor effects of the neighborhood built environment on population health.Cambridge Trust and King's Colleg

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