Welcome back. This is module two of week four. We're talking about social epidemiologic theory.

In this module, we're going to be talking about social ecological model. It's a very important model, very important theory for social epidemiology. And I want to walk you through some of the broad parameters. Then offer you some, I guess critique, of some of the shortcomings of the approach or model or theory as I see it. Again, I want to emphasize that there's no reading assignments for this week, week four. Instead, what I want you to do is continue to think about components or parts of theories or metaphors or models. That would fit into an understanding of how society affects health. What's really important, and you'll see later in these modules, is we have an understanding of how society works and then how these working of society make people healthy or not. That's the key. Understanding how society works, and then how these workings, the production of these workings, makes people healthy or not. And so your job is to search the web, and then get on the discussion boards and debate and discuss and think about on these websites what's working for you and what you think is valid or invalid, helpful or not for social epidemiology. Literally, you can be part of a group that develops a firmer, better comprehensive if not cohesive model or theory for social epidemiology, so this should be fun. OK, the social ecological model. Key component and understanding how society impacts health. Lot's of people have written about this. As I mentioned in the earlier module, a nice, accessible, it's very easily read, not too technical summary piece is by Nancy Krieger. And this article is in the International Journal of Epidemiology. And it's, theories for social epidemiology in the 21st century, an ecosocial perspective. So, ecosocial is a little bit different word. I want to say to you that By in large, or at least at this point in our training

together, these words are interchangeable. So ecosocial, social theory, all of these things are kind of the same thing. So just relax with that. This paper is worth reading. And I want to offer you a little bit about how Professor Krieger categorizes the importance of theory, and then, she'll talk about social or eco-social theory in particular. But let me lay out for you some of the components of her paper in case you don't have a chance to read it. I encourage you to, but, you know, sort of, you need not. First, she talks about this as a taxonomy or a framework for categorizing the various parts of this theory and the first one is psychosocial theory. And in short, here's a theory or an approach, a model that focuses on the biological responses, the physiological response To human interactions and emphasizes the stress response. When animals, particularly humans, are under stress various hormones and other chemicals in their body such as cortisol and adrenaline, increase and these chemicals can cause early aging, they can cause heart disease and other aspects of things that tend to wear us down as biological organisms. So the psychosocial approach to the ecosocial theory, is one that focuses on how the environment, in our case the social environment, affects the physiology of the human animal. The second part or second category of these kinds of theories, Dr. Krieger calls the political economy. And here, just think for a moment of what that means. Political economy. Often we think of the word economics, and we think about maybe the stock market or trading and exchanging. When we use the words political economy, were talking about exchanges, or trades, where there's some political tension. You have more power over me, I over you. I need the job, and therefore I have to work for you. It's the upper class versus the lower class. This is what's entailed when we use the word political economy over just regular old economics. So in the politically political economy, political economy part of this the stress

is on the political and economic determinants of health. And that's a area that I subscribe to we've been talking about it now for a few weeks. How is it that the political system the global economic forces produces exposures for some that are healthy. Exposures for others maybe a toxic dump that are not healthy. And it tends to assert or entail that powerful institutions such as laws regular law. Markets, free markets and others, court systems how these institutions produce things that create health for some and not others. The zoning of a new toxic dump must go there, the zoning of a fresh fruits Supermarket must go here by law. And where do those laws come from? That's the domain of political economy. Now the social ecological part of this is where the current social ecological theory comes from. And, what's important to recognize, again, is that there's several names. Sometimes called ecosocial, sometimes called eco-epidemiology. But they're all sort of the same thing, because it's still unfolding. And in Dr. Krieger's paper, she talks about this as nascent, that is unfolding, not yet fully developed. And that's exactly right. The social ecological approach is mulitlevel. We talked about mutlilevel phenomena in one of our early lectures. And that is, there's a group phenomena happening. Maybe a social norm. Maybe an institution. And then there's individual phenomena happening. And they interact. The group affects the individual and the individual affects health. And the social-ecologicial model entails both those phenomena. The focus is on who or what drives the patterns of social inequalities in health. So that social-ecological model tends, doesn't always, but tends to focus on why are some healthy or some not. And that's a very reasonable thing. Because if the society had no impact on health, everyone's health would be the

same. Except for their genes and their biological environment. We know that to not be the case. Which is why we have Social epidemiology. But in a social ecological framework, what's happening here is we're focusing on the determinants or the causes of these differences. The social ecological model, of course, embraces the social production of disease. We know that germs cause disease and various viruses and bacteria and injuries. But the question for this framework is, hm, what is it about society that's either having some people more exposed or some people having weaker immune systems or being more susceptible? Why do some kids have bike helmets, and others don't? Importantly for Professor Krieger, and it's more universally recognized than not, there are components of this ecosocial model or social ecological model that are important to recognize. First is this concept of embodiment. We talked about that with different words before. What it means is, how is it exactly that aspects of society, social norms, get into the body. How is it that a peer group that encourages smoking actually causes lung cancer. And so that idea of that transition from the social into the physiologic or biologic, is really important. Then how exactly, what are the pathways, this this embodiment occurs. And this can be through, obviously society. It can be through psychology. And obviously, ultimately, biological or physiological. And there's lots of discussion of, sort of, which pathways matter more. They could be through the adrenaline system, the, cortisol. They could be through injuries. And there's all kinds of other pathways. There's a cumulative interplay of exposure, susceptibility, and resistance. That is, just because you're exposed to a disease, or exposed to a bad environment, maybe a bad neighborhood, doesn't mean that that'll make you sick. Some people are resistent. Some people can be exposed to a common

cold virus and not get the cold. Some people can grow up in rather destitute or very difficult places, and not have that affect them very much. That's the resistance part. It's a very important part of research and understanding. And finally, there's an important part of account accountability and agency. That is, who's accountable. For these social institutions, and these forces that create inequalities and socioeconomic status. Where's the sort of spider in this big web of causation? In related, there's a component for agency which we'll talk about further. That is, people acting, that's what the word agency means in this case. Its a jargon term but the idea is agency means that some people are or all people are acting doing things one way or the other. And so there's a great tension someone acting as part of the social system and someone being responsible for the social system. And that's attention that's been written about and we'll revisit in a little bit. The application of the social epidemiologic framework is important. And there's some good work in this area. The Glanz and colleagues book, Health Behavior and Health Education, has a really nice chapter. by a guy named Jim Sallis and this is 2008 and they do an excellent job of reviewing components of social ecological theory for really physical activity and obesity. And so this is a review in this book I can recommend. You don't have to have it as part of our course but its worth exploring. Sallis and colleagues outlined other principals of the ecological framework and I'll just walk you through a few. There are multiple influences on specific health behaviors. And these are intra-personal or inside the person. Interpersonal, between persons. Organizational, what's the context of your group. company, a workforce and so forth, community and public policy levels. So all these things are working together, or against one another, and they're multiply causing health or illness. These influences on behavior interact

across different levels. We talked about the multi-level stuff in an earlier lecture. This is exactly what's happening in this framework. Ecological models should be behavior specific. In a sense that we don't have a complete universal theory of how people behave, but various parts of theories for health behavior for exercise or fitness or cardiovascular disease or cancer prevention. So different parts, or different diseases, can be carved up. And the key idea here is that multi-level interventions, where we actually want to do something that we talked of earlier. Do something to improve health. This is now a multi-level intervention. We might intervene on a community. Through various health messaging maybe changing sidewalks or removing a toxic dump. And individuals supporting them helping them learn things and this is an idea of a multi-level intervention and the social ecological theory fits this perfectly. Finally, and quickly, I want to talk about some important advances by two other scholars, Tom Glass and Matt McAtee. And this is a little bit different. It's a bit of a twist on the social ecological model, and I just want to wet your whistle with it a little bit. Here these scholars are talking about two axis of causation, and I'll explain what that means. There's an integration of the biological and the social behavioral sciences and that's of course what Dr. Krieger was talking aout with this idea of embodiement. And here what these guys are tyring to do is talk about upstream. and downstream causes, proximal, nearby, and distal are other words that we have used in this course. And they want to say that environments, and social circumstances are risk of disease regulators, or risk regulators. Instead of actual causes. So it's a slightly different twist on the same old theme. But it offers some new insights. Let's look at the model just briefly. So here's the two axis uphill and downhill and then over here we have time. Okay so these two big black lines the two

axis. They talk about, and under this line, they call it under water. Above, we talk about it as downhill, but above water. And so what's all this stuff? Well, there are things that affect health that are at the global level. Geopolitical, economic, and environmental forces. The climate. global trade. There's the macro-level and the macro-level is stuff at the national or state level national policy, state policy. The mezzo-level or middle level. This is work sites or schools. And of course the micro-level. Groups and families and social networks. And all of these levels have an influence. On actual human behavior and exposures to disease. And this is the idea here of embodiment, this is how this stuff gets into the body. Now within the body, or underwater, there are multiple organ systems and cells and genomes, genes that actually. Are the biological part of this big old equation, or big old model. So above here, we have the social stuff. Down here we have the biological stuff. And they work together in an interplay, over time, to create health and illness. And so it's this effort, of gland, of Glass and McAtee. That are trying to say, look. All this stuff matters. Now, as we said in one of our first lectures, most people view health as only down here. Genes and cells and organ systems. But in social epidemiology, we're focusing on the system of society. And in this framework or model or conceptual diagram, we're trying to integrate both, and that's the important contribution. Glass & McAtee have a summary that's worth repeating. The control and manipulation of these structured contingencies, laws, social norms, rules, life conditions and so forth, may have a greater impact on the public's health and the control of proximate biological causes. What does this mean? They mean that when we can focus on

social conditions, such as the norm to smoke or not to smoke. The norm to wear a seatbelt, the law to wear seatbelt. Conditions of poverty or great advantage. These things can have a bigger impact on population health than control of just genes, individual blood pressure, vaccines and so forth. And so that's sort of the message of the social ecological model. Now finally the big critique one of the things I don't like about the social ecological model is it doesn't emphasize a lot of where the ecology comes from. So if we say that the environment or the ecology affects persons. To me, that begs the question where did that come from to begin with? Why is there an ecology? Further, the model tends to be used, there's nothing inherit in the model, but it tends to be used as saying the outside the individual stuff, the big corporations, the global market. These are bad things that end up causing bad health in certain populations, the disadvantaged. This doesn't need to be so, and so part of the problem of the theory is the use of the theory. Third, I'm a little troubled by the. Explanation or the articulation, of how the environment, the group affects persons. That's the macro to micro transition. And then how persons ultimately affect groups. That's the big challenge in understanding social epidemiology. How groups affect persons and how persons affect groups. That's not very well articulated in the social ecological model. The model finally, or second to finally, doesn't have a lot of room, doesn't have a lot of emphasis on one's personal liberty or choices. It's true that we're trying to understand the system, but individuals are acting or are agentic in that system. And the social ecological model tends to down play that. And finally, so much of the theory of social ecological model doesn't dovetail or conform with what traditional economic or political science theory discusses. And so this can create problems. Right or wrong, we want to use the socioecological model to influence

policy. It doesn't entail the language of modern policy, at least in the Western world. And so this can create problems for health researchers, social epidemiologists. Who want to use the approach to influence change and hopefully improve health.