Social interventions
Social epidemiology
Andrea Dalecká
Consuelo Quispe Haro
Social interventions in epidemiology
What we already know:
• Mortality and morbidity are distributed unequally between countries, groups and people.
• Health is best in high income countries and high income groups and worst in low income countries and
low income groups.
• Social inequality is characterized by the existence of unequal opportunities for different social
positions or statuses within a group or society.
• Social interventions aim to attenuate/prevent health inequality to achieve better health of
individuals and populations.
• Social interventions are actions that might be implemented on levels:
• Macrosystem – healthcare policy, political decisions etc.
• Community level (exosystem) – worksites, city-level, schools
• Microsystem – family, invidividual behavioural changes etc.
Social inequality
Typology of actions to reduce heath inequalities
Strengthening
individuals
1
Strengthening
families
2
Strengthening
communities
3
Improving
living and
working
conditions
4
Promoting
healthy macro-
policies
5
Applying the typology to smoking interventions
INDIVIDUALS AND FAMILIES
- Mass media campaigns
- Anti-smoking educational programs
- Smoking cessation clinics and consultancy
- Targetting poorer patients or areas
- Nicotine replacement therapy
COMMUNITIES
- Greater community participation
- Build confidence and stimulate mutual support
to generate circumstances for participants to
quit smoking.
ENVIRONMENTS
- Smoke-free environments
- Control smoking in public places
- Ban the supply of cigarettes to children
MACRO POLICICES
- Restrictions on paid advertisements and brand
sponsorship
- Increase access to services to help quitting
- Regulate taxes for tobacco products
- Protect against smuggling („pašování“)
- Controlling product use and distribution
- Reduce EU subsidies to farmers for growing
tobacco
Micro-Exo-Macro
Systems Framework
• Measures of characteristics of inequality:
– Individual: e.g., sex, age, IQ,
education, income, wealth
– Community: e.g., unemployment
rate, crime rate, neighbourhood
deprivation, social support
– Group-level (national): GDP, GINI,
crime rate, life expectancy
Chain of causes (“causes of the causes”)
GINI coefficient
• Measure of income (or wealth) dispersion in a country – equality of income
• Gini coefficient, 0 = complete equality; 1 = complete inequality
2017-2020.
OECD Data.
https://data.oec
d.org/inequality/
income-
inequality.htm
GINI = INCOME INEQUALITY
Poverty rate
• The poverty rate is the ratio of the number of people (in a given age group) whose income
falls below the poverty line
2017-2020.
OECD Data.
https://data.oec
d.org/inequality/
poverty-
rate.htm#indicat
or-chart
Life expectancy
at birth and
income
(Preston‘s curve)
Life expectancy at birth and percentage of income received by
least well off 70% of families, 1981 (Wilkinson, BMJ 1992)
Why Do Americans Have Shorter Life Expectancy and Worse Health Than
Do People in Other High-Income Countries? (2004)
• Representative samples of adults aged
50 to 74 years were interviewed in
2004 in 10 European countries (n = 17
481), England (n = 6527), and the
United States (n = 9940).
• SHARE, ELSA and HRS adult cohorts
included.
RESULTS:
• Health disparities by wealth were
significantly smaller in Europe than in
the United States and England.
• The poorest Americans experience the
greatest disadvantage relative to
Europeans.
Avendano M., et al. 2009:Health Disadvantage in US Adults Aged 50 to 74
Years: A Comparison of the Health of Rich and Poor Americans With That of
Europeans.American Journal of Public Health 99, 540_548.
WHICH FACTORS MAY PLAY A ROLE IN
DIFFERENCES IN HEALTH BETWEEN
EUROPE AND US?
(a) heart disease, (b) stroke, (c) hypertension, (d) diabetes
LOESS function of chronic disease and disability by wealth among men
and women aged 50 to 74 years (evidence from 2004)
• Lifestyle differences? (prevalence of
smoking or obesity)
• Health care system? European
countries have:
– stronger primary care orientation
– more equitable distribution of
resources
• Social policies? European countries
have:
– Higher provision of social transfers
(social retirement benefits,
unemployment compensation, sick
pay)
– Lower level of uninsured people
Affordable Care Act (ACA)
„Obamacare“
• Based on the previous studies from
US, insurance coverage as an important
determinant of disparities in access to
care.
• The Affordable Care Act (ACA) has made
new health insurance options available to
uninsured individuals in low- and middleincome
households.
• Provides „premium tax credits“ that lower
costs for households with incomes up to
400% of the federal poverty level (FPL),
• For those with a family income below
138% of (FPL), ACA created federal
funding (Medicaid) covering all costs for
medical expenses.
Effect of Medicaid expansions on smoking cessation
prescription fills and refills using an event study: 2011-2015
Macleam JC. Et al., THE EFFECT OF INSURANCE EXPANSIONS ON SMOKING CESSATION MEDICATION PRESCRIPTIONS: EVIDENCE FROM ACA MEDICAID EXPANSIONS.
NATIONAL BUREAU OF ECONOMIC RESEARCH. 2018. Working Paper 23450 http://www.nber.org/papers/w23450
• Trends in Slope Index of Inequality
(SII) inUS countries with and
without extension (ACA Medicaid)
SII reflects changes in the mean or
the prevalence of the health
outcome among the population.
Kino S., Kawachi I., The impact of ACA Medicaid expansion on
socioeconomic inequality in health care services utilization.
PLOS One. 2018. 12(2).
Conditional Cash Transfers (CCT)
• Endogenous innovation
from Latin America and
the Caribbean
• Aims to reduce current
poverty, to develop the
human capital of the
next generation, and to
break the
intergenerational
transmission of poverty.
https://publications.iadb.org/publications/english/document/The-Growth-of-Conditional-Cash-Transfers-in-Latin-America-and-the-Caribbean-Did-They-Go-Too-Far.pdf
https://www.worldbank.org/content/dam/Worldbank/Event/social-protection/Lindert%20-%20CCTs%20.pdf
CCT characteristics
Conditions:
• Target: Poor families with children under 5.
• Mothers from poor backgrounds receive
cash. They must take their children to
growth and development check-ups.
• For children <6 years old – visits to
preventive healthcare centers in which
their growth is monitored.
• For children between 7-17 years old: School
attendance is the most common stipulation
• Mothers are also encouraged to attend
courses on hygiene, vaccination, and
contraception.
Considerations:
• The mere existence of a program does not mean
that individuals will enroll.
• Administrative obstacles and costly conditionalities.
• Corruption and other administrative problems
might lead to their not receiving the transfer.
• The amount of the transfer could be too small to
make a difference in key outcomes.
• Households could use part of the transfer payment
to consume tobacco, alcohol, or other ‘adult’
commodities, increasing consumption of leisure.
• Changes to the details and implementation of the
program.
Orazio Attanasio, Erich Battistin, Emla Fitzsimons, Alice Mesnard And Marcos Vera-Hernandez (2005) HOW EFFECTIVE ARE CONDITIONAL CASH TRANSFERS? Evidence From Colombia
CCT in Colombia
Social interventions in low income
countries
Free Basic Education
• To improve a poverty rate in developing
countries, it is important to:
• Build political freedom
• Build transparent government and
reduce corruption
• Provide socio-economic facilities
• Support social opportunities and security
• Support education in all levels
• Social protection interventions have been
used as a poverty reduction strategy in many
countries.
• Major donors of the free Universal Education
Policy are the World Bank and other
subsidiary agencies
Brenyah JK. Implementation of Social Protection Interventions in Africa. „The trend in the
outcomes of free basic eductaion in Ghana, Malawi, Kenya and Uganda. Univ J of Educ Res.
2018; 6(12).
Primary schools enrolment rate in Uganda and
Malawi
Example of Governmental intervention in France
Smoking intervention
• The French government increased
taxes substantially and regularly
between the early 1990s and 2005.
• This led to a reduction in sales by
more than 50%.
• The health impact of this dramatic
reduction in consumption was seen
only a few years later with the
reduction of lung cancer death rates
among young men.
• Death rates among men aged 35–
44 also went down by 50% from
1996.
Source: Graph reproduced using data from Hill C. Prévention et dépistage des cancers [Cancer
prevention and screening]. Bulletin du Cancer. 2013;100:6.
Income-transfer programs and health
Examples of programs:
• Earned Income Tax Credit program have led to increased birth weight and reduced maternal
smoking
• Pregnancies in women exposed to the Food Stamps program had better birth outcomes than
did pregnancies in women who were not exposed to this program, particularly among African
American mothers.
• The Massachusetts farmers‘ market coupon program for low-income elders led to 32% increase
in vegetable and fruit comsumption (1992).
Strully KW, et al. 2010. Effects of prenatal poverty on infant health: state earned
income tax credits and birth weight. Am. Sociol. Rev. 75: 534–62
Almond D, et al. 2011. Inside the war on poverty: the impact of Food Stamps on birth
outcomes. Rev. Econ. Stat. 93: 387–403
Sustainable Development Goals (SDGs)
• Inequality is a major obstacle to
sustainable economic growth.
• SDGs were set in 2015 by the
European Commission
• The goal is to find sustainable and
inclusive development solutions,
ensure everyone’s human rights
• 17 SDGs have been defined, with 169
associated targets, to be reached by
2030.
• https://ec.europa.eu/international-
partnerships/sustainable-development-
goals_en
SDGs-10 Reduce inequality
• Covers different dimensions:
– Economic inequality - refers to differences in economic
outcomes, such as in income, consumption or wealth.
– Social inequality - refers to differences in social
outcomes (such as in education or employment), or to
differences in social status or position.
– Political inequality - refers to unequal influence over
decisions made by political bodies, and the unequal
outcomes of those decisions. It is closely related to
differences in the distribution of political resources, which
can lead to the exclusion of particular groups from
participating in political processes.
– Environmental inequality - used to indicate an unequal
distribution of environmental risks and hazards (e.g. air
or water pollution) and unequitable access to natural
resources and other ecosystem services (e.g. land, parks
and freshwater) between different social groups.
Reducing inequality | International Partnerships
(europa.eu)
Risk groups
Some individual sociodemographic
characteristics
might be disadvantaged in
various situations. =
INEQUALITY
Could you come up with
some situations where one
could experience
inequality?
Community-based interventions characteristics
• As setting, the community is primarily defined
geographically, but should address the
community characteristics related to specific
needs of population.
• Such interventions may be citywide (using e.g.
mass media), or may take place within community
institutions such as neighbourhoods, schools,
churches, work sites, agencies, etc.
• The focus of these community-based projects is
primarily on changing individuals’ behaviours
as a method for reducing the population’s risk
of disease.
Building a trust
with community
„Everything on the
table“ approach
Understanding the
cultural/social
context
Ongoing plans
preparation to
ensure
sustainability
ESSENTIAL ELEMENTS OF THE SUCCESSFUL
COMMUNITY-BASED INTERVENTION
Cambel MK. Et al. Process evaluation of an effective church-based diet intervention: body
and soul. Health Educ Behav. 2007;34(6):864-80.
Social contextual framework
Socio-demographic
characteristics
• Social class
• Ethnicity
• Language
• Place of birth
• Gender
• Age
Modifying conditions:
Interpersonal factors:
• Material circumstances
• Daily hassles
Interpersonal factors
• Social ties
• Diversity of friendship
patterns
• Family role/responsibilities
Organizational factors
• Job strain
• Social capital
• Organizational support for
behavioural change
Neighbourhood/community
• Safety
• Access to resources
• Housing
• Transportation
Societal factors
• discrimination
Mediating mechanisms
• Social norms
• Social support
• Organizational
environment
Individual mediating
mechanisms
• Self-efficacy
• Attitudes/beliefs
• Intentions to perform
behaviour
• skills
INTERVENTIONS
Health behaviour
Worksites interventions
• Occupational health screening aims to:
– prevent work-related illness and injury (primary prevention)
– reveal diseases related to exposures to risk factors on workplace (secondary prevention)
• Besides that, a wide range of risk factors have been targeted through the workplace,
including smoking, nutrition, physical activity, work-family stress, addiction, cancer screening,
occupational exposures.
• Notably, workplace can play an important role in supporting unhealthy behaviour.
• Controlling for social class, probability of smoking cessation decreased with exposure to
occupational hazards.
Microsystem
Family Social support
• Lack of social support indicates the share of people who report having no friends or relatives whom
they can count on in times of trouble.
• Individuals with social support are consistently more likely to be satisfied with their personal health.
• Research has linked social isolation and loneliness to higher risks for a variety of physical and
mental conditions including
– high blood pressure,
– heart disease,
– obesity,
– weakened immune system,
– anxiety and depression,
– cognitive decline and Alzheimer's disease.
Thanakwang K, Soonthorndhada K. Mechanisms by Which Social Support Networks Influence Healthy
Aging Among Thai Community-Dwelling Elderly. Journal of Aging and Health. 2011;23(8):1352-1378.
2017-2020.
OECD Data.
https://data.oec
d.org/healthrisk/
lack-of-social-
support.htm
Social support
• Social support indicates people who report having friends or relatives whom they can count
on in times of trouble
School-based interventions
• Research suggests there is strong evidence that
school-based physical education (PE) is effective in
increasing levels of physical activity.
WHAT WOULD YOU SUGGEST TO INCREASE
PHYSICAL ACTIVITY IN CHILDREN (using schools)?
• Increasing the physical activity in children at school
environment might be achieved by:
– adding free PE activities for low-income families
– adding new or additional PE classes,
– lengthening existing PE classes, or
– increasing moderate to vigorous physical activity
of students during PE class without necessarily
lengthening the class time.
Individual-based interventions
• Based on health behaviour change interventions
– health education and advice giving
• Usually targeted to individual risk factors
• Interventions were typically small-scale, long in
duration and complex.
• The interventions usually aimed to highly motivated
individuals – not also representative of the general
population.
• Interventions should focus on
– success with the most vulnerable population
groups
– address the social and economic
circumstances
Motivational Interviewing
• Delivery by phone, Internet etc.
• Smoking cessation, mental health crisis
etc.
eHealth interventions
• Require not limited access to internet
• Young people oriented
• Regular physical activity, improved diet
Adverse effects of Public Health Interventions
Direct harm
Increased sport
participation and
injuries
Psychological
harm
Screening cancer
programs and falsepositive
results
Equity harm
Public health
expenditure target
the wealthier
Group and
Social harm
Increased stigma in
targeted groups
(obese people,
marginalized groups)
Lorenc T, Oliver K. Adverse effects of public health interventions: a conceptual framework. J Epidemiol Community Health 2014;68:288-290.
Castro-Leal F, Dayton J, Demery L, Mehra K. Public spending on health care in Africa: do the poor benefit? Bull World Health Organ. 2000;78(1):66-74. PMID: 10686734;
PMCID: PMC2560601.
Thank you for your attention!