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Social Epidemiology: Strategies for Public Health Activism

Julie Cwikel

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December, 2006
Cloth, 632 pages, 91 illus.
ISBN: 978-0-231-10048-9
$55.00 / £38.00


It's no secret: Health and disease interest all of us. Good health and its maintenance are central values the world over. Each cultural group has its own definition of health, including values and traditions that govern health behavior. For example, according to the Indian Ayurvedic philosophy, good health is a delicate balance between the three primary humors, wind, bile, and phlegm, which are disturbed by stress, injuries, and demonic presence (Magner 1992). The Bantu African tradition suggests,

"Health signifies that one's life force is intact, and that one is sufficiently in harmony with the social, physical, and supernatural environment to enjoy what is positively valued in life, and to ward off misfortunes and evils." (McKeown 1997:16)

We are concerned about our own health, the health of family members, and often the health of those who share our lifestyle, cultural background, workplace, neighborhood, city, and region of the country. Most people do something on a daily basis to maintain their health, whether it is exercising, taking vitamins, eating a balanced diet, meditating, wearing seatbelts, taking medications, or living according to religious precepts. Not only is self-care important, but healers and health care practitioners are found throughout history and are central to every culture. Views of health and health care in their particular cultural context are a core theme of this book.

In Western cultures the centrality of health as a value has not escaped the close attention of advertisers and marketers. Promises of better health and a beautiful body are used to sell everything from diet plans, breakfast cereals, and soft drinks to running shoes, cosmetic treatments, and leisure activities such as cruises. Wallack and Dorfman (1992) analyzed a composite day of television in order to extract the health messages contained in commercials and public service announcements. Almost one-third of the commercials (31%) used a health message as a sales pitch, promoting mostly foods and beverages. Curiously, although public service announcements used health messages as often as commercials, not a single announcement was geared toward promoting healthful behaviors connected with tobacco, alcohol use, or diet, key behaviors that are associated with many controllable aspects of disease. Communications about health and how they can be used to achieve public health goals are another salient issue in this book.

What Is Social Epidemiology?

Social epidemiology is the systematic and comprehensive study of health, well-being, social conditions or problems, and diseases and their determinants, using epidemiology and social science methods to develop interventions, programs, policies, and institutions that may reduce the extent, adverse impact, or incidence of a health or social problem and promote health. This definition provides evidence-based methods for public health activism. Social problems are specifically included in this definition because many of today's challenges in public health, including obesity, infectious diseases, violence, child abuse, and drug use, are associated with both personal behavior and macro trends in the social structure such as the distribution of wealth, social resources, and exposure to media and market forces. Furthermore, those who specifically study social problems can enrich their research and practice through the methods of social epidemiology, revealing how social problems are intrinsically linked to the health status of populations. Social epidemiology is the combination of epidemiology (the study of the distribution and determinants of disease and injury in human populations) with the social and behavioral sciences.

This definition of social epidemiology emphasizes that determining the distribution of disease and social problems and understanding the relevant risk factors and their interrelationship are only one part of social epidemiology. Risk factors are the behaviors, attributes, inherited characteristics, and exposures that increase the probability of a specific outcome such as a health or social condition, problem, or disease (Last 1995). In addition to determining distribution and identifying risk factors, a central focus of social epidemiology is implementing what we know about a particular condition in order to maintain and improve health and well-being. Inherent in this definition is the equal emphasis given to the psychosocial and the biological or medical determinants of disease and well-being. This definition emphasizes the use of multidisciplinary approaches to analyze complex social problems.

Some theorists have proposed an alternative definition of social epidemiology as "the branch of epidemiology that studies the social distribution and social determinants of states of health" (Berkman and Kawachi 2000:6). This approach to social epidemiology contrasts with classic epidemiology in its explicit emphasis on investigating social factors such as poverty and gender through the judicious use of theories, concepts, and methods instead of merely assuming their effects as background variables in biomedical research (Krieger 2001). This research-focused definition does not include the need for activist public health practice that is one focus of this book.

For example, alcohol consumption and driving are common activities among young people. However, their occurrences together in time and place make them risk factors that increase the likelihood of a motor vehicle accident. Numerous community groups, lawmakers, and policymakers have applied this knowledge to the development of programs and policies to combat driving under the influence of alcohol. Activities range from educating youth and police about the dangers of drinking and driving to providing alcohol-free events for youth and changing the legal drinking age. Although alcohol consumption has been illegal for those under twenty-one years of age since 1988, according to the 1998 national Household survey on Drug abuse an estimated 10.5 million current drinkers were twelve to twenty years old (Center for Mental Health Services 1999). There have been no statistically significant changes in the rates of underage drinking since 1994, which reinforces the conclusion that simply enacting laws does not necessarily change behavior.

The approach of social epidemiology reflects the understanding that social variables or conditions can lie on either side of the equation determining which factors affect health and illness. They can be independent variables, which are the characteristics hypothesized to explain the phenomena of health and disease. They can also be the social condition or outcome that we are trying to understand, or the dependent variable. For example, depression can be a risk factor for some diseases or social conditions, such as alcohol abuse or child neglect. It can also be the illness outcome of interest in its own right, measured by either reported symptoms or psychiatric diagnoses. Similarly, homelessness can be a risk factor for contracting an infectious disease or becoming the victim of violent crime, and it can also be a social condition that we seek to elucidate.


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About the Author

Julie Cwikel is professor in the Spitzer Department of Social Work and founder and director of the Center for Women's Health Studies and Promotion at Ben Gurion University of the Negev, Beer Sheva, Israel.Julie Cwikel, MSW, PhD is Associate Professor in the Department of Social Work at Ben Gurion University of the Negev, Beer-Shiva, Israel, where she also founded and co-leads The Center for Women's Health Studies and Promotion. Cwikel is trained in both social work and public health and received her MSW and PhD from the University of Michigan.

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