Social Obstacles to Change The Intersection of Epidemiology,

Neurobiology, and Clinical Practice with Veterans

Katharine Bloeser, LICSWKelly McCoy, PsyD

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Social Determinants of Health

What are social determinants of health?

World Health Organization, August, 2008

“The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system.”

Macro

Mezzo

Micro

The Biopsychosocial Model (1978)

The Biopsychosocial Model

Veteran Health

and Wellbeing

MacroMezzo

Micro

Do social or environmental factors influence health outcomes?

Social Capital and Glucose Control– Black Veterans living in Philadelphia– After controlling for individual factors (e.g., BMI,

age), neighborhood poverty, and individual level mediators (e.g., medication adherence); those Veterans who reported that their neighborhood was a place where people worked together had a statistically significantly positive effect on HbA1c.

Long, J.A., et al. (2010)

Do social or environmental factors influence health outcomes?

Outcome No. of respondents

% Awarded benefits (95% CI)

% Denied benefits (95% CI)

P-value

Employment 2,257 13.2% (12.1-14.3) 19.0% (17.3-20.6) .11

Income below poverty 2,257 15.2% (14.5-15.9) 44.8% (43.2-46.3) <.001

Ever homeless 3,077 12.0% (11.6-12.4) 20.0% (19.2-20.5) .02

Deceased 3,077 10.4% (10.0-10.8) 9.7% (9.2-10.2) .66

10 years later…

Demographic characteristic

Overall PTSD disability awarded

PTSD disability denied

P-value

Male sex 96.3% 96.3% 96.3% >.99

Age, mean 61.2(9.7) 61.9 (9.5) 59.3(9.8) <.001

WhiteAfrican AmericanHispanic

73.6%15.5%5.8%

77.2%11.6%0.9%

64.8%25.0%<0.1%

<.001<.001<.001

Married 58.2% 61.7% 49.1% <.001

Murdoch, M., et al. (2011)

Do social or environmental factors influence health outcomes?

Poverty

DisabilityHealth, disease,

functional limitation

Employment statusWork hours

Government assistance

Mental health and wellbeing

National Poverty Center, April, 2011

Veterans and Disability

Do social or environmental factors influence mental health outcomes?

Neighborhood Violent Crime and Depression-Sample of current and former drug users-270 block groups within Baltimore, MD from 1997-1998-Violence is associated with psychological distress through perceptions of

neighborhood disorder and personal experiences of violence.

Curry, A., Latkin, C., & Davey-Rothwell, M. (2008)

Do social or environmental factors influence mental health outcomes?

Why does neighborhood violence impact depression?

1. Fear of crime and violence less interaction among residents social isolation

2. “Mood congruent bias” Depression recall of more violence

3. Lack of financial means / Depression move towards less safe or more depressed areas

Curry, A., Latkin, C., & Davey-Rothwell, M. (2008)

Do social or environmental factors influence mental health outcomes?

Neighborhood socioeconomic status and individual perceptions of efficacy-Bandura’s social cognitive theory defines self-efficacy, “people’s judgments of their capabilities to organize and execute a course of action required to attain designated types of performances.”

Bandura (1986)

Model 1: Neighborhood SES Beta (p-value)

Model 2: Individual and Neighborhood SES

Beta (p-value)Controls

Age .002 (.001) .005 (.000)

Female -.056 (.010) -.020 (.353)

Black -.066 (.125) -.053 (.136)

Neighborhood SES

% below poverty -.008 (.000) -.001 (.354)

Individual SES

Income (log) .132 (.000)

Assets .073 (.028)

Missing assets .111 (.047)

Education .025 (.000)

Unemployed -.133 (0.72)

Intercept .080 -.900

R2 .0277 .1047

Boardman, J.D. & Robert, S.A. (2000)

Do social or environmental factors influence mental health outcomes?

Maciejewski, P.K., Prigerson, H.G., Mazure, C.M. (2000)

• Repeated trauma

• Chronic Stress

Stressful Life

Events

• Race• SES• Poverty• Disability

Self-Efficacy

• Spiraling• TreatmentDepression

Do social or environmental factors influence health outcomes?

Formation of individual self-efficacy:

1. Reflective self: How individuals feel they appear to others.

2. Comparative self: How individuals feel they compare with others.

3. Observational self: How individuals view their behaviors.

Reflective self: “I must be not worth much, because my neighborhood is in such chaos. No one seems to care.”

Comparative self: “Everyone around me is just as depressed as I am, isn’t that normal?”

Observational self: “Its not like I contribute anything to people, why try?

Social Influences on Health: Foundational Research

• Suicide (Durkheim, 1897)

– A deeply “psychological” and “private” act influenced by social integration and cohesion

– Suicide patterns explained by social facts– Anomic suicide

• Attachment Theory (Bowlby, 1940s-1980s)

– Importance of attachment bonds in early childhood to adult social development

– Emotional development during childhood important to overall health

In Berkman, Glass, Brissette & Seeman (2000)

Current Example: Military Sexual Trauma

• “Victims are often forced to choose between continuing military careers during which they are forced to have frequent contact with their perpetrators or sacrificing their career goals in order to protect themselves from future victimization.” – VA National Center for PTSD website

Adult Social Attachments

• Numerous epidemiological findings link adult social attachments to health outcomes– E.g., adult attachment style associated with symptom

perception and health care utilization (Ciechanowski, Walker, Keaton, & Russo, 2002)

• While early childhood development is important, adult socialization also has large ramifications– E.g., employment opportunities, social upheaval, work

stress• Social factors influence adult neurobiology,

cardiovascular heath, and other biological systems

What is “social support”?

Pathways to Health OutcomePsychological pathways, physiological pathways, and health behaviors

Psychosocial Factors

Social support, influence, and engagement, and access to resources

Social Networks

Social network structure and characteristics

Social-Structural Conditions

Culture, socioeconomic factors, politics, social change

Berkman, Glass, Brissette & Seeman (2000)

What is “social support”?

• Social and cultural context• Network structure• Quantity and structure of relationships• Quality of relationships • Types of support– Emotional: love, caring, sympathy, esteem, intimacy– Instrumental: material needs– Appraisal: assistance with decision making– Informational: provision of advice or information

What is “stress”?

• Stress is perceived by the brain• Responses to stress can be adaptive or

maladaptive• Brain initiates behavioral and physiological

responses to stress• The stress response involves communication

between brain, cardiovascular, immune, autonomic, and endocrine systems

Figure 1.Non-linear network of mediators of allostasis involved in the stress response. Arrows indicate that each system regulates the others in a reciprocal manner, creating a non-linear network. Moreover, there are multiple pathways for regulation – e.g. inflammatory cytokine production is negatively regulated via anti-inflammatory cytokines, as well as via parasympathetic and glucocorticoid pathways, whereas sympathetic activity increases inflammatory cytokine production. Parasympathetic activity, in turn, contains sympathetic activity. Reprinted from McEwen 2006 by permission.

McEwen (2009)

Environmental factorse.g., Access to healthy foods Exposure to war, death, and destruction Social isolation Exposure to toxins Child abuse Insufficient finances Unsafe living conditions Occupational stress

Effects of Social Environment on Personal Health

• Neurobiology– Structural remodeling

• Cardiovascular health• Metabolic changes• Immune function– The immune-brain loop

• Life expectancy– Telomere length

What about “good” stress?• Eustress versus distress

• Common examples of eustress: – Meaningful community participation, overcoming a challenge,

physical exercise, competing in a tournament, advocacy work

Eustress Distress

Positive perception of stressors (“a challenge”)

Negative perception of stressors (“a threat”)

Fosters meaning and hope Fosters aggression and withdrawal

Promotes hardiness and effective coping

Promotes anxiety and depression

Social and Psychological Interventions Help

• Changes in brain structure in response to stress can be reversed

• Behavioral and social factors promote resilience• Evidence of changed brain functioning in response to

psychotherapy• Evidence of increased telomerase activity following

lifestyle change in men with prostate cancer (Ornish et al., 2008)

• Social and behavioral interventions “reduce the chronic stress burden and benefit brain and body health and resilience” (McEwen, 2009)

Effects of Illness and Injury on Social Cognition

• Specific illnesses and injuries are associated with restricted social support

• Some illnesses and injuries are also associated with difficulty processing social information– e.g., traumatic brain injury, frontotemporal

dementia, autism, schizophrenia• In both cases, rehabilitation includes

development of enhanced social support

Macro

Mezzo

Micro

The Biopsychosocial Model (1978)

Person Level Interventions• Awareness of effects of social hierarchy in clinical

encounters• Prevent experiences of rejection• Promote experiences of caring and esteem• Awareness of importance of social interactions on health• Provide emotional, instrumental, appraisal, and

informational support• Assess past and present social experiences and their

influence on current health and health behaviors• Patient-centered care approaches that emphasize Veteran

empowerment and patient-provider relationship

Local Community Interventions• Facilitate development of health-promoting social networks

for Veterans • Prevent provider burnout through healthy relationships at

work• Appreciate the importance of social influences on behavior

change • Provide green space in the local setting• Provide access to resources and education for Veterans• Connect the dots between health care and social services• Promote Veteran empowerment and involvement in decision

making• Study and address health care and other benefit inequities

Larger Community Interventions• Advocate for political decisions that promote

healthy communities • Advocate for political decisions that promote

income and health care equality• Look for and address institutional discrimination• Promote adequate access to healthy foods and

health education for people of all income levels• Promote cultural norms that reflect values of

respect for all people, physical exercise, stress reduction, work-life balance, and holistic health care

Using Social Determinants of Health to Guide Interventions: Some examples

• Informing policy,• Mental Health Impact Assessment (MHIA)

Englewood, Chicago, Illinois

Neurobiology and Policy• “Finally, it should be noted that the social and physical

environments in which we live are, at least in part, the products of practices and policies of private enterprise and government and these can be changed by changing those policies. Indeed, virtually all of the policies of government and business have powerful effects on health. Indeed, they have a top down effect via the brain on all the physiological systems involved in stress and adaptation (McEwen, 2007). Therefore, monitoring how the brain is affected by such policies is another important future direction of neuroimaging research because animal models can only give clues, but the study of the adaptability of the human brain is the ultimate goal!” (McEwen, 2009)

Harlem Children’s Zone• “By addressing the needs of the entire community,

Harlem Children’s Zone isn't simply helping children beat the odds, it's helping to change the odds.”

Veterans’ Horticulture Initiative

Resurrection After Rape (Atkinson, 2010)

• Interventions combine cognitive processing therapy with a social justice approach– “Rape is a social problem, not

individual pathology”

• Appropriately acknowledges the roles of politics and culture in sexual trauma and recovery

• E.g., addresses unhealthy social norms including those that blame the victim, addresses rape as a men’s issues as much as it is a women’s issue, community engagement

Veteran Webinar

• “Life Through the Eyes of Wounded Warriors”• Veteran presentation as part of Patient Care

Services Grand Rounds• Mutual benefit to Veterans

(self-efficacy) and VA employees (informs policy)

Veteran-Driven Research

Question for the Audience

• Are there any initiatives you have undertaken that illustrate the principles of social determinants of health?

Resources

World Health Organization (WHO) Commission on Social Determinants of Health

http://www.who.int/social_determinants/en/

VA Center for Health Equity Research and Promotionhttp://www.cherp.research.va.gov/

HHS National Partnership for Action to End Health Disparities

http://minorityhealth.hhs.gov/npa/

ReferencesAtkinson, M. (2010). Resurrection after Rape: A guide to transforming from victim to

survivor. Oklahoma City, OK: Resurrection After Rape PublishingBandura, A. (1986). Social Foundations of Thought and Action. Englewood Cliffs, NJ:

Prentice-Hall.Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). From social integration

to health: Durkheim in the new millennium, 51(6): 843-857.Boardman, J. D., & Robert, S. A. (2000). Neighborhood socioeconomic status and

perceptions of self efficacy. Sociological Perspectives, 43(1): 117-136.Ciechanowski, P. S., Walker, E. A., Katon, W. J., & Russo, J. E. (2002). Attachment

theory: A model for health care utilization and somatization. Psychosomatic Medicine, 64: 660-667

Curry, A., Latkin, C., & Davey-Rothwell, M. (2008). Pathways to depression: The impact of neighborhood violent crime on inner-city residents in Baltimore, Maryland, USA. Soc Sci Med, 67(1)L 23-30.

References (cont.)Long, J. A., Field, S., Armstrong, K., Chang, V. W., & Metlay, J. P. (2010). Social capital

and glucose control. Journal of Community Health, 35(5): 519-526.Maciejewski, P. K., Prigerson, H. G., & Mazure, C. M. (2000). Self-efficacy as a

mediator between stressful life events and depressive symptoms: Differences based on history of prior depression. British Journal of Psychiatry, 176: 373-378.

McEwen, B.S. (2009). The brain is the central organ of stress and adaptation. Neuroimage, 47(3): 911-913.

Murdoch, M., Sayer, N. A., Spoont, M. R., Rosenheck, R., Noorbaloochi, S., Griffin, J. M., Arbisi, P. A., & Hagel, E. M. (2011). Long-term outcomes of disability benefits in US veterans with posttraumatic stress disorder. Arch Gen Psychiatry, 68(10): 1072-1080.

Ornish, D., Lin, J., Daubenmier, J., Weidner, G., Epel, E., Kemp, C., Magbanua, M. J., Marlin, R., Yglecias, L., Carroll, P. R., & Blackburn, E. H. (2008). Increased telomerase activity and comprehensive lifestlye changes: A pilot study. Lancet Oncology, 9: 1048-1057.