Social Obstacles to Change - PowerPoint Presentation

Slide1

Social Obstacles to Change

The Intersection of Epidemiology, Neurobiology, and Clinical Practice with Veterans

Katharine Bloeser, LICSW

Kelly McCoy, PsyDSlide2

VANTS Line

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71037Slide3

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.”Slide4

The

Biopsychosocial

Model

(1978)Slide5

The

Biopsychosocial

ModelSlide6

Do social or environmental factors influence

health

outcomes?Social Capital and Glucose Control

Black Veterans living in PhiladelphiaAfter 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)Slide7

Do social or environmental factors influence health outcomes?

Outcome

No. of respondents% Awarded benefits (95% CI)

% Denied benefits (95% CI)P-value

Employment2,25713.2%

(12.1-14.3)19.0% (17.3-20.6).11Income below poverty2,257

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, mean61.2(9.7)61.9 (9.5)59.3(9.8)<.001WhiteAfrican AmericanHispanic73.6%15.5%5.8%77.2%11.6%0.9%64.8%25.0%<0.1%<.001<.001<.001Married58.2%61.7%49.1%<.001

Murdoch, M., et al. (2011)Slide8

Do social or environmental factors influence health outcomes?

Employment status

Work hours

Government assistance

Mental health and wellbeing

National Poverty Center, April, 2011Veterans and DisabilitySlide9

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)Slide10

Do social or environmental factors influence mental health outcomes?

Why does neighborhood violence impact depression?

Fear of crime and violence  less interaction among residents  social isolation

“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)Slide11

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)Slide12

Model 1: Neighborhood SES

Beta (p-value)

Model 2: Individual and Neighborhood SESBeta (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

R

2

.0277

.1047

Boardman, J.D. & Robert, S.A. (2000)Slide13

Do social or environmental factors influence mental health outcomes?

Maciejewski

, P.K.,

Prigerson

, H.G.,

Mazure, C.M. (2000)Slide14

Do social or environmental factors influence health outcomes?

Formation of individual self-efficacy:

Reflective self: How individuals feel they appear to others.

Comparative self: How individuals feel they compare with others.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?Slide15

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 factsAnomic suicideAttachment 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) Slide16

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 websiteSlide17

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 ramificationsE.g., employment opportunities, social upheaval, work stressSocial factors influence adult neurobiology, cardiovascular heath, and other biological systemsSlide18

What is “social support”?

Berkman

, Glass, Brissette & Seeman (2000) Slide19

What is “social support”?

Social and cultural context

Network structureQuantity and structure of relationshipsQuality of relationships Types of support

Emotional: love, caring, sympathy, esteem, intimacyInstrumental: material needsAppraisal: assistance with decision makingInformational: provision of advice or information Slide20

What is “stress”?

Stress is perceived by the brain

Responses to stress can be adaptive or maladaptiveBrain initiates behavioral and physiological responses to stressThe stress response involves communication between brain, cardiovascular, immune, autonomic, and endocrine systemsSlide21

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 factors

e.g., Access to healthy foods Exposure to war, death,

and destruction Social isolation Exposure to toxins Child abuse Insufficient finances

Unsafe living conditions Occupational stressSlide22

Effects of Social Environment on Personal Health

Neurobiology

Structural remodelingCardiovascular health

Metabolic changesImmune functionThe immune-brain loopLife expectancyTelomere lengthSlide23

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

DistressPositive perception of stressors (“a challenge”)Negative perception of stressors (“a threat”)

Fosters meaning and hope

Fosters aggression and withdrawalPromotes hardiness and effective

coping

Promotes anxiety and depressionSlide24

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 psychotherapyEvidence 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)Slide25

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 informatione.g., traumatic brain injury,

frontotemporal dementia, autism, schizophreniaIn both cases, rehabilitation includes development of enhanced social supportSlide26

The

Biopsychosocial

Model

(1978)Slide27

Person Level Interventions

Awareness of effects of social hierarchy in clinical encountersPrevent experiences of rejection

Promote experiences of caring and esteemAwareness of importance of social interactions on healthProvide emotional, instrumental, appraisal, and informational supportAssess past and present social experiences and their influence on current health and health behaviorsPatient-centered care approaches that emphasize Veteran empowerment and patient-provider relationshipSlide28

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 settingProvide access to resources and education for VeteransConnect the dots between health care and social servicesPromote Veteran empowerment and involvement in decision makingStudy and address health care and other benefit inequitiesSlide29

Larger Community Interventions

Advocate for political decisions that promote healthy communities Advocate for political decisions that promote income and health care equalityLook for and address institutional discrimination

Promote adequate access to healthy foods and health education for people of all income levelsPromote cultural norms that reflect values of respect for all people, physical exercise, stress reduction, work-life balance, and holistic health care Slide30

Using Social Determinants of Health to Guide Interventions: Some examples

Informing policy,Mental Health Impact Assessment (MHIA)

Englewood, Chicago, IllinoisSlide31

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)Slide32

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.” Slide33

Veterans’ Horticulture InitiativeSlide34

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 recoveryE.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 Slide35

Veteran Webinar

“Life Through the Eyes of Wounded Warriors”Veteran presentation as part of Patient Care Services Grand RoundsMutual benefit to Veterans (self-efficacy) and VA

employees (informs policy)Slide36

Veteran-Driven ResearchSlide37

Question for the Audience

Are there any initiatives you have undertaken that illustrate the principles of social determinants of health?Slide38

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 Disparitieshttp://minorityhealth.hhs.gov/npa/Slide39

References

Atkinson, M. (2010). Resurrection after Rape: A guide to transforming from victim to survivor. Oklahoma City, OK: Resurrection After Rape Publishing

Bandura, 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: 660-667Curry, 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.Slide40

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.