Theory of fundamental causes

Last updated

In 1995, Jo C. Phelan and Bruce G. Link developed the theory of fundamental causes. This theory seeks to outline why the association between socioeconomic status (SES) and health disparities has persisted over time, [1] particularly when diseases and conditions previously thought to cause morbidity and mortality among low SES individuals have resolved. [2] The theory states that an ongoing association exists between SES and health status because SES "embodies an array of resources, such as money, knowledge, prestige, power, and beneficial social connections that protect health no matter what mechanisms are relevant at any given time." In other words, despite advances in screening techniques, vaccinations, or any other piece of health technology or knowledge, the underlying fact is that those from low SES communities lack resources to protect and/or improve their health.

Contents

Key components

According to Link and Phelan, a fundamental social cause of health inequalities has four key components:

  1. The cause influences multiple disease outcomes
  2. The cause affects disease outcomes through multiple risk factors.
  3. The cause involves access to resources that can assist in avoiding health risks or to minimize the sequelae of disease once it occurs.
  4. "The association between a fundamental cause and health is reproduced over time via the replacement of intervening mechanisms" [2]

By these criteria, SES is a fundamental cause for healthcare disparities.

Previous school of thought on health disparities

Health has been linked to social class dating back to the early 19th century, when the French tracked mortality in connection with areas of poverty. Similarly, the English began documenting mortality by occupation in the mid-1800s. [3] In the United States, more attention was paid to racial connections to health disparities up until 1973, when Evelyn M. Kitagawa and Philip Hauser published a report connecting SES to increased morbidity and mortality. [4]

In the 19th century, the major causes of mortality were typically infectious diseases, as well as diseases that resulted from poor sanitation and crowded living conditions. [2] In 1900, the top three causes of death were pneumonia, tuberculosis, and diarrhea. [5] Because lower SES individuals were more likely to live in crowded, unsanitary conditions, it was thought that the improvement of these conditions would lead to an improvement in health. Enormous progress was made in the 20th century in alleviating these conditions thanks to the development of antibiotics, vaccination, sewage management systems, hygiene, and improved education regarding sanitation and food safety, and life expectancy increased for all SES groups. [6] Yet disparities in healthcare and health outcomes have persisted. [6]

The role of resources

Link and Phelan state that the key resources that lower SES individuals lack include knowledge, money, power, prestige, and beneficial social connections. [2] At a given SES level, this lack of resources persists despite what other factors, beneficial or not so, are at play.

Knowledge

Knowledge primarily includes health literacy, but may also involve the knowledge that is gained via access to physicians and the medical establishment. Health literacy can be defined as "the knowledge and competencies of persons to meet the complex demands of health in society." [7] While previously health literacy was defined as the ability to read materials in a medical context, the definition has evolved to include more than simply the ability to read. It now encompasses a broad range of skills and activities that decrease the asymmetry of information in the health care marketplace.

Money

The relationship between money and health is linear with a positive slope; that is, the more money a person has, the better their health, with some exceptions. [8] At a basic level, income enables people to access and pay for health care when it is necessary or to purchase health insurance. Beyond this, money also provides the ability to fund healthy choices, including purchasing nutritious food, a gym membership, and medications. On an even larger scale, it provides the ability to make adaptations to the work or residential environment, e.g., changing jobs, relocating to a safer neighborhood, or retiring from work at the time of one's choosing. Each of these factors demonstrate that finances play a key role in health decisions and overall health.

Power and prestige

In the context of health care and access, power is the ability to exert one's influence to effect change on the behalf of oneself or others. Prestige is the "reputation or influence arising from success, achievement, rank, or other favorable attributes." Power and prestige are factors in determining a person's place in the social hierarchy, and they manifest themselves in multiple ways. [9] One is power and prestige in the workplace. Those with power in their jobs are able to take days off of work for leisure or to access medical care. According to the Whitehall Studies, a gradient was observed across all levels of employment, with those wielding the greatest amount of power in their jobs having the lowest mortality levels. [10]

Another example of the use of power and prestige is the ability to exert political power. Specifically, "electoral engagement is positively correlated with income at the individual level." [11] This demonstrates that those who are of lower socio-economic status are at a disadvantage in terms of the political clout that they possess. Because lower-income individuals are less likely to vote for representatives and for other ballot measures, the policies and laws put into place may not serve their interests.

Beneficial social connections

Social connections can be conceptualized in two ways: one, connections between unrelated social worlds, and, two, social relations within relatively closed worlds. [12] Those of lower SES may lack the first type more than the second, which places them at a more significant disadvantage in terms of their health status. Someone from a higher-SES group may have friends or colleagues who are health care providers, attorneys, or politicians. Through these social connections, broader networks can be accessed that may provide health benefits.

Conversely, some lower-SES individuals, specifically Latinos, benefit from strong community relationships. This has been referred to as the Barrio advantage, which states that Mexican-Americans living in areas with high densities of Mexicans experience "sociocultural advantages" that "outweigh the disadvantages conferred by the high poverty of those neighborhoods." [13]

Intervening mechanisms

A final key part of the theory is the persistence of resource disparities that perpetuate unequal health outcomes, despite intervening mechanisms that may otherwise appear to improve health status. An example of this is the Pap smear for cervical cancer screening. Since the development of the Pap smear in the 1940s, a disparity has existed in utilization of this screening test given differences in resources mentioned above. [2] Another example is the polio vaccine. Prior to the vaccine, polio could afflict people of all socioeconomic classes. Once the vaccine became available, it was primarily accessible by those who possessed the resources to obtain it. We also see an example of this in colorectal cancer, in which diffusion of information plays a role. This led to a theoretical expansion discussing when inequalities tend to arise in new situations and highlighting when inequalities might disappear for older diseases that are more effectively controlled. [14] Under this theory, diffusion of information plays two roles - it can help to reduced mortality, and is a mechanism through which knowledge operates, but it is not sufficient to eliminate SES inequalities as seen in Wang et al. 2012. [15]

These examples demonstrate how intervening mechanisms, e.g., the Pap smear and the polio vaccine, did not decrease health disparities given that certain groups possessed resources to access them and others did not.

Related Research Articles

<span class="mw-page-title-main">Social mobility</span> Mobility to move social classes

Social mobility is the movement of individuals, families, households or other categories of people within or between social strata in a society. It is a change in social status relative to one's current social location within a given society. This movement occurs between layers or tiers in an open system of social stratification. Open stratification systems are those in which at least some value is given to achieved status characteristics in a society. The movement can be in a downward or upward direction. Markers for social mobility such as education and class, are used to predict, discuss and learn more about an individual or a group's mobility in society.

Health equity arises from access to the social determinants of health, specifically from wealth, power and prestige. Individuals who have consistently been deprived of these three determinants are significantly disadvantaged from health inequities, and face worse health outcomes than those who are able to access certain resources. It is not equity to simply provide every individual with the same resources; that would be equality. In order to achieve health equity, resources must be allocated based on an individual need-based principle.

The Whitehall Studies investigated social determinants of health, specifically the cardiovascular disease prevalence and mortality rates among British civil servants. The initial prospective cohort study, the Whitehall I Study, examined over 17,500 male civil servants between the ages of 20 and 64, and was conducted over a period of ten years, beginning in 1967. A second cohort study, the Whitehall II Study, was conducted from 1985 to 1988 and examined the health of 10,308 civil servants aged 35 to 55, of whom two thirds were men and one third women. A long-term follow-up of study subjects from the first two phases is ongoing.

<span class="mw-page-title-main">Population health</span> Health outcomes of a group of individuals

Population health has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group". It is an approach to health that aims to improve the health of an entire human population. It has been described as consisting of three components. These are "health outcomes, patterns of health determinants, and policies and interventions".

<span class="mw-page-title-main">Social determinants of health</span> Economic and social conditions that influence differences in health status

The social determinants of health (SDOH) are the economic and social conditions that influence individual and group differences in health status. They are the health promoting factors found in one's living and working conditions, rather than individual risk factors that influence the risk or vulnerability for a disease or injury. The distribution of social determinants is often shaped by public policies that reflect prevailing political ideologies of the area.

Diseases of poverty, also known as poverty-related diseases, are diseases that are more prevalent in low-income populations. They include infectious diseases, as well as diseases related to malnutrition and poor health behaviour. Poverty is one of the major social determinants of health. The World Health Report (2002) states that diseases of poverty account for 45% of the disease burden in the countries with high poverty rate which are preventable or treatable with existing interventions. Diseases of poverty are often co-morbid and ubiquitous with malnutrition. Poverty increases the chances of having these diseases as the deprivation of shelter, safe drinking water, nutritious food, sanitation, and access to health services contributes towards poor health behaviour. At the same time, these diseases act as a barrier for economic growth to affected people and families caring for them which in turn results into increased poverty in the community. These diseases produced in part by poverty are in contrast to diseases of affluence, which are diseases thought to be a result of increasing wealth in a society.

<span class="mw-page-title-main">Social medicine</span> Understanding how culture and larger groups of people shape health procedures

Social medicine is an interdisciplinary field that focuses on the profound interplay between socio-economic factors and individual health outcomes. Rooted in the challenges of the Industrial Revolution, it seeks to:

  1. Understand how specific social, economic, and environmental conditions directly impact health, disease, and the delivery of medical care.
  2. Promote conditions and interventions that address these determinants, aiming for a healthier and more equitable society.
<span class="mw-page-title-main">Rural health</span> Interdisciplinary study of health and health care delivery in rural environments

In medicine, rural health or rural medicine is the interdisciplinary study of health and health care delivery in rural environments. The concept of rural health incorporates many fields, including wilderness medicine, geography, midwifery, nursing, sociology, economics, and telehealth or telemedicine.

<span class="mw-page-title-main">Socioeconomic status</span> Economic and social measure of a persons affluence and/or influence

Socioeconomic status (SES) is an economic and sociological combined total measure of a person's work experience and of an individual's or family's access to economic resources and social position in relation to others. When analyzing a family's SES, the household income and the education and occupations of its members are examined, whereas for an individual's SES only their own attributes are assessed. Recently, research has revealed a lesser-recognized attribute of SES as perceived financial stress, as it defines the "balance between income and necessary expenses". Perceived financial stress can be tested by deciphering whether a person at the end of each month has more than enough, just enough, or not enough money or resources. However, SES is more commonly used to depict an economic difference in society as a whole.

While epidemiology is "the study of the distribution and determinants of states of health in populations", social epidemiology is "that branch of epidemiology concerned with the way that social structures, institutions, and relationships influence health." This research includes "both specific features of, and pathways by which, societal conditions affect health".

Social epidemiology focuses on the patterns in morbidity and mortality rates that emerge as a result of social characteristics. While an individual's lifestyle choices or family history may place him or her at an increased risk for developing certain illnesses, there are social inequalities in health that cannot be explained by individual factors. Variations in health outcomes in the United States are attributed to several social characteristics, such as gender, race, socioeconomic status, the environment, and educational attainment. Inequalities in any or all of these social categories can contribute to health disparities, with some groups placed at an increased risk for acquiring chronic diseases than others.

Cognitive epidemiology is a field of research that examines the associations between intelligence test scores and health, more specifically morbidity and mortality. Typically, test scores are obtained at an early age, and compared to later morbidity and mortality. In addition to exploring and establishing these associations, cognitive epidemiology seeks to understand causal relationships between intelligence and health outcomes. Researchers in the field argue that intelligence measured at an early age is an important predictor of later health and mortality differences.

Research shows many health disparities among different racial and ethnic groups in the United States. Different outcomes in mental and physical health exist between all U.S. Census-recognized racial groups, but these differences stem from different historical and current factors, including genetics, socioeconomic factors, and racism. Research has demonstrated that numerous health care professionals show implicit bias in the way that they treat patients. Certain diseases have a higher prevalence among specific racial groups, and life expectancy also varies across groups.

The social determinants of health in poverty describe the factors that affect impoverished populations' health and health inequality. Inequalities in health stem from the conditions of people's lives, including living conditions, work environment, age, and other social factors, and how these affect people's ability to respond to illness. These conditions are also shaped by political, social, and economic structures. The majority of people around the globe do not meet their potential best health because of a "toxic combination of bad policies, economics, and politics". Daily living conditions work together with these structural drivers to result in the social determinants of health.

Ecosocial theory, first proposed by name in 1994 by Nancy Krieger of the Harvard T.H. Chan School of Public Health, is a broad and complex theory with the purpose of describing and explaining causal relationships in disease distribution. While it incorporates biological and psychosocial influences on disease occurrence, the theory is also suited to analyze the relationships between social factors and disease development in public health research. The core constructs of Ecosocial Theory are: Embodiment; Pathways to Embodiment; the cumulative interplay between exposure, resistance, and susceptibility; and agency and accountability. Further, the theory specifies that all constructs must be considered in concert, as they work together in a synergistic explanation of disease distribution. The theory assumes that distributions of disease are determined at multiple levels and that analyses must incorporate historical, political economic, temporal, and spatial analyses

The World Health Organization (WHO) has defined health as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity." Identified by the 2012 World Development Report as one of two key human capital endowments, health can influence an individual's ability to reach his or her full potential in society. Yet while gender equality has made the most progress in areas such as education and labor force participation, health inequality between men and women continues to harm many societies to this day.

Arline Geronimus wrote about the weathering hypothesis the early 1990s to account for health disparities of newborn babies and birth mothers due to decades and generations of racism and social, economic, and political oppression. It is well documented that people of color and other marginalized communities have worse health outcomes than white people. This is due to multiple stressors including prejudice, social alienation, institutional bias, political oppression, economic exclusion, and racial discrimination. The weathering hypothesis proposes that the cumulative burden of these stressors as individuals age is "weathering", and the increased weathering experienced by minority groups compared to others can account for differences in health outcomes. In recent years, social scientists investigated the biological plausibility of the weathering hypothesis in studies evaluating the physiological effects of social, environmental and political stressors among marginalized communities. The weathering hypothesis is more widely accepted as a framework for explaining health disparities on the basis of differential exposure to racially based stressors. Researchers have also identified patterns connecting weathering to biological phenomena associated with stress and aging, such as allostatic load, epigenetics, telomere shortening, and accelerated brain aging.

<span class="mw-page-title-main">Racial capitalism</span> Post-Marxist social and economic concept

Racial capitalism is a concept reframing the history of capitalism as grounded in the extraction of social and economic value from people of marginalized racial identities, typically from Black people. It was described by Cedric J. Robinson in his book Black Marxism: The Making of the Black Radical Tradition, published in 1983, which, in contrast to both his predecessors and successors, theorized that all capitalism is inherently racial capitalism, and racialism is present in all layers of capitalism's socioeconomic stratification. Jodi Melamed has summarized the concept, explaining that capitalism "can only accumulate by producing and moving through relations of severe inequality among human groups", and therefore, for capitalism to survive, it must exploit and prey upon the "unequal differentiation of human value."

The COVID-19 pandemic has had an unequal impact on different racial and ethnic groups in the United States, resulting in new disparities of health outcomes as well as exacerbating existing health and economic disparities.

White Americans, as the largest racial group in the United States, have historically had better health outcomes than oppressed racial groups in America. However, in recent years, the scholarly discourse has switched from recognition of the immense positive health outcomes of white Americans towards understanding the growing persistence of negative outcomes unique to this racial group. Scholars have discussed the effects of racial prejudice and its negative effect on health outcomes to not only those being oppressed but also those being given privileges. In addition to the effects of living in a racialized society, white Americans have the highest rate of suicide and lifetime psychiatric disorders of any other ethnicity or racial category. In conjunction with these psychiatric issues, the population presents higher rates of alcohol usage alongside lower levels of psychological flourishing. Given this information, the health status of white Americans has gained increasing importance due to the differences in health outcomes between white Americans and white people from other parts of the world.

References

  1. Clouston, Sean A.P.; Link, Bruce G. (2021-07-30). "A Retrospective on Fundamental Cause Theory: State of the Literature and Goals for the Future". Annual Review of Sociology. 47 (1): annurev–soc–090320-094912. doi:10.1146/annurev-soc-090320-094912. ISSN   0360-0572. PMC   8691558 . PMID   34949900.
  2. 1 2 3 4 5 Phelan, JC; Link, BG; Tehranifar, P (2010). "Social conditions as fundamental causes of health inequalities: Theory, evidence, and policy implications". Journal of Health and Social Behavior. 51: S28–S40. doi: 10.1177/0022146510383498 . PMID   20943581.
  3. Elo, I.T. (2009). "Social Class Differentials in Health and Mortality: Patterns and Explanations in Comparative Perspective". Annual Review of Sociology. 35: 553–572. doi:10.1146/annurev-soc-070308-115929.
  4. Kitagawa, E. M., and P. M. Hauser. 1973. Differential Mortality in the United States: A Study in Socioeconomic Epidemiology. Cambridge, Mass.: Harvard Universitv Press.
  5. Gordis, L. Epidemiology, Elsevier-Sanders, Philadelphia, 4th Ed., 2008.
  6. 1 2 Carpiano RM, Link BG, Phelan JC (208). "Social inequality and health: future directions for the fundamental cause explanation". In Lareau, A; Conley, D (eds.). Social Class: How Does It Work. New York: Russell Sage Foundation. pp. 232–263. ISBN   9781610447256.{{cite book}}: CS1 maint: multiple names: authors list (link)
  7. "Health literacy and public health: A systematic review and integration of definitions and models" (PDF). www.biomedcentral.com.
  8. Herd, P., Goesling, B., and House, J.S. 2007. Socioeconomic Position and Health. American Sociological Association. 48:223-238.
  9. Braveman, P (2006). "Health Disparities and Health Equity: Concepts and Measurement". Annual Review of Public Health. 27: 167–194. doi: 10.1146/annurev.publhealth.27.021405.102103 . PMID   16533114.
  10. Marmot, M.G. (1994). "Social Differentials in Health within and between Populations". Daedalus. 123: 197–216.
  11. Jaime-Castillo, Antonio M. "Economic Inequality and Electoral Participation. A Cross-Country Evaluation" (PDF). Archived from the original (PDF) on 2015-09-06. Retrieved 2012-02-01.
  12. Bartkus, V.O., Davis, J.H. (2010). Social Capital: Reaching Out, Reaching In. Edward Elgar Publishing.
  13. Eschbach, K.; Ostir, G.V.; Patel, K.V.; Markides, K.S.; Goodwin (Oct 2004). "Neighborhood Context and Mortality among older Mexican American: Is there a Barrio Advantage?". Am J Public Health. 94 (10): 1807–12. doi:10.2105/ajph.94.10.1807. PMC   1448538 . PMID   15451754.
  14. Clouston SA, Rubin MS, Phelan JC, Link BG (2016). "A Social History of Disease: Contextualizing the Rise and Fall of Social Inequalities in Cause-Specific Mortality". Demography. 53 (5): 1631–1656. doi: 10.1007/s13524-016-0495-5 . PMID   27531503. S2CID   11487416.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  15. Wang A, Clouston SA, Rubin MS, Colen CG, Link BG (2012). "Fundamental causes of colorectal cancer mortality: the implications of informational diffusion". Milbank Q. 90 (3): 592–618. doi:10.1111/j.1468-0009.2012.00675.x. PMC   3479384 . PMID   22985282.{{cite journal}}: CS1 maint: multiple names: authors list (link)