Some concepts used for
population health research
and interventions
Rahul Goel
TRL 702
Ecological model
• An individual’s health behavior is influenced by his
or her surroundings
• Personal, family, social, sociocultural,
organizational, community, policy, and physical
environmental factors can positively or negatively
impact a person’s engagement in physical activity
• These factors can be viewed as a framework
called an ecological model
Ecological model of four domains of active living
• Policy environment, behavioural
setting, active living domains,
perceived environment and
intrapersonal are the different
levels of ecological model that
impact the levels of active
bheaviour among population
• Information environment, social
cultural environment, and natural
environment cut across multiple
levels
Sallis, James F., et al. "An ecological approach to creating active living communities." Annu. Rev. Public Health 27 (2006): 297-322.
Ecological model of four domains of
physical activity
• Ecological model highlights that the interventions to improve active living (walking and
cycling) are multi-level in nature and needs input from multiple disciplines
• Interventions at these different levels have to work in harmony for the greatest impact on
active living
• Ecological model is a conceptual framework that helps researchers design their
interventions and study their impacts, and also policy makers to understand the different
domains to intervene
• For example, provision of a park for recreation (which is an intervention in behavoural
settings), may not be effective if we do not address the barriers under perceived
environment (e.g., perceived crime)
• This is also the key to understanding that the interventions that may work in some
countries or some settings may not work in other countries or settings
Ecological model and safe systems
approach
• There are parallels between ecological model
and the safe systems approach for road safety
• The key idea in both the models is that one
cannot make significant impact on road safety
or active living without the involvement of
multiple sectors at multiple levels
• In SSA, for reducing incidence of traffic crashes,
there is a need for safer roads (e.g. geometric
design), safe speeds (e.g., speed enforcement),
safe vehicles (e.g., ABS technology, or airbags),
and safe people (e.g., alcohol consumption,
helmet use, etc.)
Safe systems approach for road safety
Social determinants of health
• Social determinants of health (SDOH) are the conditions in
the environments where people are born, live, learn, work,
play, worship, and age that affect a wide range of health,
functioning, and quality-of-life outcomes and risks
• Social determinants of health (SDOH) have a major impact on
people’s health, well-being, and quality of life. Examples of
SDOH include:
Safe housing, transportation, and neighborhoods
Racism, discrimination, and violence
Education, job opportunities, and income
Access to nutritious foods and physical activity opportunities
Polluted air and water
Language and literacy skills
https://health.gov/healthypeople/priority-areas/social-determinants-health
Social gradient in health
and health inequalities
• Figure shows the relationship between the
gradient in neighbourhood income and life
expectancy
• In England, people living in the poorest
neighbourhoods will, on average, die seven
years earlier than people living in the richest
• Even more disturbingly, there is a greater
variation in the length of time people can
expect to live in good health (their health
expectancy)
• For example, the average difference in
disability-free life expectancy (DFLE) is 17
years
• In other words, people in poorer areas not
only die sooner, but spend more of their
shorter lives with a disability.
Social gradient in health and health
inequalities
• Risk factors for cancer and circulatory
diseases, such as smoking, physical
inactivity and obesity, are elevated along
the social gradient
• The burden of disease falls
disproportionately on people living in
deprived conditions, and for some health
conditions falls particularly heavily on
certain ethnic groups
Age standardised (a) circulatory disease and (b) cancer
death rates at ages under 75, by local ward deprivation
level, 1999 and 2001–2003
Socioeconomic gradient for different
health outcomes
• The health impact of social factors also is
supported by the strong and widely observed
associations between a wide range of health
indicators and measures of individuals’
socioeconomic resources or social position,
typically income, educational attainment, or rank
in an occupational hierarchy
Does race explain the differences in
health outcomes?
• Well, not all of it
• These socioeconomic gradients in health
have been observed not only in the U.S.
population overall, but within different
racial/ethnic groups
• This demonstrates that the socioeconomic
differences are not explained by
underlying racial/ethnic differences
• Indeed, most studies that have examined
racial/ethnic differences in health after
adjusting for socioeconomic factors have
found that the racial/ ethnic differences
disappeared or were substantially reduced
• This does not imply that the only differences in experiences between racial/ethnic groups
are socioeconomic;
• For example, racial discrimination could harm the health of individuals of all
socioeconomic levels by acting as a pervasive stressor in social interactions, even in the
absence of anyone’s conscious intent to discriminate
• Furthermore, the black-white disparity in birth outcomes is largest among highly educated
women
• Living in a society with a strong legacy of racial discrimination could damage health
through psychobiologic pathways, even without overtly discriminatory incidents
What is the causal direction: poverty
leads to poor health, or vice-versa?
• Observing a graded relationship (as opposed to a simple threshold, for instance at the
poverty line) of socioeconomic factors with many different health indicators suggests a
possible dose-response relationship, adding to the likelihood that socioeconomic factors
—or factors closely associated with them—play a causal role.
• Some have argued that income-health or education-health relationships reflect reverse
causation (i.e., sickness leading to income loss and/or lower educational achievement).
• Links between education and health, furthermore, cannot be explained by reverse
causation because once attained, educational attainment is never reduced
• Some aspects of socioeconomic factors are connected to health via responses to
relatively direct and rapid-acting exposures.
• For example, poor tend to live close to highways, with high volumes of motorised traffic
and especially freight traffic, which exposes them to different risk factors associated with
transport (air pollution, noise pollution, and traffic injuries)
Neighbourhoods in which children grow
up impact their health and wellbeing
• Similarly, poor neighbourhoods are less likely to have access to parks and recreational
areas, thus depriving residents the opportunity to engage in outdoor activities
• Children growing up in socioeconomically disadvantaged neighborhoods face greater
direct physical challenges to health status and health- promoting behaviors
• They also often experience emotional and psychological stressors, such as family
conflict and instability arising from chronically inadequate resources
• Adjusting for depression, anxiety, and other negative emotional states, however, has
not completely explained the effects of social factors on health
Upstream and downstream determinants
of health
• Upstream SDOH refers to the macro factors that comprise social structural influences on
health and health systems, government policies, and the social, physical, economic and
environmental factors that determine health
• While upstream concepts may intuitively make sense, the causal pathways linking these
determinants with health are typically long and complex, and often involve multiple
intervening factors along the way
• Education is, for example, an upstream determinant of health
• Walking and cycling is a downstream determinant of health
https://www.rand.org/content/dam/rand/pubs/working_papers/WR1000/WR1096/RAND_WR1096.pdf
Pathways through which education
impacts health
• The first pathway is widely accepted: education increases knowledge and skills and, thus,
can facilitate healthier behaviors
• The second pathway also is biologically plausible. However, while its left-sided branches
(i.e., education leading to better, higher-paid work) are not disputed, subsequent links
from income to health through various pathways, such as work-related benefits,
neighborhood opportunities, and stress, are not typically considered as education effects
• The third pathway depicts health effects of education through psychobiological processes
such as control beliefs, subjective social status, and social networks, again based on
existing literature
• As is clear, the causal directions can be disputed
• In India, depending on your socioeconomic status, your educational attainment will vary,
which will then impact your downstream determinants of health
