Epigenesis theory: a mathematical model relating causal concepts of pathogenesis in individuals to disease patterns in populations

A mathematical modeling approach called epigenesis theory is presented which relates three aspects of pathogenesis to the population distribution of disease. The three aspects of pathogenesis involve how two or more measured variables interact. They are 1) whether the measured variables are related to the same causal action, 2) whether there is only one pathogenic process leading to disease, and 3) whether the measured variables contribute to the same pathogenic process. Epigenesis theory defines the following multivariable relations between two disease causes: 1) "Complementary" causes contribute different causal actions to the sole pathogenic process leading to disease. They have multiplicative relations. 2) "Separate process" causes contribute different causal actions to different pathogenic processes. They have the relations of simple independent action which are slightly less than additive. 3) "Intermediate" causes contribute different causal actions to the same pathogenic process in the presence of additional pathogenic processes where at most one of them may also participate. They have relations somewhere between multiplicative and simple independent actions. 4) "Cooperative-competitive" causes share the same causal action and act within the same pathogenic process. Their relations can change from greater than multiplicative to less than simple independent action at increasing dichotomization points of the measured variables. Epigenesis theory unifies the sufficient-component causes model and the simple independent action model and exceeds either model in the range of observations it can explain. It is most useful given directly causal measured variables and specific disease outcomes, but it will assist in etiologic investigations of nonspecific outcomes in which new disease classifications are proposed. While it is less useful given surveillance-type variables such as age or sex or outcomes resulting from numerous pathogenic processes such as death, it gains utility as more causal variables are entered into an analysis and as more cut points of continuous complementary, independent, or intermediate variables are distinguished.     

Public reaction to toxic waste contamination: analysis of a social movement

In this article we explore citizen action against toxic waste as a social movement, emphasizing the unique challenges posed by the technological nature of the toxic waste issue. Unlike other contemporary health-related social movements such as the women's movement and anti-nuclear groups, the movement against toxic waste is not composed primarily of highly educated, upper-middle-class people who are motivated by global concerns. Toxic waste activists are typically working-class and lower-class people, politicized initially by perceptions of danger to the health of their families. However, awareness of global dangers and the larger political-economic issues related to toxic waste contamination is often emergent in the process of mobilization. The movement against toxic waste can be seen as part of a larger social trend toward increased public demand for a role in scientific and technological decision-making which challenges scientific criteria for assessing risk and experts' claim to technical knowledge. While toxic waste activism is better explained by European theorists' "new social movement theory" than by resource mobilization theory, the former theory does not account for the toxic waste movement's class composition. The necessity for developing a new theory of social movements that captures the complexities of toxic waste activism is discussed.     

The field of psychiatric contention in the UK, 1960-2000

In this paper I discuss the question of how we should understand the concept of "social movements", particularly as applied to health related movements. My argument is that movements should be understood as "fields of contention". This concept, as I develop it, emphasizes two key aspects of social movement mobilization. Firstly, departing from traditional models of movements, which tend to view them as unified "things", it draws our attention to the numerous groups and agents who interact within the internal space of a "movement" and to the relations, alliances and conflicts between those various groups/agents as they unfold through time. Secondly, it draws our attention to the embedding of social movement struggles within multiple differentiated contexts of struggle, each of which affords different opportunities for struggle but each of which makes different demands upon activists if struggle is to prove effective. The model of fields of contention is explored within the paper using empirical data on a variety of "social movement organizations" (SMOs) which have formed around the mental health system in the UK over the last forty years.     

Health by association? Social capital, social theory, and the political economy of public health

Three perspectives on the efficacy of social capital have been explored in the public health literature. A "social support" perspective argues that informal networks are central to objective and subjective welfare; an "inequality" thesis posits that widening economic disparities have eroded citizens' sense of social justice and inclusion, which in turn has led to heightened anxiety and compromised rising life expectancies; a "political economy" approach sees the primary determinant of poor health outcomes as the socially and politically mediated exclusion from material resources. A more comprehensive but grounded theory of social capital is presented that develops a distinction between bonding, bridging, and linking social capital. It is argued that this framework helps to reconcile these three perspectives, incorporating a broader reading of history, politics, and the empirical evidence regarding the mechanisms connecting types of network structure and state-society relations to public health outcomes.     

Community involvement in health promotion: progress or panacea?

There are many arenas within which health promotion may be located. This paper addresses the issues involved in the development of health promotion in one such arena: the community health movement. This movement is complex and dynamic. When reference is made to non-statutory health action, or to community involvement in health, this complexity may not be fully appreciated. There is a tendency for the range of activity to be reduced to its most "visible" form: self-help activity. However, there is more to the community health movement than this. A typology is offered here in which three levels of community-based activity in Britain are identified. These are referred to as self-help groups, community health groups and community development health projects. The breadth and range of this activity reflects the inability of formalized health care to tackle many of the underlying causes of ill-health. Each type of community health activity exists as a declaration of this failure, but some forms of activity may be welcomed by the health professions whilst others may not. In particular the numerically small community development health projects offer a significant challenge to formal health care because they seek to encourage collective health activity by those who are least in control of their own health. It is within the context of developing strategies for health promotion that community health action is most relevant. National and local strategy documents suggest that community involvement is essential for the successful promotion of health. Fully comprehensive participation by community groups signifies a major shift in our perceptions of health and health care. An appreciation of the existing range of health action in communities is an important starting point for medical health professionals engaged in this task.     

"Requested death": a new social movement

This paper addresses current developments in the right-to-die arena. While discussion of this area has traditionally been the province of disciplines other than sociology, including philosophy and bioethics, this paper offers an alternative framework from which to consider the progressive interest in control and choice at life's end which has developed this century, principally in the Western world. Taking a largely socio-historical approach, this paper argues that issues such as euthanasia and physician-assisted suicide can be seen as forming part of an international social movement, which is dubbed 'the requested death movement'. The paper traces the chronology of the movement, placing its framing activities, the emergence of individual activists and events and its progressive mobilization, within a consideration of so-called 'new' social movements, which have emerged since the 1960s. These are principally concerned with resisting state control of cultural matters, while reclaiming matters of identity, privacy and individual corporeality, which it is argued are at the core of the requested death movement. It is posited that this consideration can contribute to understandings of both the contemporary social organization of death and dying, and social movement theory more generally.     

Community involvement in health promotion: progress or panacea?

There are many arenas within which health promotion may be located.This paper addresses the issues involved in the developmentof health promotion in one such arena: the community healthmovement. This movement is complex and dynamic. When referenceis made to non-statutory health action, or to community involvementin health, this complexity may not be fully appreciated. Thereis a tendency for the range of activity to be reduced to itsmost "visible" form: self-help activity. However, there is moreto the community health movement than this. A typology is offered here in which three levels of community-basedactivity in Britain are identified. These are referred to asself-help groups, community health groups and community developmenthealth projects. The breadth and range of this activity reflectsthe inability of formalized health care to tackle many of theunderlying causes of ill-health. Each type of community healthactivity exists as a declaration of this failure, but some formsof activity may be welcomed by the health professions whilstothers may not. In particular the numerically small communitydevelopment health projects offer a significant challenge toformal health care because they seek to encourage collectivehealth activity by those who are least in control of their ownhealth. It is within the context of developing strategies for healthpromotion that community health action is most relevant. Nationaland local strategy documents suggest that community involvementis essential for the successful promotion of health. Fully comprehensiveparticipation by community groups signifies a major shift inour perceptions of health and health care. An appreciation ofthe existing range of health action in communities is an importantstarting point for medical health professionals engaged in thistask.     

Understanding nursing: the usefulness of a philosophical perspective *

Abstract The work of nursing involves both treatment orientated action and care orientated action, but there exists a ‘treatment–care’ dichotomy that is structured by social factors and views of knowledge that privilege scientific, instrumental rationality. It is a claim of this paper that there is a need to establish connections between ‘treatment’ and ‘care’. The study of work processes in the healthcare field make it possible for nursing to recognize the technical and social separation of work, the separation between manual and intellectual work, the dominance of medicine among healthcare professionals, and other relations of power within institutions. The authors believe that Habermas' theory of communicative action offers an alternative view, one suitable for transforming healthcare practices and helping nurses build new responses to healthcare needs.     

Borrowing to build: private money and public welfare.

The process of local government borrowing to finance the capital needs of social services has an impact on both central-local relations and the type of service which can be offered to the citizen-consumer. Based on an examination of these relationships in the United States, the United Kingdom, France, and Italy, it is postulated that different types of central-local relations are dependent on the nature of relations between central government and the investment community. Further, through use of material from a case study of public housing politics in Italy, it is shown how the investment criteria of the so-called "private" sector are transferred to the operations of the public sector through the mechanism of local borrowing. This transferal affects the manner in which social services are conceived and delivered.     

Bureaucratic logic in new social movement clothing: the limits of health promotion research

This paper discusses theoretical, methodological and politicalproblems in the field of health promotion research. It arguesthat these problems result from a partial and contradictoryappropriation of the discourse of new social movements. Politically,the health promotion movement is largely confined within thestate, rather than the expression of a social movement againstthe state. The direction of health promotion research and policyis, therefore, caught in the bureaucratic logic of ‘trappedadministrators’, and results in contradictory emphaseson problems like the development of ‘health promotionindicators’, which show little result in informing a broaderbut coherent conceptualization of health, let alone in effectingchange in health policy and outcomes. Such political problemsreflect parallel confusions about theory and methodology. Theoretically, the field relies heavily on a critique of bio-medicalscience, but fails to move beyond a rhetorical outline of analternative to systematic arguments about what promotes health.In this regard, the literature on health promotion remains unawareof important conceptual developments in the social sciences,relies on imprecise specifications of major constructs likecommunity empowerment, and has no conception of the state. Methodologically,the literature is influenced by contradictory epistemologicaltendencies which reflect a positivist inspiration (as in thesearch for indicators) and an anti-positivist emphasis on agencyand social change through the collective action and the discursivereconstitution of social identity, value and meaning. In regardto these questions, this paper is critical of observers whosuggest that the way ahead is to embrace post-modern researchstrategies. Movement in this direction would tend to diffusean already desultory research practice and depoliticize socialstruggles for meaningful change. The paper ends by suggestingthat the field of health promotion needs a more serious engagementwith critical social theory to construct a rigorous conceptualizationof health and its social correlates and to develop a coherentresearch practice and political project.     

Autism spectrum disorders: toward a gendered embodiment model

One of the most consistent observations in the epidemiology of autism spectrum disorders (ASD) is the preponderance of male cases. A few hypotheses have been put forth which attempt to explain this divergence in terms of sex-linked biology, with limited success. Feminist epidemiologists suggest the importance of investigating specific mechanisms for male-female differences in health outcomes, which may include sex-linked biology and/or gender relations, as well as complex biosocial interactions. Neither domain has been systematically investigated for autism, and the possible role of gender has been particularly neglected. In this article, we posit hypotheses about how social processes based on perception of persons as male or female, particularly patterns of social and physical interaction in early development, may affect the observed occurrence and diagnosis of ASD. We gesture toward an embodiment model, incorporating hypotheses about initial biological vulnerabilities to autism--which may or may not be differentially distributed in relation to sex biology--and their interactions with gender relations, which are demonstrably different for male and female infants. Toward building such a model, we first review the epidemiology of ASD with an eye toward male-female differences, then present a theory of gender as a "pervasive developmental environment" with relevance for the excess burden of autism among males. Finally, we suggest research strategies to further investigate this issue.     

Nutrition and the elderly: identifying those at risk

At present our interpretation of dietary, biochemical and clinical findings is still inadequate to diagnose marginal or subclinical malnutrition in the elderly. There are two main types of nutritional risk; the first is long-standing, against which early-warning signs and early preventive action are needed. The second type of nutritional risk may be sudden, following medical or social stress. This calls for prompt action at that critical stage. Given the means to implement research findings, practical action can be taken by the Health and Social Services, relations, friends and the elderly themselves. It is necessary to take practical action against nutritional risks at an early stage. For this reason, our current longitudinal study is concentrated on men and women at the age of retirement from work.     

Employment relations, social class and health: a review and analysis of conceptual and measurement alternatives

Employment relations, as a theoretical framework for social class, represent a complementary approach to social stratification. Employment relations introduce social relations of ownership and control over productive assets to the analysis of inequalities in economic (e.g., income), power (occupational hierarchy), and cultural (e.g., education) resources. The objectives of this paper are to briefly clarify the theoretical background on socio-economic indicators used in social epidemiology and to conduct a review of empirical studies that adopt relational social class indicators in the socio-epidemiological literature. Measures of employment relations in social determinants of health research can be classified within two major conceptual frameworks: 1) "Neo-Weberian", like the National Statistics Socio-Economic Classification (NS-SEC) which is widely used in the United Kingdom; and 2) "Neo-Marxian", like Erik O. Wright's social class indicators, which are being used by social epidemiologists in the Americas and Europe. Our review of empirical findings (49 articles found) reveals that the relation between employment relations and health does not necessarily imply a graded relationship. For example, small employers can exhibit worse health than highly skilled workers, and supervisors can display worse health than frontline workers. The policy implications of employment relations research are therefore different, and complement those of income or education health gradient studies. While the latter studies tend to emphasize income redistribution policy options, employment relations implicate other factors such as workplace democracy and social protection. Our analysis confirms that the current transformation of employment relations calls for new social class concepts and measures to explain social inequalities in health and to generate policies to reduce them.     

Comfortably,Safely, and Without Shame: Defining Menstrual Hygiene Management as a Public Health Issue

In recent years, the menstrual hygiene management challenges facing schoolgirls in low-income-country contexts have gained global attention. We applied Gusfield’s sociological analysis of the culture of public problems to better understand how this relatively newly recognized public health challenge rose to the level of global public health awareness and action. We similarly applied the conceptualization by Dorfman et al. of the role of public health messaging in changing corporate practice to explore the conceptual frames and the news frames that are being used to shape the perceptions of menstrual hygiene management as an issue of social justice within the context of public health. Important lessons were revealed for getting other public health problems onto the global-, national-, and local-level agendas.Menstrual hygiene management (MHM) has become a globally recognized public health topic. Around the world, a growing coalition of academics, donors, nongovernmental organizations (NGOs), United Nations agencies, grassroots women’s organizations, multinational feminine hygiene companies, and social entrepreneurs are mobilizing to bring attention and resources to address the menstrual-related shame, embarrassment, and taboos experienced by many girls in low- and middle-income countries (LMICs).1–4 This informal coalition is advocating the improved provision of puberty guidance, sanitary materials, and water and sanitation facilities for girls in school.5,6 In least-developed and other low-income countries in 2013, the global average for school water coverage was 47% and for school sanitation coverage was 46%.7 At the same time, the movement is generating interest in improving the often inadequate, unhygienic, and unsafe circumstances in which many women in low-resource contexts manage their monthly menses.Just 10 years ago, there was little public discussion about the menstrual management–related challenges facing girls and women in LMICs. How did this singular aspect related to female physiology—the need for girls to have access to menstruation-related infrastructure and information that would enable them to successfully advance their education and subsequent development—become a globally recognized public health issue?8 Why did this recognition lead to a growing global social movement on MHM management?9 In this article we seek to analyze the various moments, events, players, and organizations that have contributed to the definition and articulation of menstruation as a globally recognized public health challenge. This analysis provides insights about what is involved in bringing attention and resources to other critically important public health issues. It also reveals gaps that remain in the menstruation-related agenda of the future.We draw on Gusfield’s sociological analysis of the culture of public problems to analyze the factors that have shaped and influenced the shifting of menstrual management from an individual-level experience to a political problem worthy of government-level attention.8 Through this analysis, we seek to understand (1) the historical dimensions of the emergence of menstruation as a public problem, (2) the cultural and structural dimensions of changing the attribution of responsibility of menstruation from an individual experience to one with societal obligations, (3) the cognitive beliefs and moral judgments that have shaped the perception of menstruation as a public problem, and (4) the attribution of political responsibility for menstruation.Our analysis suggests that interest and action on the issue of MHM had their initial origins in the global concern for narrowing the gender gap in education. Interest existed from the education perspective, which was aimed at keeping girls in school and improving their educational outcomes, and from the public health perspective, responding to the decades of evidence indicating that educated girls contribute to healthier population outcomes.10 We will delineate the pathway from these origins up through today’s global social movement, which is attracting stakeholders from a range of different sectors. The mobilization of interest represented the coming together of 2 constituencies—one (constituency) concerned about a possible “solution” to gender disparities in education completion, and another concerned about keeping girls in school for population health reasons. As will be discussed, the market constituency (i.e., global private-sector sanitary pad companies) also played a role in influencing the growth of the global social movement.We also analyze the diverse messaging that the multiple players and sectors have used in taking up the issue of MHM. In applying the conceptualization by Dorfman et al. of the role of public health messaging in changing corporate practice, we discuss both the conceptual frames and the news frames that are being used to shape the perceptions of MHM as an issue of social justice within the context of public health.11 The role of framing is particularly salient because of the taboo nature of the topic of menstruation in many contexts across the low-, middle-, and high-income world. For some players (individuals, organizations, institutions), the existence of strong taboos has required them to develop carefully worded messages on menstruation and MHM that take into consideration local cultural sensitivity. By contrast, other players have tackled the taboo head-on, with more explicit, targeted messaging on menstrual blood. Understanding how different players have framed this issue, and the role that such framings play in building a growing global social movement on MHM, provides useful insights for public health professionals seeking to address other neglected or insufficiently recognized health concerns.     

Unfair inequalities in health and health care

Inequalities in health and health care are caused by different factors. Measuring "unfair" inequalities implies that a distinction is introduced between causal variables leading to ethically legitimate inequalities and causal variables leading to ethically illegitimate inequalities. An example of the former could be life-style choices, an example of the latter is social background. We show how to derive measures of unfair inequalities in health and in health care delivery from a structural model of health care and health production: "direct unfairness", linked to the variations in medical expenditures and health in the hypothetical distribution in which all legitimate sources of variation are kept constant; "fairness gap", linked to the differences between the actual distribution and the hypothetical distribution in which all illegitimate sources of variation have been removed. These two approaches are related to the theory of fair allocation. In general they lead to different results. We propose to analyse the resulting distributions with the traditional apparatus of Lorenz curves and inequality measures. We compare our proposal to the more common approach using concentration curves and analyse the relationship with the methods of direct and indirect standardization. We discuss how inequalities in health care can be integrated in an overall evaluation of social inequality.     

Social determinants of health: present status, unanswered questions, and future directions.

This article reviews the current status of theory and research concerning the social determinants of health. It provides an overview of current conceptualizations and evidence on the impact of various social determinants of health. The contributions of different disciplines--epidemiology, sociology, political economy, and the human rights perspective--to the field are acknowledged, but profound gaps persist in our understanding of the forces that drive the quality of various social determinants of health and why research is too infrequently translated into action. Many of these gaps in knowledge concern the political, economic, and social forces that make implementation of public policy agendas focused on strengthening the social determinants of health problematic. The author identifies the areas of inquiry needed to help translate knowledge into action.     

Catalyzing a Reproductive Health and Social Justice Movement

Objectives The maternal and child health (MCH) community, partnering with women and their families, has the potential to play a critical role in advancing a new multi-sector social movement focused on creating a women’s reproductive and economic justice agenda. Since the turn of the twenty-first century, the MCH field has been planting seeds for change. The time has come for this work to bear fruit as many states are facing stagnant or slow progress in reducing infant mortality, increasing maternal death rates, and growing health inequities. Methods This paper synthesizes three current, interrelated approaches to addressing MCH challenges—life course theory, preconception health, and social justice/reproductive equity. Conclusion Based on these core constructs, the authors offer four directions for advancing efforts to improve MCH outcomes. The first is to ensure access to quality health care for all. The second is to facilitate change through critical conversations about challenging issues such as poverty, racism, sexism, and immigration; the relevance of evidence-based practice in disenfranchised communities; and how we might be perpetuating inequities in our institutions. The third is to develop collaborative spaces in which leaders across diverse sectors can see their roles in creating equitable neighborhood conditions that ensure optimal reproductive choices and outcomes for women and their families. Last, the authors suggest that leaders engage the MCH workforce and its consumers in dialogue and action about local and national policies that address the social determinants of health and how these policies influence reproductive and early childhood outcomes.     

Quality assurance in mental health-care: a case study from social work

The quality of health and social care is now a high priority for government, professionals, and the public. This is particularly true of mental health, where explicit standards lie at the centre of current policy, demanding the development of reliable means for quality assurance. These need to allow for the multiplicity of stakeholders in mental health-care, and their different constructions of "quality". The challenges presented are illustrated by this account of an action research programme, which was developed to improve social work practice in a multidisciplinary mental health service, and evaluated using a case study design. An action research approach was chosen in preference to an "off-the-shelf" quality assurance system, because it possessed features that appeared to match the context of the work. It involved feeding back the findings of a baseline assessment of service quality to four teams of social workers, who used the information to select priority areas for improvement. An action plan was developed with them, and its implementation and impact were examined. Substantial improvements were observed in only one of the chosen target areas--the quality of case recording. For the other--securing the clients' full involvement in their care plan--very limited improvements occurred. Interview data suggested that this was due to the presence of extensive organisational support for the first objective, but not the second. These findings suggest that while some features of action research can contribute to quality improvement, these must be incorporated into a more comprehensive programme of change, which commands the support of all the stakeholders involved.     

Pathways to the Use of Health Services Research in Policy

Objective. To apply social science theory so as to define more explicitly the pathways that influence policy makers' use of health services research.
Methods. The analysis builds on a literature review and the author's observations. It identifies important social science concepts relevant to use of research in policy and organizational decision making. It integrates and expands upon existing frameworks to differentiate and analyze 10 pathways that can lead to the use of health services research by policy makers.
Principal Findings. The process through which research is applied involves many factors, only some of which are amenable to influence by researchers. Within these constraints, multiple pathways can drive research use; no one of these is likely to perform better in all circumstances. Successful uptake is more likely when these pathways cause findings to be converted into messages meaningful to policy makers. Various intermediaries play an important role in creating effective pathways, while users also can influence them.
Conclusions. The pathways open up what too often is an unexplored "black box" that mediates between health services research and its use by policy makers. Such pathways can help stakeholders to bridge different perspectives in ways that strengthen the possibility that effective research will be supported and used.     

Does socioeconomic status affect the association of social relationships and health? A moderator analysis

Background  

Social relations have repeatedly been found to be an important determinant of health. However, it is unclear whether the association between social relations and health is consistent throughout different status groups. It is likely that health effects of social relations vary in different status groups, as stated in the hypothesis of differential vulnerability. In this analysis we explore whether socioeconomic status (SES) moderates the association between social relations and health.