Transcript Social Marginalization and Health Disparities

Social Marginalization
Robert Coleman, Ph.D.
Dept. of Psychiatry,
Social Marginalization Module, 2007
Social Marginalization
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Marginal social position w. low status.
Often living at poverty level.
Handicapped for social competition by a limiting
condition.
Limited in social mobility and in social credentials.
Subject to discrimination and social distancing.
Subject to “weathering” (Geronimus, 1992) and accumulated
risk for poor medical and psychiatric health.
Who are the Socially Marginalized?
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Addicted, Mentally Ill, Mentally Retarded
Disabled, Physically Handicapped
Chronically ill
Illiterate, Uneducated, Unskilled
Immigrant, Migrant, Refugee
Person living below Poverty Level
Victim of Catastrophic Illness
Homeless Persons
Person with Felony Prison Record
Medically Uninsured
Socially Isolated
What factors contribute to Social Marginalization of
persons, and classes of people?
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Stigmatizing condition, difference.
Social isolation, loss of social support.
Lowered participation in mainstream activities in the
culture: work, education, training, community life.
Lowered access to social goods.
Lowered experience in using methods and viable
coping tools for social participation and striving.
Victimhood, depression.
The Argument so far….
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A variety of life-conditions, some of which have medical implications,
can marginalize individuals in the society.
This state of marginalization often results in lowered access to social
goods, such as education, job training, health promotion and disease
prevention activities, and lowered readiness to participate successfully
in mainstream activities in the culture, such as work, school, and
community and political life.
We may conjecture, using Antonovsky’s concept of social coherence,
that marginalized persons may feel estranged or disconnected from the
values of the society, and may lack coping and living skills for
participation in the mainstream of society.
This estrangement from the social and values mainstream may have
health consequences via perceived stress and physiologic stress
response, via lifestyle choices and behaviors, via lessened access to
health care and health promotion, and via lowered social support or
isolation.
How Do Social Class & Poverty Affect Health?
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Social Class is the most powerful factor in explaining Mortality and Morbidity
Disparities (Stoudemire).
Less access to health care: estimated 47 million uninsured.
Risk factor behaviors --re smoking, diet, alcohol & drug abuse, lack of exercise-are higher among the poor.
Other social factors--social isolation, low social coherence--lower psychological
resources, lead to physical and mental disorders, such as depression.
Exposure to damaging social contexts: noise, toxins, violence, trauma, which
may cause psychiatric illness and functional impairments.
Stress, multiple stressors raise physiologic thresholds for hypertension, high
cholesterol, insulin resistance, cardiovascular factors, such as platelet
aggregation.
Life Course Perspective
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Bio status trends to be marker of past social position.
The social is embodied: body records the past (e.g., miner’s
emphysema) as advantage or disadvantage.
– +/- in one sphere >>>>likely to be same in another sphere
(e.g. low birth weight).
Poor material and psychosocial circumstances; minimum
schooling; low-skill job; job and housing deprivation in adulthood
are associated with premature death in late middle age and
early old age.
Social policy: ID critical social transitions; note accumulation of
disadvantage.
Parental Acceptance-Rejection Theory (PAR
Theory) (Rohner, 2005)
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Children & adults who experience parents as rejecting
>>>>psych. maladaption with 7 features:
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Hostility, aggression, anger mgmt. problems.
Dependence on defensive independence.
Lowered self-esteem.
Lowered sense of self-adequacy.
Emotional unresponsiveness
Emotional instability.
Negative worldview.
Also lowered stress resistance; distortion of mental
representations of self, others, world.
Trusting adult intimate relationship may remediate some
features of this worldview and personality.
Effects of early life experience
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Many adult disease outcome ass. with early poor
growth: CV, respiratory, cognitive, COPD, stress
reactivity, CHD, diabetes.
Explanation #2: interaction of poor early growth with
poor socioeconomic circumstances: poor diet,
smoking, low income, obesity.
Poor growth may be of genetic origin, predisposing to
later disease (association of low birth weight with
adult diabetes and vascular disease).
Parental upward social mobility manifests in height
growth and rising cognitive function scores.
Early life stress
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Maltreatment, esp. abusive & punitive parenting, have high risk
of promoting conduct DO, antisocial behavior, and antisocial
personality.
Likelihood of adverse outcomes is ^ by compounded by poor SE
circumstances---poor parenting & care, overcrowding, welfare
dependence, and family emotional instability.
Effects:
– Psychological: emotional regulation, attachment, relationships, selfworth.
– Psychosocial: loss of self-esteem & self control lead to lower
achievemt. of school, job, coping, and harm to life chances.
– Biological: HPA axis reactivity; high glucocorticoids; behaviors to
moderate anxiety, depression, and stress.
The Physiologic Mechanisms of Disease
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Sapolsky: Physiologic Stress Response is adaptive in animals,
but in humans is apt to be chronically “turned on” with bad
health consequences. Worst stress is to be poor, say author.
Chronic stress leads to
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higher resting level of Glucocorticoids;
slower and smaller GC response to real challenge, and slower return to resting level;
higher resting BP; higher cortisol
suppressed levels of HDL; higher blood glucose, cholesterol
decrease testosterone;
decrease white blood cells;
lower insulin-like growth factor for wound healing
Sapolsky and Marmot emphasize the role of stress and HPA
axis reactivity in incrementally raising risk factors for diabetes
and heart disease.
Midlife: an era of special strain on health
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Difference in various countries between top and bottom
socioecon. groups in Life Expectancy is 4—10 years.
Steepest social gradient in health & mortality occurs during 1st
year, and in midlife.
Employment status and quality of work exert strongest effects
on health.
Health adverse behaviors and negative emotions trigger stress,
leading to health changes.
The psychosocial environment: how it impacts
health
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Human needs: 1. physical & mental well-being.
2. The need to experience a positive self.
Positive self-experience requires a social environs
that provides belonging, acting & contributing, and
gaining positive feedback.
Needed: self-efficacy: ability to accomplish tasks.
– Induces mastery feelings & control beliefs.
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Needed: self-esteem: continued ++ experience of
self-worth.
– Enables connection with others, receive feedback, grow in
belonging, approval, success.
Demand-control model of work
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Skill development & autonomy promote self-efficacy.
High demands with low decision latitude (low
authority, low skill utilization) >>> increased stress.
Low control leads to reduced self-efficacy, stress,
self-doubt, anxiety.
High demands, with high decision latitude, and job
task control leads to mastery feelings and selfefficacy, stimulating healthy functioning, buffering
stress.
Effort-reward imbalance model
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E-R imbalance model is based on idea of fairness
that assumes reciprocity for the worker’s effort.
High cost & low gain leads to emotional distress, selfdoubt, frustration, anger, sense of violation.
Feelings of injustice afflict worker self-esteem;
feelings of self-valuing are not validated. One may
cope by overcommitment, trying harder.
Risk of CVD, depression, alcohol dependence.
Consider synergy of work that invokes both kinds of
job strain.
More on work impact on health
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Work models may apply to housewives in their work.
Illness synergism may arise from work stress and
problems leading to unhealthful behaviors.
Two studies show that, compared to salary,
promotion, and job security, esteem & recognition
was more associated with good health outcome.
Research demonstrates lower SES work groups
show more prolonged BP, clotting factor, and raised
inflammatory markers compared to higher SES
group. Such responses related to low work control.
Coping=positive response outcome expectancy
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one acquires this expectancy via interaction of exposure and
response. One’s experience is stored as expectancies tied to
the stimuli and the available responses.
If outcome is negative, it is stored as a negative outcome
expectancy---”I can’t do this” ---and one feels hopeless.
If she believes she can succeed, she copes and feels mastery.
Many such expectancies are learned in childhood, and played
out in later learning.
This positive outcome expectancy has big effect on learning, on
adherence to goals, on goal achievement in life.
Negative outcome expectancy leads to helplessness and
hopelessness, as well as chronic stress and depression.
Summary: Socioeconomic Sources of stress (theory
as of 2006)
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Poverty: money vs. social participation.
Relative poverty (less than 60% of national
family median income: US= $33,600).
Discrimination
Importance of status (the social gradient of
work) and security.
Lowered sense of control.
Work: high demands, low control, low
rewards.
Other studies of social determinants of health
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Studies of health disparities between Western Europe and Central and
Eastern Europe 1970--90: decline of Life Expectancy in latter.
Holmes-Rahe “Stress Scale”: the variable meaning of certain events
creates cumulative physiological stress that increases risk of illness.
Alameda County, CA: Stress of social isolation was a greater risk
factor for morbidity and mortality than smoking, obesity, or other
behavioral risk factors.
Lynch et al (NEJM, 1997) reinterpretation of 2307 subjects in
Alameda County study to determine “Cumulative Impact of
Sustained Economic Hardship on Functioning”:
– “Strong consistent graded associations between sustained economic
hardship from 1965 to 1983 and reduced physical, psychological, and
cognitive functioning in 1994.”
Depression and its Health Risks
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Depression and the Poor: Solomon reports 40-50% depression
in 2 studies of women on welfare.
Risks of Recurrent Depression:
– 50% after first episode; 70% after second; 85% after third.
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Depression as Precipitant of 2nd Infarct in Cardiac Patients.
Depression as a Cause of Heart Disease (Rouse, 2001)
– Rouse:15 studies “strongly support” idea that depression
raises risk for Ischemic Heart Disease in men and women.
Mechanisms of action of Depression on heart
– + catecholamines may increase platelet aggregation and thrombus
formation.
– association of depression with dysrhythmia due to new balance of
SNS and PNS.
Complicated Grief Disorder
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Normal Grief: “the mourning-liberation process”.
Completion of tasks of grief enables a new view of
self and reality.
Traumatic Grief esp. after Homicide (Rynearson, 1985, 1993)
– specific focus on mode of dying.
– “A synergy of trauma and loss” with intrusive images,
psychic numbing, and unresolved grief.
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Complicated Grief & Traumatic Grief (Prigerson, 1995, 1997)
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long grief period
Yearning and searching for deceased, inability to accept.
Intrusive images, avoidance symptoms, failure to adapt
Heightened risk of medical illness after 18 months.
Trauma and Post-Traumatic Stress Disorder
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PTSD: “An American Epidemic” as common as Depression.
(Petty, 2002)
– can develop from experiencing or witnessing trauma.
– 50% of persons will experience traumatic stress; most will
experience Acute Stress Disorder (30 days), and 30% will develop
PTSD. (10% of traumatized men, 17%of traumatized women)
– Vulnerabilities for PTSD: previous Psych. Hx; previous trauma;
Borderline Personality; Neuroticism; Genetic Liability.
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Co-Morbidity is the rule:
– Substance Abuse, Depression, Mania, Anxiety, Panic
– Higher rates of Hypertension, obesity, STD, CA, heart disease, and
general medical problems.
Victimization/Abuse
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Victimization in Study of 95 CFS and Fibromyalgia Patients
– high frequency of lifelong feelings of victimization due to emotional
abuse and neglect, physical abuse, and/or sexual abuse.
– Sx: depression, pain-proneness, alexithymia, learned helplessness.
– Increased vulnerability to somatization, somatic hypervigilance,
altered pain perception; burden of overactive lifestyle to regulate
inner tension and low self-esteem;
– Adult victimization in marital relation may be a co-factor in
precipitating symptoms.
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Dating Violence Against Adolescent Girls (Silverman, 2001)(N=4000)
– one in five high school girls experienced physical or sexual
violence.
– Intimate Partner Violence (IPV) was associated with 1) +
Substances abuse; 2) unhealthy weight control 3) sexual risk
behaviors; 4) pregnancy, and 5) suicidality.
Conclusions
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Life Experience, because it changes the brain, changes the
person and his/her health risks via
– effects of HPA reactivity & complex effects on disease
mechanisms. (e.g., metabolic syndrome in Marmot)
– Effects of experience, stress, and negative emotions on
gene expression.
– Psychiatric effects on the brain may alter risks for other
psychiatric illnesses and physical illness. (Depression as risk
factor for heart disease and stroke.)
– Complex sequelae of abuse and trauma.
Person’s societal position and sense of control has health
consequences.
Health Disparities must be addressed via BioPsychoSocial
approach to medical practice.
What can you do as a Physician?
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Communication skills to build trust and rapport.
Ask questions regarding abuse, psychiatric history,
losses, coping with stress.
Practice Cultural Competence: ask re patient’s
Explanatory Model of Illness.
Educate your patients in coping skills, problemsolving. Assess sense of control, and teach means of
control. Facilitate behavioral change.
Provide hope, focus on one goal at a time.
Bibliography
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Lynch,et al. Cumulative Impact of Sustained Economic Hardship
on Physical, Cognitive, Psychological and Social Functioning.
NEJM 337:26, 1889-95. Dec. 25, 1997.
Prigerson, H, et al.. Complicated Grief…Am. J. Psych. 152:1,
22-30.
Rouse, S. Relationship between Depression and other Medical
Illnesses. JAMA 286:5, Oct. 1, 2001.
Silverman, J. Dating Violence against Adolescent Girls…JAMA
286:5, 572-79. August 1, 2001.