COMMUNICATIONS

Social Epidemiology Perspectives from Around the Globe

We asked Regional Councillors from the Society's Executive Council to highlight some of the key perspectives in social epidemiology and on the social determinants of health from their respective regions/countries. We are excited to share their perspectives below.

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ASIA

Epidemiology of social isolation and loneliness (Naoki Kondo)

It is anticipated that Asian countries will rapidly age in the future, leading to an increase in older individuals living alone and changes in family structures, such as the shift towards nuclear families. Accompanying these changes, there will be a focus on epidemiological research concerning the social isolation and loneliness, or social connection, which is an aspect of health known as ‘social well-being.’ This research will examine the actual conditions and related factors in various countries, as well as the efficacy/effectiveness of interventions to address these issues (for example, community-based Integrated care and social prescribing). The social well-being of older adults is expected to be a priority issue for measures in the forthcoming decades. However, the lessons learned from these measures should be implemented in a social response system that is designed for all generations, including the younger ones.
 

EUROPE

Mental ill-health in adolescents (Anne Kouvonen)

Europe has witnessed a concerning rise in mental ill-health among its adolescent and young adult population. Mental health conditions represented a major health burden for European young people already in the period 1990 to 2019 (Castelpietra et al., 2019). However, the COVID-19 pandemic further worsened the situation; the share of young people with symptoms of anxiety and depression more than doubled in several European countries, reaching prevalence levels at least twice as high as in older age groups (OECD, 2022). It is notable that mental ill-health is highly gendered: girls are more likely than boys to experience common mental disorders, such as anxiety and depression, whereas behavioural disorders, such as ADHD and conduct disorders are more common in boys. In addition, boys aged 10 to 19 die by suicide at more than twice the rate of girls. There is also a clear social gradient in adolescent mental ill-health. A systematic review (Reiss 2013) showed that socioeconomically disadvantaged children and adolescents are two to three times more likely to develop mental health problems. Particularly low socioeconomic status that persisted over time was strongly related to higher rates of mental health problems. Even in European countries with lower social inequalities, such as in Netherlands and Finland, low parental education and more adverse socio-economic backgrounds are associated with a higher probability of mental disorders in adolescence (Weinberg et al., 2023; Vaalavuo et al., 2022; Kaltiala et al., 2023). Moreover, the intersectional approach has the potential to illuminate the nuanced ways in which mental ill-health is shaped not only by isolated individual-level factors but also by broader societal and structural dynamics of discrimination, stigma, and oppression (Funer, 2023).

Population ageing (Becca Lacey)

Europe, like many other continents, has a rapidly ageing population and Europeans are living longer than ever before. According to Eurostat, more than one-fifth of the population of Europe is aged 65 years and older, with a higher proportion of older women than older men. This increase in age has not been experienced equally in all European countries; countries such as Portugal, Moldova, Slovakia and Albania having seen the largest increases in population ageing over the past decade. The rise in ageing has been accompanied by more years spent in poor health (termed the ‘Expansion of morbidity’). This has important knock-on consequences for formal and informal care provision - aspects of care which have different levels of state support across countries. For example, in the UK where there is relatively little state support for care there is a huge reliance on unpaid/informal care provided by relatives and friends. However, this in turn is potentially costly to the lives and health of those individuals, producing a cycle of care provision and care need. Relatedly, supporting the health needs of informal/unpaid carers has been raised as a crucial issue for Europe because it is a serious sustainability challenge for health and social care systems. An ageing population also means that the proportion of the population who are of working age is lower than ever before, and this has important implications for social policies, including pensions, social care, and healthcare provision. Relatedly, the ability to remain in work is socially patterned; people from the most disadvantaged groups leave the labour market involuntarily, due to poor health or providing care.
 

LATIN AMERICA & THE CARIBBEAN (Mauricio Barreto)

A complex group of 33 countries of different sizes and shapes form Latin America and the Caribbean. They share common historical roots of being colonized by European countries (Spain, Portugal, United Kingdom, etc) starting in the XVI century. Genocide acts against the original population, the millions of enslaved people taken from Africa, and the exploitation of the land by a few landowners characterized this colonial period. Even though slavery finished in the course of the XIX century, from that moment on, the different countries shared a general characteristic – a high level of social inequalities being economic or ethno-racial. Nowadays, a highly urbanized population lacking basic infrastructure is the most visible face of such inequalities. Social (critical) epidemiology developed in the continent has tried to understand the roots of such inequalities and how they are imprinted in the health situation. In this historical and inequal context, social epidemiology has been developed and has constantly confirmed itself as being part of the larger movement of social medicine or collective health. Using these as references, its social and political sense has been amplified to share the utopias and principles of humanism and social justice that guide these disciplines. It seeks to articulate its rationality and scientific objectivity with the complex reality of the sanitary conditions in Latin America, concentrating its focus on priority subjects concerning the population's health and increasing its commitment to seeking solutions, tasks very often not successful!

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MIDDLE EAST & AFRICA

Middle East & North Africa (Stephen McCall, Ghada Saad, Hazar Shamas)

Social epidemiology, which intersects with poverty, urbanisation, social inequalities, war and conflict and the threat of climate change, has diverse impacts on health and well-being in the Middle East and North Africa (MENA) region (Chaimae et al., 2024). The major contributors to morbidity and mortality are similar to other regions, and include cardiovascular disease, mental health disorders and diabetes (Mandil et al., 2013). Yet the distal drivers of these diseases may be different in the MENA region. The region is at the forefront of the impact of climate change, with increasing droughts, weather-related hazards and heat waves, which impact health through multiple modalities, including food insecurity, air pollution and water scarcity. In addition, the region continues to experience war and conflict, with recent conflicts occurring in Palestine, Lebanon, Libya, Iraq, Sudan, Yemen and Syria. Both climate change and conflict are major drivers of forced migration within the region and exacerbate existing gender and economic inequalities. Furthermore, the region has large disparities in health status between and within countries, which are due to variations in socioeconomic status and limited social protection for vulnerable populations. To exacerbate these problems further, a major challenge remains in measuring the impact of these issues due to the lack of high-quality data, preventing a holistic understanding of the social determinants and their impact on health and well-being.
 

Sub-Saharan Africa (Landon Myer, Jabulani Ncayiyana)

The issues that social epidemiology confront in the region are diverse and complex. These include young and rapidly urbanising populations; a complex burden of disease featuring the interplay of infectious and non-communicable conditions as well as high levels of violence and trauma; and pervasive absolute poverty alongside extreme inequality. In these contexts, we see social epidemiology across sub-Saharan Africa facing three distinct challenges. First is the urgent need for practical interventions. Social epidemiologists are tasked with investigating the most effective and efficient strategies for mitigating the impact of poverty on health at both micro- and macro-scales, and collaborations across the social sciences and with policy makers may be particularly valuable here. Second, there is a major gap around understanding the social elements of resilience in health, for instance understanding how social support, networks and related phenomena can be used to help leverage positive health outcomes. There are unrealised opportunities here for public health, potentially taking advantage of rapidly emerging technologies. Third, there is a profound disciplinary challenge for epidemiology at large. The social determinants of health are readily apparent across the continent, forcing anyone thinking about population health to become a ‘social epidemiologist’ in some way. However the ubiquity of social determinants also means that there can be a numbing or gradual loss of interest in grappling with upstream factors; we have a fundamental role here in advocacy to ensure that social and economic considerations remain centred as the major causes of population health.

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NORTH AMERICA (Luisa N. Borrell)

Racial/ethnic health inequities are pervasive in the United States (US). While the main health inequity has been between non-Hispanic Blacks and Whites, the increase in racial/ethnic diversity and other characteristics of the population (i.e., age, sex/gender, socioeconomic position, immigration status, etc.) underscores the need for a better understanding of the causes of health inequities.  However, to get to the roots of racial/ethnic inequities, we must examine beyond individual characteristics by identifying the causes of the causes, namely structural racism and other political determinants of health acting as socioeconomic gatekeepers for racial/ethnic racialized groups such as Blacks and Hispanics/Latinos. Using such an approach will allow us to understand how individual characteristics and factors interact or are shaped by societal and political determinants of health that may advance equity or promote and increase inequity in the US population. However, such an approach will require methods that can accommodate these factors and tease out their independent and joint effects on health outcomes. Thus, to address health inequities in the US, social epidemiology will have to use a multi-level and intersectional lens to account for the social and political determinants of health.

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OCEANIA

Australia (Tania King)

Colloquially referred to as the “lucky country”, on many metrics Australia is a good place to be for your health. Life expectancy is one of the highest globally, and the universal health care system has been the envy of many countries worldwide. But social epidemiology teaches us to look beyond population averages, to investigate the patterning of health and ask “Who gets to be healthy?” And here, when we scratch the surface on these basic health statistics and also look beyond Australia’s ingrained narrative of egalitarianism, a less-rosy picture of who-gets-to-be-healthy emerges. One of the most shameful inequities is the disadvantage and entrenched inequity experienced by Australia’s Aboriginal and Torres Strait Islander people, and the impact that this continues to have on their health and wellbeing. Another inequity is observed in the socioeconomic patterning of health outcomes, with more socially disadvantaged population groups recording higher rates of non-communicable diseases such as overweight and obesity, cardiovascular disease, and arthritis, as well as higher rates of psychological distress. But crucially, growing social inequities are emerging: income inequity is growing, housing shortages are contributing to rises in housing unaffordability and precarity, educational inequities are arising due to an increasing reliance on private education, and insecure and precarious employment is increasing. These shifts are exerting greatest impacts on some key groups including the most socially disadvantaged in society and young adults. We know that as key social determinants of health, these inequities will likely exacerbate health inequities. The challenge for us as social epidemiologists lies not in identifying these inequities, for we know they are there and are growing, but in identifying the most effective ways to use our evidence to support policy and government action.

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REFERENCES:

Castelpietra G, Knudsen AKS, Agardh EE, et al. The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990-2019: Findings from the Global Burden of Disease Study 2019. Lancet Reg Health Eur. 2022 Apr 1;16:100341. doi: 10.1016/j.lanepe.2022.100341.

Chaimae M, Jack ET, Loubna A. A scoping review of the social determinants of maternal health in the MENA region. Pan African Medical Journal. 2024;47(205).

Funer F. Admitting the heterogeneity of social inequalities: intersectionality as a (self-)critical framework and tool within mental health care. Philos Ethics Humanit Med. 2023 Nov 24;18(1):21. doi: 10.1186/s13010-023-00144-6.

Kaltiala R, Aalto-Setälä T, Kiviruusu O. Socioeconomic disparities in adolescent anxiety and depression in Finland have not increased during the COVID-19 pandemic. Scand J Public Health. 2023 Jul;51(5):656-663. doi: 10.1177/14034948231166466. Epub 2023 Apr 23.
 

Mandil A, Chaaya M, Saab D. Health status, epidemiological profile and prospects: Eastern Mediterranean region. International journal of epidemiology. 2013 Apr 1;42(2):616-26.

OECD/European Union (2022), Health at a Glance: Europe 2022: State of Health in the EU Cycle, OECD Publishing, Paris. https://doi.org/10.1787/507433b0-en.

Reiss F. Socioeconomic inequalities and mental health problems in children and adolescents: a systematic review. Soc Sci Med. 2013 Aug;90:24-31. doi: 10.1016/j.socscimed.2013.04.026. Epub 2013 May 4.

Vaalavuo M, Niemi R, Suvisaari J. Growing up unequal? Socioeconomic disparities in mental disorders throughout childhood in Finland. SSM Popul Health. 2022 Oct 29;20:101277. doi: 10.1016/j.ssmph.2022.101277. PMID: 36353094; PMCID: PMC9637807.

Weinberg D, Stevens GWJM, Peeters M, Visser K, Tigchelaar J, Finkenauer C. The social gradient in adolescent mental health: mediated or moderated by belief in a just world? Eur Child Adolesc Psychiatry. 2023 May;32(5):773-782. doi: 10.1007/s00787-021-01905-4. Epub 2021 Nov 9.