PHCM9520

Advanced Social and Behavioural Epidemiology

2014
Any quantitative population-based health
research that measures social variables such
as gender, income, education and ethnicity,
and uses these to explain, or search for
explanations for, differences in health
outcomes.
We will also look at social effects of differ-
ences in health outcomes (e.g. becoming
welfare-dependent and/or isolated if ill)
Also behavioural epidemiology, looking at
behaviours such as food consumption,
exercise, drug use, crime and healthcare-
seeking (or -avoiding) behaviour
Social variables like income and private
behaviours (such as eating at home, sex or
crime) are notoriously hard to measurebut
it is illuminating to try

Introducing my work
Your interest in social epidemiology
About the course
Teaching and assessment
A brief and selective history of social
epidemiology
Study design exercise
Editor, books and journal production
Family Planning Education Unit: Editor of
Healthright: Journal of Womens Health,
Family Planning and Sexuality
MPH majoring in epidemiology and research
design
Worked on Commonwealth AIDS Research
Grant-funded project on condoms and
condom use (infamy + media)

Ran Australian Journal of Public Health as
managing editor with Professor Charles Kerr
Set up womens health course in MPH at
University of Sydney with Julia Shelley, then
lectured in sociology of health

Worked 19962007 at National Centre in HIV Social
Research (now Centre for Social Research in Health, UNSW)
Involved with and/or ran:
gay community periodic surveys
studies of Aboriginal gay/bi men, non-gay-
identifying men, Asian gay/bi men
biennial surveys of women in contact with the gay
community (mostly lesbian and bisexual)
study of men who had recently acquired HIV
surveys of first year students


Joined group putting in grant application for
a large national representative-sample survey
of sexual behaviour and attitudes: Australian
Study of Health and Relationships (ASHR)
Surveyed 19,307 people in 200102, worlds
2nd largest national sex survey
I was only woman on team, led
contraception, sexual difficulties etc.
Learnt about sampling and phone interviews
Now lead Second Australian Study of Health
and Relationships
Interviewed 20,094 people randomly selected
by telephone
Results coming out in November
Australia is one of only three countries (with
UK and France) that has repeated survey
Larger sample than UK (why?)
food and drink
smoking
sexual behaviour
exercise
(illicit) drug use
driving and transport
use
crime
work
attitudes


psychological
constructs such as self-
efficacy
social dis/advantage
race, ethnicity and
culture
the nature of risk
measurement of social
variables
observed and reported
behaviour
modes of data
collection
official data sources
and secondary analysis
modelling social
processes

use of regression, e.g.
for correction for
confounders
individual v. household
or community-level
data and analysis
sampling: individual,
household, cluster,
non-randomised

1. What is social
epidemiology?
2. Running, walking and
sitting
3. Eating and drinking
Gender and sex
4. Thinking about
behaviour
5. Measuring thoughts
and behaviour: Patrick
Rawstorne

7. Analysing thoughts and
behaviour: Patrick
8. Asking questions
9. Sampling for surveys
10. Social inequality
11. Risky and stigmatised
behaviour
12. Publishing your research
Lectures, discussion, exercises, reading and
assessments
Marks not same as % time spent
Room for your focus (inequality, lifestyle, social
capital, social cohesion, measurement of individual risk
factors)
Marks for attendance
external course available 2014
please come and share your experience!

Not really advancedonly in sense that prior
epi basics required (well do revision)
Doesnt teach you statistics (except Patrick), but
you need to think logically and quantitatively
Doesnt set out to teach you sociological theory
(but gives you a good crap detector!)

It does focus on conceptual underpinnings and
equip you to work as the research design person
in a multidisciplinary team
I recommend Advanced Biostatistics and
Advanced Epidemiology for quantitative
researchers
Do you have SPSS? (real data)
Model answers to exercises will be handed
out during the semester and added to
Moodle


Both available to read or download from
UNSW Library
Both American, so Australian material will
also be used in class
Berkman & Kawachis Social Epidemiology is a
series of essays:
discrimination
social inequality
depression and mental illness
health behaviour in social context
Oakes & Kaufmans Methods in Social
Epidemiology:
2 introductory essays
7 chapters on measures
8 chapters on design and analysis
Always start with relevant material from the
books for any assignment or discussion
Odd foci: gender missing, race emphasis, US
p.o.v. (differences?)
Books go further than the course
1. Critique of published studies 15%
Due 19 August
2. Class presentation 20%
Pick your topic!
Various dates
3. Questionnaire design 25%
Due 23 September
4. Study design 30%
Due 7 November
5. Class participation 10%
Activities for practice in class, e.g. study
design today
Exercises to do at home and prepare for
following week, e.g. revision quiz for next
week
Reading
Media alerts and online sources
Any questions?
History of public health is social
epidemiology, from before germ theory
All epidemiology is social in a sense, i.e.
population not individual
Awareness that conditions caused ill health
from ancient times (e.g. miasma)
19th century social reform

Berkman & Kawachi regard it as emerging
during 1970s
Hamlin (in Oakes & Kaufman) takes historical
and philosophical view

conceptually fundamental to medical inquiry
the understanding of disease in terms of
factors usually designated as social
economic position, family and community
class, ethnicity, culture
legal and political system
troublesome dichotomy: social and biological
diet & exercise: calories and heart condition, or
cultures of eating and exercise?

1. To elucidate causation of disease not caused
by simple agent/process (e.g. heart disease)
2. Even where pathogen recognised, to
identify social elements (e.g. footwear for
hookworm control)
3. To guide intervention to improve health
generally
4. a key to a non-reductive pathology
[recognising] milieu, a sense of self, and
somatic state
Hamlin traces connections to Hippocrates
and Galen
Exciting and predisposing causes (reflected in
modern epi; see over)
Exciting cause usually infectious agent
Theorising about society is a product of the
18th century
Hamlin traces connections to Hippocrates
and Galen
Exciting and predisposing causes (reflected in
modern epi; see over)
Exciting cause usually infectious agent
Theorising about society is a product of the
18th century
The social order: medieval view static
What about social mobility?
Social radicals conceptualised social change
to allow opportunity and freedom
Individual as the unit
[Source of the modern notion of a right to
health]
Parish records
Early quasi-quantitative theories: natural
selection, Malthus
Prussian army chaplain Johan Peter
Sssmilch (17071777), calculated sex ratios
and mortality rates
Rejection of vague qualitative notions:
Does it contain any abstract reasoning
concerning quantity or number? No. Does it con-
tain any experimental reasoning, concerning
matter of fact and existence? No. Commit it
then to the flames: for it can contain nothing
but sophistry and illusion.

Hume, D. (1748). An Enquiry Concerning
Human Understanding, sec. 12, pt III.

Amassed data means nothing
Tables gave access to an aggregated domain
hitherto invisible
Even plotting 2-dimensional data on a grid
not widespread until 19th century
Hamlin argues that:
1. a theory of disease causation
2. a conception of a dynamic society
3. a set of methods of [mathematical]
inference
were preconditions for social epidemiology

Germ theorists versus social theorists
Despite new knowledge, death rates and
misery remained high
More amenable to structural and political changes
and social control such as health education
Even when infection known, no use for prevention
Philosophy different in France, Scotland ad
England
Poor relief in England drove need for rational
policy
Edwin Chadwick
18001890
appointed to Royal
Commission into the
Poor Laws
Sanitary Conditions of
the Labouring
Population of Great
Britain (1842)

Friedrich Engels
not medically trained
Pietism blamed poor
for their plight
journalism; lived in
industrial town
workers suffering
The Condition of the
Working Class in
England (1844)
Rudolf Virchow
18211902
born German/Polish
medical scholarship
later reputation for
cellular pathology
vision of largely social
origins of illness
argued for govt inter-
vention in famine and
public health service
See essay by Waitzkin for details including
Salvador Allende (link in session notes)
Director-General of Health, Commonwealth
of Australia
Founder of Quarantine Service
Major work published posthumously, edited
by historian Milton Lewis
Health and Disease in Australia: A History
Trad medical rather than social, but included
industrial hygiene, lead intoxication, mining,
wages and conditions of employment

Charles Baldwin Kerr
1932
Born UK, St Andrews
University and USyd
population genetics at
Oxford
1968 Professor of Social
and Preventive Medicine,
SPHTM
Ranger Inquiry, Family
Planning, Aboriginal,
homeless, migrants,
disability
Are social changes subject to
experimentation?
Can one randomise social change?
Do Activity 1.1 in Session 1 notes as revision
of epidemiological concepts
Bring to discuss next week