Responsibility amid the social determinants of health

It is natural to think that there is a tight connection between whether someone is responsible for some outcome and whether it is appropriate to hold her accountable for that outcome. And this natural thought naturally extends to health: if someone is responsible for her health, then, all else being equal, she is accountable for it. Given this, some have thought that responsibility for health has an important role to play in distributing the benefits and burdens of healthcare. But there is a reason for caution. That health is influenced by social, economic, and environmental factors is a matter of consensus. And some have argued that in light of these social determinants of health, individuals are not typically responsible for their health, rendering inappropriate policies that employ a responsibility‐for‐health criterion. This debate implicates a number of overlapping concepts and questions that are often difficult to pull apart. And I worry that those who maintain that social determinants undermine responsibility for health have latched on to the wrong target. The social determinants of health are relevant to such policies, but, I argue, not by globally undermining responsibility. Rather, social determinants are sometimes responsibility‐undermining, sometimes responsibility‐preserving, and often relevant to whether we should hold individuals accountable for their health regardless of their responsibility. This calls for a more nuanced appraisal of the ways in which the social determinants of health are relevant to such policies. And here I attempt to provide one.     

Yin-yang genetics,or the HSD deCODE controversy

This paper examines a number of social, ethical and cultural issues related to the application of biotechnology. The focus of the paper relies on two different cases of governing biotechnology in Portugal, referring to donation of biological material: the act of donation of eggs and sperm; and volunteers for donation of DNA material for the forensic national DNA database. We analyze the discourses on donation of biological material framing them in rhetorical devices of gift, altruism, informed consent and social responsibility. This comes blended with still unclear and emergent regulation and policies of access, retention, preservation and governing of biological material and of donors' identification. The risks are mitigated by narratives of science and technology as social progress and providers of public good and health benefits, as well as by underlining the individual responsibility in this domain and by reinforcing the rhetoric of gene quality, based on socio-cultural and bio-genetic criteria.     

Inhibition of Personally-Relevant Angry Faces Moderates the Effect of Empathy on Interpersonal Functioning

While empathy is typically assumed to promote effective social interactions, it can sometimes be detrimental when it is unrestrained and overgeneralized. The present study explored whether cognitive inhibition would moderate the effect of empathy on social functioning. Eighty healthy young adults underwent two assessments six months apart. Participants’ ability to suppress interference from distracting emotional stimuli was assessed using a Negative Affective Priming Task that included both generic and personally-relevant (i.e., participants’ intimate partners) facial expressions of emotion. The UCLA Life Stress Interview and Empathy Quotient were administered to measure interpersonal functioning and empathy respectively. Multilevel modeling demonstrated that higher empathy was associated with worse concurrent interpersonal outcomes for individuals who showed weak inhibition of the personally-relevant depictions of anger. The effect of empathy on social functioning might be dependent on individuals’ ability to suppress interference from meaningful emotional distractors in their environment.     

BIOETHICS AND DEMOCRACY: COMPETING ROLES OF NATIONAL BIOETHICS ORGANISATIONS

In establishing National Bioethics Organisations (NBOs), liberal democracies seek to acknowledge the diversity of strongly held ethical positions and the imperative to engage in public debate about important bioethical decisions. NBOs are typically given a range of responsibilities, including contributing to and stimulating public debate; providing expert opinion on relevant issues for policy deliberations; and developing public policy. The state is now found to have an interest in areas previously thought to be a matter of individual choice. NBOs can provide one way of opening up public debate to allow the diversity of views to be heard in a manner that is well‐informed, articulate and responsive to both expert and ‘lay’ public views. We draw on debates in political theory about democratic decision‐making and on the policy making roles of some key NBOs. We are particularly interested in examining the capacity of NBOs to meet the democratic ideal of effective participation by the public, or citizenry, especially by those who are directly affected by the policies, in the development of effective public policy. We provide a basic framework for policy development involving NBOs that can begin to meet this ideal, a process of ‘contested deliberation’.     

“Like Throwing a Bowling Ball at a Battle Ship” Audience Responses to Australian News Stories about Alcohol Pricing and Promotion Policies: A Qualitative Focus Group Study

Introduction

Policies affecting alcohol’s price and promotion are effective measures to reduce harms. Yet policies targeting populations are unpopular with the public, whose views can be influenced by news framings of policy narratives. In Australia, alcohol taxation receives high news coverage, while advertising restrictions have not until recently, and narratives are highly contested for each. However, research specifically examining how audiences respond to such news stories is scant. We sought to explore audience understanding of news reports about two alcohol policy proposals.

Method

From June to August 2012, 46 participants were recruited for 8 focus groups in age-brackets of young people aged 18–25 years, parents of young people, and adults aged 25 or older. Groups were split by education. Participants were asked their prior knowledge of alcohol policies, before watching and discussing four news stories about alcohol taxation and advertising.

Results

Participants were clear that alcohol poses problems, yet thought policy solutions were ineffective in a drinking culture they viewed as unamenable to change and unaffected by alcohol’s price or promotion. Without knowledge of its actual effect on consumption, they cited the 2008 alcopops tax as a policy failure, blaming cheaper substitution. Participants had low knowledge of advertising restrictions, yet were concerned about underage exposure. They offered conditional support for restrictions, while doubting its effectiveness. There was marked distrust of statistics and news actors in broadcasts, yet discussions matched previous research findings.

Conclusions

News coverage has resulted in strong audience understanding of alcohol related problems but framed solutions have not always provided clear messages, despite audience support for policies. Future advocacy will need to continue recent moves to address the links between alcohol’s price and promotion with the drinking culture, as well as facilitate understandings of how this culture is amenable to change through the use of evidence-based policies.     

Geographic determinants of individual obesity risk in Spain: A multilevel approach

This paper seeks to understand the determinants of individual body weight status and obesity risk in Spain by concurrently examining individual and regional characteristics. The data are drawn from the National Health Survey of Spain for the year 2011–2012 (INE-National Statistical Institute of Spain) and contain information for a representative sample of 12,671 adults across 50 provinces in Spain. A multilevel analysis is carried out to examine the determinants of individual weight status and obesity, controlling not only for the individual effects and those of the immediate environment but also for the broader setting to which individuals and their immediate environment belong. Our findings suggest that attributes from all three levels of analysis have an effect on individual weight status and obesity. Lack of green spaces and criminality taken as proxies of the social environment positively affect individual and women's BMI and obesity, respectively.     

I Know How You Feel: The Warm-Altruistic Personality Profile and the Empathic Brain

The ability to empathize with other people is a critical component of human social relationships. Empathic processing varies across the human population, however it is currently unclear how personality traits are associated with empathic processing. This study was designed to test the hypothesis that specific personality traits are associated with behavioral and biological indicators of improved empathy. Extraversion and Agreeableness are personality traits designed to measure individual differences in social-cognitive functioning, however each trait-dimension includes elements that represent interpersonal social functioning and elements that do not represent interpersonal social functioning. We tested the prediction that interpersonal elements of Extraversion (Warmth) and Agreeableness (Altruism) are associated with empathy and non-interpersonal elements of Extraversion and Agreeableness are not associated with empathy. We quantified empathic processing behaviorally (empathic accuracy task using video vignettes) and within the brain (fMRI and an emotional perspective taking task) in 50 healthy subjects. Converging evidence shows that highly warm and altruistic people are well skilled in recognizing the emotional states of other people and exhibit greater activity in brain regions important for empathy (temporoparietal junction and medial prefrontal cortex) during emotional perspective taking. A mediation analysis further supported the association between warm-altruistic personality and empathic processing; indicating that one reason why highly warm-altruistic individuals may be skilled empathizers is that they engage the temporoparietal junction and medial prefrontal cortex more. Together, these findings advance the way the behavioral and neural basis of empathy is understood and demonstrates the efficacy of personality scales to measure individual differences in interpersonal social function.     

Characterization of Courtesy Stigma Perceived by Parents of Overweight Children with Bardet-Biedl Syndrome

Background

A child’s obesity is generally perceived by the public to be under the control of the child’s parents. While the health consequences of childhood obesity are well understood, less is known about psychological and social effects of having an obese child on parents. We set out to characterize stigma and courtesy stigma experiences surrounding obesity among children with Bardet-Biedl syndrome (BBS), a multisystem genetic disorder, and their parents.

Methods

Twenty-eight parents of children with BBS participated in semi-structured interviews informed by social stigmatization theory, which describes courtesy stigma as parental perception of stigmatization by association with a stigmatized child. Parents were asked to describe such experiences.

Results

Parents of children with BBS reported the child’s obesity as the most frequent target of stigmatization. They perceived health care providers as the predominant source of courtesy stigma, describing interactions that resulted in feeling devalued and judged as incompetent parents.

Conclusions

Parents of children with BBS feel blamed by others for their child’s obesity and described experiences that suggest health care providers may contribute to courtesy stigma and thus impede effective communication about managing obesity. Health care providers may reinforce parental feelings of guilt and responsibility by repeating information parents may have previously heard and ignoring extremely challenging barriers to weight management, such as a genetic predisposition to obesity. Strategies to understand and incorporate parents’ perceptions and causal attributions of their children’s weight may improve communication about weight control.     

Determinants of obesity in transition economies: The case of Russia

This paper examines human obesity, measured as weight and body mass index (BMI), and its determinants in Russia. Obesity increased dramatically during transition from a planned to a market economy, by 38%. We determine the factors contributing to rising obesity using individual level data from the Russia Longitudinal Monitoring Survey for 1994 and 2004. We find a strong positive effect of diet/caloric intake and a strong negative effect of smoking on weight and BMI. Gender, education, and income are other major determinants of obesity. Our analysis provides information on dietary patterns and other determinants of obesity in Russia which is essential for formulation and implementation of effective policies designed to reduce the problem and improve the health of the population.     

Peer effects of obesity on child body composition

This study investigates whether peer obesity is a driver of individual weight changes in public school children and whether the impact of peer effects changes as children age. Quantifying peer effects is important for understanding the social determinants of obesity and for planning effective school wellness policies. However, the extant empirical research on peer effects is limited due to difficulties in separating causal influences from confounding factors. This study overcomes some of these difficulties by using a within-school, across-cohort empirical design to separate confounding factors at the individual, school and school-grade level for over one million public school children. The results show that increases a one standard deviation increase in average classmate body mass index (BMI) leads to a modest but meaningful increase of 0.395 standard deviation increase in a child's own BMI. Peer-effects are highest (0.813) for children in Kindergarten and decline with age. These findings suggest that the critical time for school-grade level intervention may be in the earliest ages of childhood development.     

Policy actors' narrative constructions of migrants' integration in Malmö and Bologna

Governments have policies explicitly directed at the integration of migrants. This article addresses how policymakers and politicians privilege certain constructions of the social relationship between migrants and the majority society (expressed through narratives of ‘integration’), while making it seem as if they were presenting facts in their policies. These constructions provide the justifications for adopting a direction in policy-making over other alternatives. This article sets to analyse comparatively how policy actors in two urban contexts construct migrants' integration through policy narratives and how, within this, they evaluate migrants as ‘integrated’ and ‘non-integrated’. Through narrative analysis, the article sheds light on how migrants are positioned by political institutions within the normative order of the society in which they live. Furthermore, it shows that local policy-making is shaped by national citizenship regimes, models of steering, welfare regimes and stories about the nation and its people.     

A prospectus for ethical analysis of ageing individuals' responsibility to prevent cognitive decline

As the world's population ages, governments and non‐governmental organizations in developed countries are promoting healthy cognitive ageing to reduce the rate of age‐related cognitive decline and sustain economic productivity in an ageing workforce. Recommendations from the Productivity Commission (Australia), Dementia Australia, Government Office for Science (UK), Presidential Commission for the Study of Bioethical Issues (USA), Institute of Medicine (USA), among others, are encouraging older adults to engage in mental, physical, and social activities. These lifestyle recommendations for healthy cognitive ageing are timely and well supported by scientific evidence but they make implicit normative judgments about the responsibility of ageing individuals to prevent cognitive decline. Ethical tensions arise when this individual responsibility collides with social and personal realities of ageing populations. First, we contextualize the priority given to healthy cognitive ageing within the current brain‐based medical and social discourses. Second, we explore the individual responsibility by examining the economic considerations, medical evidence and individual interests that relate to the priority given to healthy cognitive ageing. Third, we identify three key ethical challenges for policymakers seeking to implement lifestyle recommendations as an effective population‐level approach to healthy cognitive ageing. The result is a prospectus for future in‐depth analysis of ethical tensions that arise from current policy discussions of healthy cognitive ageing.     

Impact of Repeated Exposures on Information Spreading in Social Networks

Clustered structure of social networks provides the chances of repeated exposures to carriers with similar information. It is commonly believed that the impact of repeated exposures on the spreading of information is nontrivial. Does this effect increase the probability that an individual forwards a message in social networks? If so, to what extent does this effect influence people’s decisions on whether or not to spread information? Based on a large-scale microblogging data set, which logs the message spreading processes and users’ forwarding activities, we conduct a data-driven analysis to explore the answer to the above questions. The results show that an overwhelming majority of message samples are more probable to be forwarded under repeated exposures, compared to those under only a single exposure. For those message samples that cover various topics, we observe a relatively fixed, topic-independent multiplier of the willingness of spreading when repeated exposures occur, regardless of the differences in network structure. We believe that this finding reflects average people’s intrinsic psychological gain under repeated stimuli. Hence, it makes sense that the gain is associated with personal response behavior, rather than network structure. Moreover, we find that the gain is robust against the change of message popularity. This finding supports that there exists a relatively fixed gain brought by repeated exposures. Based on the above findings, we propose a parsimonious model to predict the saturated numbers of forwarding activities of messages. Our work could contribute to better understandings of behavioral psychology and social media analytics.     

Narratives Reflecting the Lived Experiences of People with Brain Disorders: Common Psychosocial Difficulties and Determinants

Background

People with brain disorders - defined as both, mental disorders and neurological disorders experience a wide range of psychosocial difficulties (PSDs) (e.g., concentrating, maintaining energy levels, and maintaining relationships). Research evidence is required to show that these PSDs are common across brain disorders.

Objectives

To explore and gain deeper understanding of the experiences of people with seven brain disorders (alcohol dependency, depression, epilepsy, multiple sclerosis, Parkinson’s disease, schizophrenia, stroke). It examines the common PSDs and their influencing factors.

Methods

Seventy seven qualitative studies identified in a systematic literature review and qualitative data derived from six focus groups are used to generate first-person narratives representing seven brain disorders. A theory-driven thematic analysis of these narratives identifies the PSDs and their influencing factors for comparison between the seven disorders.

Results

First-person narratives illustrate realities for people with brain disorders facilitating a deeper understanding of their every-day life experiences. Thematic analysis serves to highlight the commonalities, both of PSDs, such as loneliness, anger, uncertainty about the future and problems with work activities, and their determinants, such as work opportunities, trusting relationships and access to self-help groups.

Conclusions

The strength of the methodology and the narratives is that they provide the opportunity for the reader to empathise with people with brain disorders and facilitate deeper levels of understanding of the complexity of the relationship of PSDs, determinants and facilitators. The latter reflect positive aspects of the lives of people with brain disorders. The result that many PSDs and their influencing factors are common to people with different brain disorders opens up the door to the possibility of using cross-cutting interventions involving different sectors. This strengthens the message that ‘a great deal can be done’ to improve the lived experience of persons with brain disorders when medical interventions are exhausted.     

"Carrying Ibuprofen in the Bag": Priority Health Concerns of Latin American Migrants in Spain- A Participatory Qualitative Study

Background

An estimated 2.7 million Latin Americans reside in Europe, mostly in Spain. Part of a broader project aimed at developing a research agenda on the health status and determinants of this population, this qualitative study engaged Latin American migrants in the identification of research priorities.

Methods

We conducted 30 group discussions between November 2012—March 2013 with 84 participants purposively selected for maximum diversity in Madrid and Barcelona (Spain). We facilitated sequences of task-oriented visual activities to explore their views on priority health concerns. We tape-recorded and transcribed discussions and developed a coding frame based on socio-ecological frameworks, which we applied to all the data using NVIVO-10. A final round of eight group discussions allowed us to triangulate and enrich interpretations by including participants’ insights.

Findings

The cumulative toll of daily stresses was the major health concern perceived by a population that conceptualised ill-health as a constellation of symptoms rather than as specific diseases. Work-related factors, legislative frameworks regulating citizenship entitlements and feeling ethnically discriminated were major sources of psycho-social strain. Except for sexually transmitted infections, participants rarely referred to communicable diseases as a concern. The perception that clinicians systematically prescribed painkillers discouraged health seeking and fostered self-medication. Participants felt that the medicalised, chemicalised, sexually liberal and accelerated culture of the host society damaged their own, and the local populations’ health.

Conclusion

Health systems bear a disproportionate responsibility in addressing health problems rooted in other sectors. Occupational and migration policies should be recognised explicitly as health policies. The mismatch between researchers’ emphasis on communicable infections and the health concerns of Latin American migrants highlights the need for greater interaction between different forms of knowledge. In this process, the biomedical culture of reliance on pharmacological solutions should not remain unquestioned.     

Workplace Social and Organizational Environments and Healthy-Weight Behaviors

Background

The workplace is an important setting for health promotion including nutrition and physical activity behaviors to prevent obesity. This paper explores the relationship between workplace social environment and cultural factors and diet and physical activity (PA) behaviors and obesity among employees.

Methods

Between 2012 and 2013, telephone interviews were conducted with participants residing in four Missouri metropolitan areas. Questions included demographic characteristics, workplace socio/organizational factors related to activity and diet, and individual diet and PA behaviors, and obesity. Multivariate logistic regression was used to examine associations between the workplace socio/organizational environment and nutrition, PA, and obesity.

Results

There were differences in reported health behaviors and socio/organizational environment by gender, race, age, income, and worksite size. For example, agreement with the statement the ‘company values my health’ was highest among Whites, older employees, and higher income workers. As worksite size increased, the frequency of reporting seeing co-workers doing several types of healthy behaviors (eat fruits and vegetables, doing PA, and doing PA on breaks at work) increased. In adjusted analyses, employees agreeing the company values my health were more likely to engage in higher PA levels (aOR=1.54, 95% CI: 1.09-2.16) and less likely to be obese (aOR=0.73, 95% CI: 0.54-0.98). Seeing co-workers eating fruits and vegetables was associated with increased reporting of eating at least one vegetable per day (aOR=1.43, 95% CI: 1.06-1.91) and seeing co-workers being active was associated with higher PA levels (aOR 1.56, 95% CI: 1.19-2.05).

Conclusions

This research suggests that social/organizational characteristics of the workplace environment, particularly feeling the company values the workers’ health and to seeing co-workers engaging in healthy behaviors, may be related to nutrition and PA behaviors and obesity. These findings point to the potential for intervention targets including environment and policy changes.     

What Should I Eat and Why? The Environmental,Genetic, and Behavioral Determinants of Food Choice: Summary from a Pennington Scientific Symposium

This review details the proceedings of a Pennington Biomedical scientific symposium titled, “What Should I Eat and Why? The Environmental, Genetic, and Behavioral Determinants of Food Choice.” The symposium was designed to review the literature about energy homeostasis, particularly related to food choice and feeding behaviors, from psychology to physiology. This review discusses the intrinsic determinants of food choice, including biological mechanisms (genetics), peripheral and central signals, brain correlates, and the potential role of the microbiome. This review also address the extrinsic determinants (environment) of food choice within our physical and social environments. Finally, this review reports the current treatment practices for the clinical management of eating‐induced overweight and obesity. An improved understanding of these determinants will inform best practices for the clinical treatment and prevention of obesity. Strategies paired with systemic shifts in our public health policies and changes in our “obesogenic” environment will be most effective at attenuating the obesity epidemic.     

Science in the Service of Patients: Lessons from the Past in the Moral Battle for the Future of Medical Education

Medical schools instill a classic moral standoff in which the responsibility for the betterment of the patient stands at odds with the responsibility for the betterment of society. In critical ways, the latter, in the form of a robust research and technology-driven enterprise, has taken precedence over the former, resulting in harm to patients and individual dignity. This tradeoff can be traced to Abraham Flexner, the father of American medical education. In the wake of the Flexner report, American medicine set out on a course of exponential scientific advancement, but the mistreatment of research subjects and the erosion of the doctor-patient relationship in a health care system that is increasingly unaffordable, complex, and impersonal suggest that such progress has come at a price. Recent efforts by medical schools to emphasize humanism in their curricula and admissions processes have shown promise in orienting the values of academic medicine toward the individual patient’s well-being.     

Foreign medical school graduates problems of qualifying as competent to practice

It is financially and practically impossible to investigate thoroughly all the medical schools in the world and to keep the records current. There is at present no acceptable method for screening the graduates. The official policy of the American Medical Association regarding licensing to practice medicine in the United States is that it is a state right and that it is entirely under the jurisdiction of the governments of the individual states. Hospitals in this country have a great responsibility to the public and to their attending physicians not to engage incompetent physicians and not to exploit the physicians they engage. It is the obligation of all medical licensing boards to constantly help in elevating and improving the standards of medical care. The foreign - trained physicians who have received medical education and training comparable to that given in this country will always be welcome. The exchange of students and faculty members between schools in friendly foreign countries and the United States should be encouraged. The number of foreign physicians serving as interns and residents in this country is steadily increasing.