. Describe the major social determinants of your group s chosen
disease/health issue (or another disease/health issue of your choice).
II. Explain how one or two of those social determinants influence the
prevalence or severity of the disease/health issue.
III. Present and defend relevant plausible policy implications.
IV. Submit your completed assignment to D2L. Label your file
[YOURLASTNAME]3
Grading Rubric for Individual Assignment #3
Grading rubrics are designed to ensure consistency in grading and are provided
as a courtesy to students. They are guidelines as opposed to strict rules and are
not intended to serve as a template for your paper. A good paper is logically
organized and builds a persuasive argument.
1. Content and analysis (50%)
The assignment should clearly and correctly identify the major social
determinants of health associated with the disease/health issue.
The assignment should explain how one or two key social determinants
impact the prevalence or severity of the disease/health issue.
The assignment should make relevant policy suggestions at the national
regional or municipal level. (Tip: these must be plausible
recommendations and you must show how these recommendations are
warranted by your findings.)
2. Quality of writing (30%).
The assignment should be clearly organized and presented in a logical
manner.
Information should be organized in paragraphs. Each paragraph should
begin with a topic sentence.
The assignment should be written in academic prose using complete
sentences and should be free of grammatical errors.
The main arguments or claims stated by the writer should be supported by
relevant evidence examples and/or statistics. The writer should make
explicit connections between works cited and their own thoughts to create
a logical flow of ideas.
3. Appropriateness of paper and format (20%)
References should be presented in accepted academic format and ideas
that are not your own should be cited.
The assignment should not contain extensive or unnecessary quotations
of text from published sources.
All works cited should be from academically accepted sources.
All sources referred to in the text of the assignment should be listed in a
References section at the end of the assignment.
Syphilis HSOC NotesFor review articles that cite other studies I have once again just put down basic citations to save time if we choose to use any of this information I can go back and verify the information as well as provide a full citation Brian Social practices and social support networks (coping with social exclusion) and social networks (geographical aspect ) among MSM (Brian and Rumika)
Access to supportive and safe environments impacts rates of syphilis
Internet and social media provide sources of social support but also fosters anonymity and promotes casual sex.
Anal sex more abrasive Condomless sex
Social support affects gay men s ability to cope with stress of discrimination and impacts disclosure access and continued use of medical care.
Social practices such as anonymous sex alcohol and recreational drug use and non-verbal communication increases the practice of unsafe sex
How social exclusion 4access to healthcare (Brian and Rumika)
Discrimination stigma and lack of confidentiality are barriers
Knowledge and attitudes of healthcare providers
Ignorance about the specific health needs of gay men and MSMSexual Orientation as a possible social determinant:
http://search.proquest.com.ezproxy.lib.ucalgary.ca/docview/1039585400 pq-origsite=summon
Possibly consider the 1999 and 2006 American national plans for syphilis elimination
Website with lots of citations for studies on health care access among gay/bisexual/lesbian/MSM: http://www.ohtn.on.ca/Pages/Knowledge-Exchange/Rapid-Responses/Documents/RR79.pdfInfo from Infectious syphilis in high-income settings in the 21st century (Fenton et al 2008 Review)
GENERAL TRENDS (US-CENTRIC)
As the 21st century neared and affluent countries undertook preventative and treatment efforts directed at syphilis incidence rates declined but since the turn of the century there has been an observed resurgence of syphilis (credited to both homosexual/MSM and heterosexual relations). (Golden et al. 2003 Fenton 2004 Fenton and Imrie 2005)
The treatment of participants in a 1932-1972 study of African American males with syphilis in America (Tuskegee syphilis study) was widely criticized and gave rise to some of the ethical rules regarding human study (patients were misguided and not given sufficient treatment to see how disease progressed). (White 2000 Reverby 2001)
Figure 1 shows syphilis incidence US 1940s-2000s. The figure shows that after the WWII era syphilis incidence rates go down (attributed to the introduction of antibiotics penicillin specifically) markedly then fluctuating until the 1990s where the rates drop again (the 2000s part of the graph shows a recent uptick).
While comparing statistics between states is vulnerable to the diversity in each country s diagnostic standards in general the majority of syphilis cases in the world are found in the south-east asian or sub saharan african regions (heterosexual transmission mainly in these locales). (Gerbase et al. 1998)
Since the late 1990s syphilis rates have risen in some European countries (Fenton and Lowndes 2004).
In American men from 2000-2004 syphilis rates increased especially in the south. Also in 2004 African Americans were greatly overrepresented in the syphilis rates versus caucasians (9.0 vs 1.6 cases per 100 000). (CDC release 44) This is reminiscent of syphilis presence in America s south and urban cores during the 80s and 90s. (Golden et al. 2003)
In addition to risky sex behavior the syphilis rate increases in MSM (US recent years) were associated with also being infected with HIV. (CDC releases 45 46 Chen et al. 2002)
Social determinants leading to syphilis prevalence can vary among different populations
Increases in syphilis rates in the 90s and 80s especially affected minority low SES groups (US) (Louis et al. 1996 Aral 1996).
It has been suggested that locations related sexual interaction between men may be associated with the transmission of the disease (including internet sites which facilitate communication between potential partners) (Elwood and Greene 2005 Fenton and Imrie 2005 Klausner 2000)
Mathematical modelling suggests that if high risk groups are targeted for intervention syphilis can be managed but should continue following epidemic containment (outbreaks encouraged by high-risk concentration/lack of treatment) (Oxfam et al. 1996 Pourbohlol et al. 2003).
Info from Increasing Rates of Sexually Transmitted Diseases in Homosexual Men in Western Europe and the United States: Why (Fenton and Imrie 2005 REVIEW)
http://www.sciencedirect.com.ezproxy.lib.ucalgary.ca/science/article/pii/S0891552005000358
EXPLAINING STD TRENDS AMONG MSM In a reversal of the significant drops in bacterial STIs underwent in the 1980s and to some extent the 1990s (in affluent countries) since the late 1990s there have been increases in STIs in the MSM population (Macdonald et al. 2004 and Resurgent bacterial (10))
In the UK infectious syphilis rates grew by ~6 times in four years from 1999-2003 within the MSM population (Focus on prevention (13))
Coinfection with HIV is of concern within the MSM population diagnosed with syphilis -> London study found over half MSM with syphilis also had HIV (Righarts 2004). In Ireland it is 1/5th and Belgium 3/5ths (Cronin et al. 2004 Sasse et al. 2004)
Syphilis infection associated with networks that allow for numerous sexual partners to mix (23-28)
In America the ratio between male-female infectious syphilis rate rose from 1.2 in 1996 to 5.2 in 2003 (similar to what was observed in UK) (Figure 1)
STD risk for MSM is made up of a complex web of factors: some which are more individualistic biomedical (biology of individual) and behavioural factors. Others include the networks in which sexual partners are sourced from and the partnerships themselves
A 2003 study suggested that the deadly impact of AIDs was associated with decreased syphilis incidence rates in men (selective mortality of individuals with AIDs) (Chesson et al. 2003)
Demographic changes: in some countries MSM behaviour has been increasingly reported over time 1990-2000 (check Natsal 3 for latest) (Mercer et al 2004 -> Natsal surveys 1-3 in UK) although it has been suggested the increases could be attributed to social attitudes (Mercer et al. 2005)
In the 2000 Natsal-2 it was found that nearly 60% of MSM had anal intercourse without protection and nearly half had 5+ sexual partners within 5 years (Mercer et al. 2004)
The demographic changes described above could potentially account for increases in STD numbers from the MSM population (without representing change in proportion)
A mathematical model suggested that bacterial STD rates could be associated with increased survival of MSM with HIV as highly active antiretroviral therapy use becomes more prevalent (HAART treatment for HIV) (Boily et al. 2004)
Behaviour can act as determinant for STD acquisition (including number and rate of sexual partnerships). Numerous studies point to increasing risky sexual behaviour within the MSM population (50515657). In the US a study found that MSM reporting both unprotected anal sex (UAI) and numerous sexual partners increased from 1994 to 1999 24% to 45% (6564)
The proliferation of sexual/social networks that allow MSM to develop new partnerships is suggested to affect the spread of STDs. These networks include online websites/ communities (70 71). Other emerging networks include increased sexual interaction overseas/sex-tourism and community events such as circuit parties and pride festivals
High MDMA usage was recorded among gay men at circuit parties (72) and another study associated drug use with risky sexual behaviour (73)
The networks or venues that facilitate sexual behaviour among MSM could potentially be targeted for interventions (including actions on internet networks (79-80) and venues that facilitate sexual behaviour (eg. bathhouses) (77-78))
In certain countries attitudes and legal changes have become more inclusive of homosexuality but the authors suggest that this may result in greater acceptance within the MSM population for risky sexual behaviour
In connecting homophobia/stigma/exclusion to the sexually-risky behaviour of MSM (studied in 101102103) one study associated more experiences of social discrimination (and economic instability) with psychological distress and involvement with difficult sexual situations (104)Info from Sociodemographic Factors and the Variation in Syphilis Rates among US Counties 1984 through 1993: An Ecological Analysis (Kilmarx et al. 1997)
COMMUNITY DETERMINANTS OF SYPHILIS RATES
Study argues that explaining the dissemination of syphilis throughout the US (especially prevalent in the southeast and urban centers) requires taking an ecological analysis approach to account for group/population level factors (took government census/CDC syphilis surveillance data and analyzed it)
Syphilis incidence among different American counties was associated with different population-level factors in the counties (proportion of population that is black non-Hispanic/location in south or urban areas/violent crime rate/female household heads per 1000 people/proportion Hispanic/percentage of babies born to mothers younger than 20) -> Among the 3085 counties analyzed the sociodemographic variables could be attributed to 71% of the differences between counties
In explaining the race differences observed authors suggest that it is likely social factors associated with race rather than biological variation that is main cause -> suggest whites more likely to use private physicians who don t may not report stats to government/ that different race s homophily /preference for similar partners may differentiate the races into different sexual pools (+15)/ cites differences in risky sexual behaviour among racial groups in US (17-20)
The geographical favorance of syphilis in the south and urban areas may reflect demographic differences or environmental risk factor variations (or better reporting in urban)
General health care access factors across the counties such as physician number/ hospital beds per 100000 people/ local per capita spending on healthcare/ infant mortality rate did not impact rate of syphilis (author cautions that these do not necessarily equate to access to STD care/prevention services)
Possible study for secondary social determinant if race is used: 3: Race and the prevalence of syphilis seroreactivity in the United States population (Hahn et al.1989)Info from Social network investigation of a syphilis outbreak in Ottawa Ontario (D Angelo-Scott et al. 2015)
SOCIAL TRENDS IN OTTAWA SYPHILIS OUTBREAK
Syphilis cases increased from 1/100 000 (2000) to 8.85/100 000 (2012) in Canada (3 PHAC article)
Also mentions homophily where people group together with individuals with similar characteristics and draw sexual partners from these circles (6)
(Figure 1) shows syphilis rate increases in Ottawa 0.1 to 3.4/100 000 from 2000-2013 can be mainly attributed to a rise in cases in men (0.3-6.3/100 000 same timeframe)
72 individuals involved in 2009 Ottawa syphilis outbreak investigated; surveyed for information on social networks combined with additional data (eg. demographics) -> 17 (all men) underwent additional surveillance
(Table 1) A high proportion nearly 95% of cases (n=72 in Ottawa) were male; 86% reported sex without a condom and 76% reported sex with the same sex. 15% reported sexual activity in a bathhouse and 8% met a sexual partner online.
Participants showed higher awareness of sexual-health messaging in certain social venues such as bathhouses sex clubs and spas as well as in bars/clubs. Only about half were aware of online sexual-health promotion messages. They suggested messaging in additional locations such as public washrooms more inclusive messaging (not just targeted at heterosexuals) and better education of doctors on syphilis
Study s use of venue-based social networks may remedy some of the difficulties with individual-level contact tracing (venues act as proxies for homophily levels between individuals)
There are some figures illustrating the contacts between individuals and venues etc.Info from Increased incidence of syphilis in men who have sex with men and risk management strategies Germany 2015 (Jansen et al. 2016)
http://www.eurosurveillance.org/ViewArticle.aspx ArticleId=22627
MSM SYPHILIS INCREASE IN GERMANY
Looked at data from the mandatory syphilis notifications in Germany and surveyed groups of MSM 4 times (2003 n=4750 2007 n=8170 2010 n=54387 2013 n=16734).
(Figure 1) In Germany the number of notifications for syphilis by transmission group was graphed. MSM notifications rose from under 1000 in 2001 to over 4000 by 2015 compared to the heterosexual men women and other transmission groups which remained stable well below 500 over the entire study period.
Men made up 94% of 2015 cases and for cases where transmission group was identified 85% were attributed to MSM contact.
Overall from 2003 to 2013 the proportion of MSM (urban 30-44) reporting anal intercourse without a condom with a non-steady partner rose slightly in people who were diagnosed with HIV were not and who had not been tested.
Increases in German syphilis notifications primarily caused by increase in cases among MSM especially in urban areas.Info from Beyond Anal Sex: Sexual practices of men who have sex with men and associations with HIV and other sexually transmitted infections (Rice et al. 2016)
Waiting for interlibrary loan abstract looks promising https://www-ncbi-nlm-nih-gov.ezproxy.lib.ucalgary.ca/pubmed/26853044Info from Patterns of Communication Between Gay and Lesbian Patients and Their Health Care Providers (Klitzman and Greenberg 2002)
Surveyed 66 gay men and 28 lesbians on their experience with physicians.
Acknowledges that because of social trends results from many previous studies suggesting non-heterosexual individuals have negative views about disclosing their sexuality due to stigma (possibly avoiding care altogether) may change.
Lesbians faced greater difficulty in this study with communicating with their health care provider than gay men.
Info from Sexual Risk as an Outcome of Social Oppression: Data From a Probability Sample of Latino Gay Men in Three US Cities (Rafael et al. 2004)
http://dc8qa4cy3n.search.serialssolutions.com/ ctx_ver=Z39.88-2004&ctx_enc=info%3Aofi%2Fenc%3AUTF-8&rfr_id=info%3Asid%2Fsummon.serialssolutions.com&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Sexual+Risk+as+an+Outcome+of+Social+Oppression%3A+Data+From+a+Probability+Sample+of+Latino+Gay+Men+in+Three+U.S.+Cities&rft.jtitle=Cultural+Diversity+and+Ethnic+Minority+Psychology&rft.au=D%C3%ADaz%2C+Rafael+M&rft.au=Ayala%2C+George&rft.au=Bein%2C+Edward&rft.date=2004&rft.issn=1099-9809&rft.eissn=1939-0106&rft.volume=10&rft.issue=3&rft.spage=255&rft.epage=267&rft_id=info:doi/10.1037%2F1099-9809.10.3.255&rft.externalDBID=n%2Fa&rft.externalDocID=10_1037_1099_9809_10_3_255¶mdict=en-US
Studied attitudes/behavior of Latino MSM in the US across three cities finding that instances of social oppression (especially relevant items in survey related to homophobia and events where they were harassed for their sexuality) were associated with psychological distress (high concurrent rates of depressive symptoms with psychologically distressed individuals)
Psychological distress connected to participation in difficult sexual situations (situations where it is challenging to have safe sex ie. drunk or high or in public/unsafe areas). They suggested this was used by participants to mediate effects of oppression and the effect was enhanced if the individual was impoverished.Info from: Social Determinants of Health: The Canadian Facts (Mikkonen and Raphael 2010)
http://www.thecanadianfacts.org/the_canadian_facts.pdf
Education: education heavily associated with other factors such as income level can both lead to the creation of health promoting conditions (such as stable employment and understanding of health access) and affect an individuals ability to self advocate for their health
Gender: there are numerous health differences among men and women (distribution of socioeconomic resources) and relating to syphilis prevalence although (1) worldwide rates are pretty much equal (CITATION) and (2) in general women are disadvantaged by social factors relating to health (life expectancy=healthy fulfilling lives) in western countries much of the recent increases have been seen in men over women (as demonstrated by the previously shown graphs)
Race: in Canada racial minorities are disadvantaged in education neighborhood selection employment and in some cases health status (decreases more readily in non-European immigrants). With syphilis rates in the US are concentrated amongst .ADD
Social Safety Net: the services available to citizens especially relating to health promotion (for MSM could include the availability of social supports like mental health centers sexual health clinics etc.). To illustrate the interconnectedness of many social determinants this can tie into geographical inequities regarding the social services available to citizens in the nearby vicinity.
Social Exclusion: an inequity among different groups in society which can restrict their ability to access the resources available to other Canadians and enjoy their quality of life (includes socioeconomic political and cultural aspects).
Exclusion is often related to other barriers to equitable resource access such as financial insecurity and education level
There may be social factors that limit access to services ( denial of social goods ) and can create conditions that can negatively impact health outcomes (eg. increased incidence of risky sex).
4 sub-aspects to social exclusion: denial of participation in civil affairs denial of social goods exclusion from social production economic exclusion
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