Sandra Echeverria, PhD, with mentors George Rhodes, MD, MPH, Professor and acting chair, Epidemiology Department, UMDNJ-School of Public Health, and Barbara DiCicco-Bloom, PhD, assistant professor, Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School and Director of the National Research Service Award Primary Care/Health Services Research Training Program
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ocial contexts are important determinants of health. The socioeconomic condition of neighborhoods, for example, has been associated with a wide range of health outcomes after adjusting for personal-level measures, suggesting that neighborhood contexts independently pattern disease. There is also increasing evidence to suggest that racial and ethnic disparities in health may be produced or exacerbated by the social conditions that minority populations experience. But how do social conditions influence health? What specific features are most relevant to study and what sources of data do we have to examine this relation? And importantly, what can we, as public health professionals, do to address the broader social conditions that produce and sustain disease? As a social epidemiologist, my postdoctoral research has focused on studies examining the complex set of factors behind these questions and has explored novel and feasible approaches for addressing social inequalities in health.
The founding of public health in the 19th century was rooted in the notion that health was intimately tied to the social conditions under which populations lived. In fact, this broader social focus gave way to the many successful public health programs that we benefit from today: safe drinking water, public sanitation, nutritional campaigns, public health clinics, and childhood immunization, to name a few. Despite these origins, however, only as recently as the 1980s did the field of epidemiology begin to once again explicitly examine the effect of social conditions on health, and formally forge the field of social epidemiology.
Social epidemiology is a branch of epidemiology that studies the social distribution and social determinants of health conditions. The aim of the field is to explicitly examine social conditions as main predictors of health, and, as such, social epidemiologists can study health conditions ranging from cardiovascular disease and cancer to depression and health behaviors, including violence.
My post-doctoral training has consisted of three interconnected areas of research in social epidemiology, which I have carried out through a joint appointment between the Department of Epidemiology in UMDNJ’s School of Public Health and the Research Division of the Department of Family Medicine at UMDNJ-Robert Wood Johnson Medical School (RWJMS). George Rhoads, MD, MPH, professor and acting chair, has been my mentor in the Department of Epidemiology and Barbara DiCicco-Bloom, RN, PhD, assistant professor, my mentor in the Department of Family Medicine.
Under the mentorship of Dr. Rhoads, my first area of research has been to expand my focus on neighborhood-health effects to include cancer outcomes. In one study, I examined if neighborhood socioeconomic characteristics predicted the incidence of advanced-stage breast cancer in 2 urban counties in New Jersey and tested whether this association varied by race/ethnicity and distinct neighborhood measures. I found that women who lived in poorer neighborhoods were 60% more likely to be diagnosed with advanced-stage breast cancer than women living in relatively wealthier neighborhoods. This association did not appear to vary among white, black and Latina women, although sample size issues may have limited our abiltiy to detect this effect. Moreover, I found that in this study sample, a neighborhood scale composed of various socioeconomic indicators and neighborhood-level median income were equally strong predictors of advanced-stage cancer, whereas neighborhood-level poverty was a much weaker predictor. It may be that in the highly urban counties included in this study, with overall higher levels of poverty, there may not be sufficient variability in this measure to detect any meaningful effect on cancer staging. I am building on this study and plan to examine if cancer survival varies by neighborhood of residence within one urban area of New Jersey.
A second research focus of my postdoctoral training has been to build the evidence base regarding how neighborhoods influence health. Prior neighborhood-health studies have largely relied on census-based socioeconomic indicators to characterize the local area. Census-based data are useful because they allow researchers to use aggregate measures of socioeconomic conditions (e.g. average years of education, average household income) to systematically characterize neighborhoods or places. However, census-based socioeconomic indicators are likely to be only crude proxies of the neighborhood characteristics most likely to influence health. Thus, in a study based on my doctoral dissertation, we asked participants of a large population-based cohort to rate various measures of their neighborhood environment. I found that measures of neighborhood problems and neighborhood social cohesion were associated with depression, drinking, smoking, and walking, suggesting that these specific neighborhood measures may prove useful for future interventions. In another study, I conducted a 40-year trend analysis of all causes of death, including cancer, for the city of Newark, NJ. This study showed that despite improvements in cancer and heart disease mortality, Newark residents have experienced a concentration of poverty and unemployment over the last few decades and residents today are disproportionately dying from diabetes, AIDS and homicide when compared to state and national trends.
As the case of Newark suggests, there is an urgent need to address the social conditions that place people at increased risk of disease and ultimately death. In some of my most recent work, I have started to explore how we can begin to chip away at this enormous task. I am developing a project to examine if changing specific features of the neighborhood, such as building or revamping neighborhood parks, leads to improvements in population-level health. Because this study will examine changes over time in populations exposed to changes in their neighborhood environment, it will provide much needed data to strengthen causal inferences regarding neighborhood-health associations. It will also demonstrate the increasing importance of public health professionals to build collaborations across disciplines, sectors and the community. In this proposed project, we will build on initiatives implemented by the City Parks Department and will work closely with community advocacy groups involved in the design of these neighborhood parks.
Lastly, under the guidance of Dr. DiCicco-Bloom, I participated in a qualitative research study examining how work relations within medical practices may impact practice performance and eventually patient care. I worked alongside a medical anthropologist to conduct a “mini” ethnographic study involving direct observation of practice members and in-depth interviews with staff. This experience strengthened my resolve to integrate qualitative research methods in my epidemiologic work. As an example, while my research seeks to specify the features of the neighborhood context most relevant for health, qualitative methods will help to define the meaning that local residents attach to their neighborhoods, and how these meanings may be specific to certain populations and certain contexts.
Sandra E. Echeverría received her PhD from Columbia University, Mailman School of Public Health - Department of Epidemiology. She was a recipient of the W.K. Kellogg Foundation Award in Health Policy Research while at Columbia and joined UMDNJ in the fall of 2006. She is now an assistant professor in the Department of Epidemiology at UMDNJ-School of Public Health.
