The word “systems” echoes through conversation with Kathleen Ethier, PhD, director of the Division of Adolescent and School Health in the National Center for HIV, Viral Hepatitis, STD, and TB Prevention at the Centers for Disease Control and Prevention (CDC). The social psychologist discovered early that knowing how people make choices in the context of social systems, such as education, could help her to “make a difference in people’s lives.”
Nearing completion of her PhD in the 1990s, Ethier took a job at Yale University’s School of Public Health. She spent the next 6 years leading applied research on how to prevent unplanned pregnancies and sexually transmitted diseases (STDs) like the human immunodeficiency virus (HIV). Ethier found the work so rewarding that she decided to stay in public health.
She joined the CDC in 1999 as a senior scientist in the Division of STD Prevention. Since then, she has served in a variety of leadership and management roles, most recently refocusing on young people’s health.
What drew you, a social psychologist, to public health fairly early in your career?
When I studied at the Graduate Center of the City University of New York, the social psychology PhD program had a strong health psychology component. At the same time, the emergence of HIV had a strong influence. Once I branched out at Yale into working on other aspects of health for women and adolescents, I learned that when it comes to health behavior, it’s essential to understand not only how we individually process the social world but also how social systems impact our behavior and our sense of well-being.
What about social psychology training is especially useful in public health?
In social psychology, we work hard to understand social systems and how humans interact with them. We can see in the news every day how social systems create the social determinants of health, which are influential factors such as income, education, gender, racism, social support, and access to health services. That helps us to think about how to change those systems.
Because there’s a really strong scientific basis for this work, we can take on some issues that are not necessarily clear. For instance, you can’t always do randomized controlled trials in social science the way you often can in medicine. There’s messiness in how humans engage with one another in a social system, but sometimes it’s more important to understand the things you can’t control.
For example, you could have two adolescents making the same individual decision to engage in sexual activity, but it would result in different outcomes based on differences like the local prevalence of STDs, the availability of condoms in their network, their education in using condoms, and even whether they have regular health care so they can be screened and prevented from infecting anyone else. And all those systemic factors don’t have anything to do with the individual choices that they make.
As more is understood about the critical role played by the social determinants of health, how do you apply those insights in your work?
We have to understand the interplay among individual behavior choices and the educational and social systems. As we do that, we can develop more outside tools to improve outcomes and reduce risk for the individual choices that adolescents make, for example, to make sure that sexual health care is available to them. Again, as an example, changing STD rates broadly is not necessarily about any one person but about the geographic and health care environments in which people live.
Sometimes we use retrospective data to inform new approaches. For example, we analyzed data from Waves 1 and 4 of the National Longitudinal Study of Adolescent to Adult Health, which follows 14,800 participants over time. In just one slice, we found that feeling connected to family and feeling connected to school during adolescence appear to protect adult health across multiple outcomes related to mental health, violence, sexual behavior, and substance use. That means that increasing social “connectedness” in the teen years has lasting potential to promote better health in adulthood.
Can you talk about how psychological science can make a measurable difference in population health?
We looked for ways to improve school inclusivity for LGBTQ+ students, such as setting up clubs with student associations and creating safe spaces, establishing policies to prohibit harassment, and training educators. All these things weren’t done for any one child but to change the system and make it more supportive for all.
I know I said that human behavior can be messy, but we were able to use statistical analysis to be specific, multilevel cross-sectional logistic regressions to look at the relationships between school-level policies and practices and student-level health outcomes by sexual identity while controlling for sex, grade, race and ethnicity, and schools already identified for worse student health. For health outcomes, we looked at key indicators of psychosocial health both before the interventions occurred and 2 years after the interventions were completed, using Youth Risk Behavior Surveillance System survey data from more than 75,000 students.
We found that in large urban school districts, schools that set up these policies showed mental health improvements not only among the more vulnerable students but also among students who identified as straight. They reported better mental health and reduced suicidal thoughts and behaviors as well.
This study showed how understanding educational and health systems gives us ways to reduce inequities to fully support the health and well-being of all youth in those systems. We can’t reach every individual, but we can look for broadly safe and supportive approaches to help the most vulnerable youth, and that turns out to help everyone.
What’s your advice for mental health professionals who want to contribute to public or population health?
We have a workforce crisis, in terms of sheer numbers of trained professionals. Given the mental health crisis among young people, one of the most important choices for individuals going into the field is to consider what they can do to support young people in schools. School districts are struggling to fill positions even when they have funding.
As for researchers, the areas we need to work on as social scientists are developing preventive interventions, keeping problems from becoming crises, developing mental health literacy from very young ages, and helping schools put systems into place to address adverse events. We can always use more help in these areas.
