![SDOH model](https://upload.wikimedia.org/wikipedia/commons/6/60/SDOH_model.gif)
The social determinants of health (SDOH) are the economic and social conditions that influence individual and group differences in
health status. They are the
health promoting factors found in one's living and working conditions (such as the distribution of income, wealth, influence, and power), rather than individual
risk factor
In epidemiology, a risk factor or determinant is a variable associated with an increased risk of disease or infection.
Due to a lack of harmonization across disciplines, determinant, in its more widely accepted scientific meaning, is often use ...
s (such as behavioral risk factors or genetics) that influence the risk for a
disease
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
, or vulnerability to disease or
injury
An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, o ...
. The distributions of social determinants are often shaped by public policies that reflect prevailing political ideologies of the area.
The
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
says that "the social determinants can be more important than health care or lifestyle choices in influencing health." and "This unequal distribution of health-damaging experiences is not in any sense a 'natural' phenomenon but is the result of a toxic combination of poor social policies, unfair economic arrangements
here the already well-off and healthy become even richer and the poor who are already more likely to be ill become even poorer and bad politics."
[ Pg 2]
Issues of particular focus are
social determinants of mental health The social determinants of mental health (SDOMH) are societal problems that disrupt mental health, increase risk of mental illness among certain groups, and worsen outcomes for individuals with mental illnesses. Much like the social determinants of ...
,
social determinants of health in poverty
The social determinants of health in poverty describe the factors that affect impoverished populations' health and health inequality. Inequalities in health stem from the conditions of people's lives, including living conditions, work environment ...
and
social determinants of obesity
While genetic influences are important to understanding obesity, they cannot explain the current dramatic increase seen within specific countries or globally. It is accepted that calorie consumption in excess of calorie expenditure leads to obes ...
.
Historical development
![Social_determinants_of_health_visualization](https://upload.wikimedia.org/wikipedia/commons/b/b8/Social_determinants_of_health_visualization.png)
Starting in the early 2000s, the World Health Organization facilitated the academic and political work on social determinants in a way that provided a deep understanding of health disparities in a global perspective.
In 2003, the
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
(WHO) Europe suggested that the social determinants of health included: the social gradient,
stress
Stress may refer to:
Science and medicine
* Stress (biology), an organism's response to a stressor such as an environmental condition
* Stress (linguistics), relative emphasis or prominence given to a syllable in a word, or to a word in a phrase ...
, early life,
social exclusion
Social exclusion or social marginalisation is the social disadvantage and relegation to the fringe of society. It is a term that has been used widely in Europe and was first used in France in the late 20th century. It is used across discipline ...
, work,
unemployment
Unemployment, according to the OECD (Organisation for Economic Co-operation and Development), is people above a specified age (usually 15) not being in paid employment or self-employment but currently available for Work (human activity), w ...
,
social support
Social support is the perception and actuality that one is cared for, has assistance available from other people, and most popularly, that one is part of a supportive social network. These supportive resources can be emotional (e.g., nurturance), ...
,
addiction
Addiction is a neuropsychological disorder characterized by a persistent and intense urge to engage in certain behaviors, one of which is the usage of a drug, despite substantial harm and other negative consequences. Repetitive drug use o ...
,
food
Food is any substance consumed by an organism for nutritional support. Food is usually of plant, animal, or fungal origin, and contains essential nutrients, such as carbohydrates, fats, proteins, vitamins, or minerals. The substance is inge ...
, and
transportation
Transport (in British English), or transportation (in American English), is the intentional movement of humans, animals, and goods from one location to another. Modes of transport include air, land (rail and road), water, cable, pipeline, ...
.
In 2008, the WHO Commission on Social Determinants of Health published a report entitled "Closing the Gap in a Generation", which aimed to understand, from a social justice perspective, how health inequity could be remedied, and what actions could combat factors that exacerbated injustices.
[ Pg 2] The work of the commission was based on development goals, and thus, connected SDH (social determinants of health) discourse to economic growth and bridging gaps in the healthcare system.
This report identified two broad areas of social determinants of health that needed to be addressed.
The first area was daily living conditions, which included healthy physical environments, fair employment, and decent work,
social protection
Social protection, as defined by the United Nations Research Institute for Social Development, is concerned with preventing, managing, and overcoming situations that adversely affect people's well-being. Social protection consists of policies and p ...
across the lifespan, and access to health care. The second major area was distribution of power, money, and resources, including
equity
Equity may refer to:
Finance, accounting and ownership
* Equity (finance), ownership of assets that have liabilities attached to them
** Stock, equity based on original contributions of cash or other value to a business
** Home equity, the dif ...
in health programs, public financing of action on the social determinants,
economic inequalities,
resource depletion
Resource depletion is the consumption of a resource faster than it can be replenished. Natural resources are commonly divided between renewable resources and non-renewable resources (see also mineral resource classification). Use of either ...
healthy working conditions gender equity
Gender equality, also known as sexual equality or equality of the sexes, is the state of equal ease of access to resources and opportunities regardless of gender, including economic participation and decision-making; and the state of valuing d ...
,
political empowerment
Empowerment is the degree of autonomy and self-determination in people and in communities. This enables them to represent their interests in a responsible and self-determined way, acting on their own authority. It is the process of becoming strong ...
, and a balance of power and prosperity of nations.
The 2010
Affordable Care Act
The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by Presid ...
(ACA) established by the Obama administration in the United States, embodied the ideas put in place by the WHO by bridging the gap between
community-based health and healthcare as a medical treatment, meaning that a larger consideration of social determinants of health was emerging in the policy. The ACA established community change through initiatives like providing Community Transformation Grants to community organizations, which opened up further debates and talks about increased integration of policies to create change on a larger scale.
The 2011 World Conference on Social Determinants of Health, in which 125 delegations participated, created the Rio Political Declaration on Social Determinants of Health. With a series of affirmations and announcements, the Declaration aimed to communicate that the social conditions in which an individual exists were key to understanding
health disparities
Health equity arises from access to the social determinants of health, specifically from wealth, power and prestige. Individuals who have consistently been deprived of these three determinants are significantly disadvantaged from health inequiti ...
that individual may face, and it called for new policies across the world to fight health disparities, along with global collaborations.
Commonly accepted social determinants
The United States
Centers for Disease Control and Prevention
The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency, under the Department of Health and Human Services, and is headquartered in Atlanta, Georgi ...
(CDC) defines social determinants of health as "life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care, whose distribution across populations effectively determines length and quality of life."
These include access to care and resources such as food, insurance coverage, income, housing, and transportation.
According to a report by the
Center for Migration Studies of New York
The Center for Migration Studies of New York (CMS) is an educational institute and nonpartisan think tank based in New York City that studies domestic immigration and international migration issues. The organization is devoted to public policies ...
, the different social determinants of health are strongly correlated. People living in an area with one identified determinant also tend to be affected by other determinants. Social determinants of health influence
health-promoting behaviors, and
health equity
Health equity arises from access to the social determinants of health, specifically from wealth, power and prestige. Individuals who have consistently been deprived of these three determinants are significantly disadvantaged from health inequitie ...
among the population is not possible without equitable distribution of social determinants among groups.
A commonly used model that illustrate the relationship between biological, individual, community, and societal determinants is Whitehead and Dahlgren's model originally presented in 1991 and has been adapted by the CDC. Additionally, within the United States, th
Healthy People 2030is an objective-driven framework which can guide public health practitioners and healthcare providers on how to address social determinants of health at the community level.
In Canada, these social determinants of health have gained wide usage:
Income
Income is the consumption and saving opportunity gained by an entity within a specified timeframe, which is generally expressed in monetary terms. Income is difficult to define conceptually and the definition may be different across fields. For ...
and
income distribution
In economics, income distribution covers how a country's total GDP is distributed amongst its population. Economic theory and economic policy have long seen income and its distribution as a central concern. Unequal distribution of income causes eco ...
;
Education
Education is a purposeful activity directed at achieving certain aims, such as transmitting knowledge or fostering skills and character traits. These aims may include the development of understanding, rationality, kindness, and honesty. Va ...
;
Unemployment
Unemployment, according to the OECD (Organisation for Economic Co-operation and Development), is people above a specified age (usually 15) not being in paid employment or self-employment but currently available for Work (human activity), w ...
and
job security
Job security is the probability that an individual will keep their job; a job with a high level of security is such that a person with the job would have a small chance of losing it. Many factors threaten job security: globalization, outsourcing, ...
;
Employment
Employment is a relationship between two parties regulating the provision of paid labour services. Usually based on a contract, one party, the employer, which might be a corporation, a not-for-profit organization, a co-operative, or any othe ...
and
working conditions {{Short description, 1=Overview of and topical guide to working time and conditions
This is a list of topics on working time and conditions.
Legislation
* See :Employment law
Working time
* See :Working time
* Flextime
Working conditions
* Bios ...
;
Early childhood development
Early childhood development is the period of rapid physical, psychological and social growth and change that begins before birth and extends into early childhood. While early childhood is not well defined, one source asserts that the early years b ...
;
Food insecurity
Food security speaks to the availability of food in a country (or geography) and the ability of individuals within that country (geography) to access, afford, and source adequate foodstuffs. According to the United Nations' Committee on World F ...
;
Housing
Housing, or more generally, living spaces, refers to the construction and assigned usage of houses or buildings individually or collectively, for the purpose of shelter. Housing ensures that members of society have a place to live, whether it ...
;
Social exclusion
Social exclusion or social marginalisation is the social disadvantage and relegation to the fringe of society. It is a term that has been used widely in Europe and was first used in France in the late 20th century. It is used across discipline ...
/inclusion;
Social safety net
The social safety net (SSN) consists of non-contributory assistance existing to improve lives of vulnerable families and individuals experiencing poverty and destitution. Examples of SSNs are previously-contributory social pensions, in-kind and fo ...
work;
Health services
Health care or healthcare is the improvement of health via the preventive healthcare, prevention, diagnosis, therapy, treatment, wiktionary:amelioration, amelioration or cure of disease, illness, injury, and other disability, physical and menta ...
;
Aboriginal status;
Gender
Gender is the range of characteristics pertaining to femininity and masculinity and differentiating between them. Depending on the context, this may include sex-based social structures (i.e. gender roles) and gender identity. Most cultures u ...
;
Race
Race, RACE or "The Race" may refer to:
* Race (biology), an informal taxonomic classification within a species, generally within a sub-species
* Race (human categorization), classification of humans into groups based on physical traits, and/or s ...
;
Disability
Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be Cognitive disability, cognitive, Developmental disability, dev ...
.
The list of social determinants of health can be much longer. A recently published article identified several other social determinants .
Unfortunately, there is no agreed taxonomy or criteria as to what should be considered a social determinant of health. In the literature, a subjective assessment—whether social factors impacting health are avoidable through structural changes in policy and practice—seems to be the dominant way of identifying a social determinant of health.
Gender
Race
Ongoing debates
Steven H. Woolf, MD of the Virginia Commonwealth University Center on Human Needs states, "The degree to which social conditions affect health is illustrated by the association between education and mortality rates."
Reports in 2005 revealed the
mortality rate
Mortality rate, or death rate, is a measure of the number of deaths (in general, or due to a specific cause) in a particular population, scaled to the size of that population, per unit of time. Mortality rate is typically expressed in units of de ...
was 206.3 per 100,000 for adults aged 25 to 64 years with little education beyond high school, but was twice as great (477.6 per 100,000) for those with only a high school education and three times as great (650.4 per 100,000) for those less educated. Based on the data collected, the social conditions such as education, income, and race were dependent on one another, but these social conditions also apply to independent health influences.
Marmot and Bell of the University College London found that in wealthy countries, income and mortality are correlated as a marker of relative position within society, and this relative position is related to social conditions that are important for health including good
early childhood development
Early childhood development is the period of rapid physical, psychological and social growth and change that begins before birth and extends into early childhood. While early childhood is not well defined, one source asserts that the early years b ...
, access to high quality education, rewarding work with some degree of autonomy, decent housing, and a clean and safe living environment. The social condition of
autonomy
In developmental psychology and moral, political, and bioethical philosophy, autonomy, from , ''autonomos'', from αὐτο- ''auto-'' "self" and νόμος ''nomos'', "law", hence when combined understood to mean "one who gives oneself one's ...
, control, and empowerment turns are important influences on health and disease, and individuals who lack social participation and control over their lives are at a greater risk for heart disease and mental illness.
Early childhood development can be promoted or disrupted as a result of the social and environmental factors effecting the mother, while the child is still in the womb. Janet Currie's research finds that women in New York City receiving assistance from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), in comparison to their previous or future childbirth, are 5.6% less likely to give birth to a child who is underweight, an indication that a child will have better short term, and long term physical, and cognitive development.
Several other social determinants are related to health outcomes and public policy, and are easily understood by the public to impact health.
They tend to cluster together – for example, those living in poverty experience a number of negative health determinants.
International health inequalities
![Health gap in England and Wales, 2011 Census](https://upload.wikimedia.org/wikipedia/commons/4/44/Health_gap_in_England_and_Wales%2C_2011_Census.png)
Even in the wealthiest countries, there are health inequalities between the rich and the poor.
Researchers Labonte and Schrecker from the Department of Epidemiology and Community Medicine at the University of Ottawa emphasize that globalization is key to understanding the social determinants of health, and as Bushra (2011) posits, the impacts of globalization are unequal.
Globalization has caused an uneven distribution of wealth and power both within and across national borders, and where and in what situation a person is born has an enormous impact on their health outcomes. The Organization for Economic Cooperation and Development found significant differences among developed nations in
health status indicators
There are several scoring systems in intensive care units (ICUs) today.
Adult scoring systems
* APACHE II was designed to provide a morbidity score for a patient. It is useful to decide what kind of treatment or medicine is given. Methods exist ...
such as life expectancy,
infant mortality
Infant mortality is the death of young children under the age of 1. This death toll is measured by the infant mortality rate (IMR), which is the probability of deaths of children under one year of age per 1000 live births. The under-five morta ...
,
incidence of disease, and death from injuries. Migrants and their family members also experience significant negatives health impacts.
These inequalities may exist in the context of the
health care system
Health, according to the World Health Organization, is "a state of complete physical, Mental health, mental and social well-being and not merely the absence of disease and infirmity".World Health Organization. (2006)''Constitution of the World H ...
, or in broader social approaches. According to the WHO's Commission on Social Determinants of Health, access to health care is essential for equitable health, and it argued that health care should be a common good rather than a market
commodity
In economics, a commodity is an economic good, usually a resource, that has full or substantial fungibility: that is, the market treats instances of the good as equivalent or nearly so with no regard to who produced them.
The price of a comm ...
.
However, there is substantial variation in health care systems and coverage from country to country. The commission also calls for government action on such things as access to clean water and safe, equitable working conditions, and it notes that dangerous working conditions exist even in some wealthy countries.
In the Rio Political Declaration on Social Determinants of Health, several key areas of action were identified to address inequalities, including promotion of participatory
policy
Policy is a deliberate system of guidelines to guide decisions and achieve rational outcomes. A policy is a statement of intent and is implemented as a procedure or protocol. Policies are generally adopted by a governance body within an organ ...
-making processes, strengthening
global governance
Global governance refers to institutions that coordinate the behavior of transnational actors, facilitate cooperation, resolve disputes, and alleviate collective action problems. Global governance broadly entails making, monitoring, and enfor ...
and
collaboration
Collaboration (from Latin ''com-'' "with" + ''laborare'' "to labor", "to work") is the process of two or more people, entities or organizations working together to complete a task or achieve a goal. Collaboration is similar to cooperation. Most ...
, and encouraging developed countries to reach a target of 0.7% of
gross national product
The gross national income (GNI), previously known as gross national product (GNP), is the total domestic and foreign output claimed by residents of a country, consisting of gross domestic product (GDP), plus factor incomes earned by foreign ...
(GNP) for official
development assistance
Development aid is a type of foreign/international/overseas aid given by governments and other agencies to support the economic, environmental, social, and political development of developing countries. Closely-related concepts include: developm ...
.
Theoretical approaches
The UK ''Black'' and ''The Health Divide'' reports considered two primary mechanisms for understanding how social determinants influence health: cultural/behavioral and
materialist
Materialism is a form of philosophical monism which holds matter to be the fundamental substance in nature, and all things, including mental states and consciousness, are results of material interactions. According to philosophical materialis ...
/structuralist The cultural/behavioral explanation is that individuals' behavioral choices (e.g., tobacco and alcohol use, diet, physical activity, etc.) were responsible for their development and deaths from a variety of diseases. However, both the ''Black'' and ''Health Divide'' reports found that behavioral choices are determined by one's material conditions of life, and these behavioral
risk factors
In epidemiology, a risk factor or determinant is a variable associated with an increased risk of disease or infection.
Due to a lack of harmonization across disciplines, determinant, in its more widely accepted scientific meaning, is often use ...
account for a relatively small proportion of variation in the incidence and death from various diseases.
The materialist/structuralist explanation emphasizes the people's material living conditions. These conditions include availability of resources to access the
amenities
In property and land use planning, amenity (lat. ''amoenitās'' “pleasantness, delightfulness”) is something considered to benefit a location, contribute to its enjoyment, and thereby increase its value.
Tangible amenities can include the ...
of life,
working conditions {{Short description, 1=Overview of and topical guide to working time and conditions
This is a list of topics on working time and conditions.
Legislation
* See :Employment law
Working time
* See :Working time
* Flextime
Working conditions
* Bios ...
, and quality of available food and housing among others. Within this view, three frameworks have been developed to explain how social determinants influence health. These frameworks are: (a) materialist; (b) neo-materialist; and (c)
psychosocial
The psychosocial approach looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function. This approach is ...
comparison. The materialist view explains how living conditions – and the social determinants of health that constitute these living conditions – shape health. The neo-materialist explanation extends the materialist analysis by asking how these living conditions occur. The psychosocial comparison explanation considers whether people compare themselves to others and how these comparisons affect health and wellbeing.
A nation's wealth is a strong indicator of the health of its population. Within nations, however, individual
socio-economic
Socioeconomics (also known as social economics) is the social science that studies how economic activity affects and is shaped by social processes. In general it analyzes how modern societies progress, stagnate, or regress because of their local ...
position is a powerful predictor of health.
[Graham, H. (2007). Unequal Lives: Health and Socioeconomic Inequalities. New York: Open University Press.] Material conditions of life determine health by influencing the quality of individual development, family life and interaction, and community environments. Material conditions of life lead to differing likelihood of physical (
infections
An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmiss ...
,
malnutrition
Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is "a deficiency, excess, or imbalance of energy, protein and other nutrients" which adversely affects the body's tissues a ...
,
chronic disease
A chronic condition is a health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time. The term ''chronic'' is often applied when the course of the disease lasts for more than three mo ...
, and
injuries
An injury is any physiological damage to living tissue caused by immediate physical stress. An injury can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or ...
), developmental (delayed or impaired
cognitive
Cognition refers to "the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses". It encompasses all aspects of intellectual functions and processes such as: perception, attention, thought, ...
,
personality
Personality is the characteristic sets of behaviors, cognitions, and emotional patterns that are formed from biological and environmental factors, and which change over time. While there is no generally agreed-upon definition of personality, mos ...
, and
social development), educational (
learning disabilities
Learning disability, learning disorder, or learning difficulty (British English) is a condition in the brain that causes difficulties comprehending or processing information and can be caused by several different factors. Given the "difficult ...
, poor learning, early school leaving), and social (
socialization
In sociology, socialization or socialisation (see spelling differences) is the process of internalizing the norms and ideologies of society. Socialization encompasses both learning and teaching and is thus "the means by which social and cultur ...
, preparation for work, and family life) problems. Material conditions of life also lead to differences in psychosocial stress.
When the fight-or-flight reaction is chronically elicited in response to constant threats to income, housing, and food availability, the
immune system
The immune system is a network of biological processes that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to parasitic worms, as well as cancer cells and objects such as wood splinte ...
is weakened,
insulin resistance
Insulin resistance (IR) is a pathological condition in which cell (biology), cells fail to respond normally to the hormone insulin.
Insulin is a hormone that facilitates the transport of glucose from blood into cells, thereby reducing blood gluco ...
is increased, and lipid and clotting disorders appear more frequently. The effects of chronic fight-or-flight is described in the allostatic load model
The materialist approach offers insight into the sources of health inequalities among individuals and nations. Adoption of health-threatening behaviors is also influenced by material deprivation and stress.
Environments influence whether individuals take up tobacco, use alcohol, consume poor diets, and have low levels of physical activity. Tobacco use, excessive alcohol consumption, and carbohydrate-dense diets are also used to cope with difficult circumstances.
The materialist approach seeks to understand how these social determinants occur.
The neo-materialist approach is concerned with how nations, regions, and cities differ on how economic and other resources are distributed among the population. This distribution of resources can vary widely from country to country. The neo-materialist view focuses on both the social determinants of health and the societal factors that determine the distribution of these social determinants, and especially emphasizes how resources are distributed among members of a society.
The social comparison approach holds that the social determinants of health play their role through citizens' interpretations of their standings in the
social hierarchy
Social stratification refers to a society's categorization of its people into groups based on socioeconomic factors like wealth, income, race, education, ethnicity, gender, occupation, social status, or derived power (social and political). As su ...
.
There are two mechanisms by which this occurs. At the individual level, the perception and experience of one's status in unequal societies lead to stress and poor health. Feelings of shame, worthlessness, and envy can lead to harmful effects upon neuro-endocrine, autonomic and metabolic, and immune systems.
Comparisons to those of a higher social class can also lead to attempts to alleviate such feelings by overspending, taking on additional employment that threaten health, and adopting health-threatening coping behaviors such as overeating and using alcohol and tobacco.
[ At the communal level, widening and strengthening of hierarchy weakens ]social cohesion
Group cohesiveness (also called group cohesion and social cohesion) arises when bonds link members of a social group to one another and to the group as a whole. Although cohesion is a multi-faceted process, it can be broken down into four main co ...
, which is a determinant of health. The social comparison approach directs attention to the psychosocial effects of public policies that weaken the social determinants of health. However, these effects may be secondary to how societies distribute material resources and provide security to its citizens, which are described in the materialist and neo-materialist approaches.
Life-course perspective
Life-course approaches emphasize the accumulated effects of experience across the life span in understanding the maintenance of health and the onset of disease. The economic and social conditions – the social determinants of health – under which individuals live their lives have a cumulative effect upon the probability of developing any number of diseases, including heart disease and stroke. Studies into the childhood and adulthood antecedents of adult-onset diabetes show that adverse economic and social conditions across the life span predispose individuals to this disorder.
Hertzman outlines three health effect
Health effects (or health impacts) are changes in health resulting from exposure to a source. Health effects are an important consideration in many areas, such as hygiene, pollution studies, occupational safety and health, ( utrition and health s ...
s that have relevance for a life-course perspective. Latent effects are biological or developmental early life experiences that influence health later in life. Low birth weight
Low birth weight (LBW) is defined by the World Health Organization as a birth weight of an
infant of or less, regardless of gestational age. Infants born with LBW have added health risks which require close management, often in a neonatal intensi ...
, for instance, is a reliable predictor of incidence of cardiovascular disease and adult-onset diabetes in later life. Nutritional deprivation during childhood has lasting health effects as well.
Pathway effects are experiences that set individuals onto trajectories that influence health, well-being, and competence over the life course. As one example, children who enter school with delayed vocabulary are set upon a path that leads to lower educational expectations, poor employment prospects, and greater likelihood of illness and disease across the lifespan. Deprivation associated with poor-quality neighborhoods, schools, and housing sets children off on paths that are not conducive to health and well-being.
Cumulative effects are the accumulation of advantage or disadvantage over time that manifests itself in poor health, in particular between women and men. These involve the combination of latent and pathways effects. Adopting a life-course perspective directs attention to how social determinants of health operate at every level of development – in utero, infancy, early childhood, childhood, adolescence, and adulthood – to both immediately influence health and influence it in the future.
Chronic stress and health
Stress
Stress may refer to:
Science and medicine
* Stress (biology), an organism's response to a stressor such as an environmental condition
* Stress (linguistics), relative emphasis or prominence given to a syllable in a word, or to a word in a phrase ...
is hypothesized to be a major influence in the social determinants of health. There is a relationship between experience of chronic stress and negative health outcomes. This relationship is explained through both direct and indirect effects of chronic stress on health outcomes.
The direct relationship between stress and health outcomes is the effect of stress on human physiology. The long term stress hormone, cortisol
Cortisol is a steroid hormone, in the glucocorticoid class of hormones. When used as a medication, it is known as hydrocortisone.
It is produced in many animals, mainly by the ''zona fasciculata'' of the adrenal cortex in the adrenal gland ...
, is believed to be the key driver in this relationship. Chronic stress has been found to be significantly associated with chronic low-grade inflammation, slower wound healing, increased susceptibility to infections, and poorer responses to vaccines. Meta-analysis
A meta-analysis is a statistical analysis that combines the results of multiple scientific studies. Meta-analyses can be performed when there are multiple scientific studies addressing the same question, with each individual study reporting me ...
of healing studies has found that there is a robust relationship between elevated stress levels and slower healing for many different acute and chronic conditions However, it is also important to note that certain factors, such as coping styles and social support, can mitigate the relationship between chronic stress and health outcomes.
Stress can also be seen to have an indirect effect on health status. One way this happens is due to the strain on the psychological resources of the stressed individual. Chronic stress is common in those of a low socio-economic status, who are having to balance worries about financial security, how they will feed their families, housing status, and many other concerns. Therefore, individuals with these kinds of worries may lack the emotional resources to adopt positive health behaviors. Chronically stressed individuals may therefore be less likely to prioritize their health.
In addition to this, the way that an individual responds to stress can influence their health status. Often, individuals responding to chronic stress will develop potentially positive or negative coping behaviors. People who cope with stress through positive behaviors such as exercise or social connections may not be as affected by the relationship between stress and health, whereas those with a coping style more prone to over-consumption (i.e. emotional eating
Emotional eating, also known as stress eating and emotional overeating, is defined as the "propensity to eat in response to positive and negative emotions". While the term often refers to eating as a means of coping with negative emotions, it als ...
, drinking, smoking or drug use) are more likely to be see negative health effects of stress. Vape shops are also found more in low socioeconomic status areas. The owners target these areas in particular to gain profit. Since people with low-income status are not highly educated, they are more prone to make poor health behavior choices. Socioeconomic status also has a huge impact in lives of people of color. According to Kids Count Data Center, Children in Poverty 2014, in the United States 39% of African American children and adolescents, and 33% of Latino children and adolescents are living in poverty (Kids Count Data Center, Children in Poverty 2014). The stress these racial groups with low socioeconomic status face, is higher than the same race group from a high-income community. According to the research done on socioeconomic disparities in vape shop density and proximity to public schools, the researchers found that vape shops were located a lot more in the areas with schools where African-Americans/Latinos/Hispanic students were in higher population than the areas with schools where White population was more.
The detrimental effects of stress on health outcomes are hypothesized to partly explain why countries that have high levels of income inequality have poorer health outcomes compared to more equal countries.[Wilkinson, R. & Pickett, K. (2009) The spirit level : why more equal societies almost always do better. London: Allen Lane.] Wilkinson and Picket hypothesized in their book The Spirit Level that the stressors associated with low social status are amplified in societies where others are clearly far better off.[
A landmark study conducted by the ]World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
and the International Labour Organization
The International Labour Organization (ILO) is a United Nations agency whose mandate is to advance social and economic justice by setting international labour standards. Founded in October 1919 under the League of Nations, it is the first and o ...
found that exposure to long working hours, operating through psychosocial stress, is the occupational risk factor with the largest attributable burden of disease, i.e. an estimated 745,000 fatalities from ischemic heart disease and stroke events in 2016.
Improving health conditions worldwide
Reducing the health gap requires that governments build systems that allow a healthy standard of living for every resident.
Interventions
Three common interventions for improving social determinant outcomes as identified by the WHO are education, social security and urban development. However, evaluation of interventions has been difficult due to the nature of the interventions, their impact and the fact that the interventions strongly affect children's health outcomes.[World Health Organization (2013)]
The economics of social determinants of health and health inequalities: a resource book (PDF)
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
. . retrieved 2018-04-02
#Education: Many scientific studies have been conducted and strongly suggests that increased quantity and quality of education leads to benefits to both the individual and society (e.g. improved labor productivity). Health and economic outcome improvements can be seen in health measures such as blood pressure
Blood pressure (BP) is the pressure of circulating blood against the walls of blood vessels. Most of this pressure results from the heart pumping blood through the circulatory system. When used without qualification, the term "blood pressure" r ...
, crime
In ordinary language, a crime is an unlawful act punishable by a State (polity), state or other authority. The term ''crime'' does not, in modern criminal law, have any simple and universally accepted definition,Farmer, Lindsay: "Crime, definit ...
, and market participation trends. Examples of interventions include decreasing size of classes and providing additional resources to low-income school districts. However, there is currently insufficient evidence to support education as a social determinants intervention with a cost-benefit analysis.
#Social Protection: Interventions such as “health-related cash transfers”, maternal education, and nutrition-based social protections have been shown to have a positive impact on health outcomes. However, the full economic costs and impacts generated of social security interventions are difficult to evaluate, especially as many social protections primarily affect children of recipients. The landmark Cochrane Collaboration
Cochrane (previously known as the Cochrane Collaboration) is a British international charitable organisation formed to organise medical research findings to facilitate evidence-based choices about health interventions involving health profess ...
Review of the health impact of unconditional cash transfers in low- and middle-income countries found a large body of evidence that these cash transfers clinically meaningfully reduce in the likelihood of being sick (by an estimated 27%), may also improve food security and dietary diversity, and may also reduce extreme poverty and improve school attendance, as well as increase healthcare spending.
#Urban Development: Urban development interventions include a wide variety of potential targets such as housing, transportation, and infrastructure improvements. The health benefits are considerable (especially for children), because housing improvements such as smoke alarm installation, concrete flooring, removal of lead paint, etc. can have a direct impact on health. In addition, there is a fair amount of evidence to prove that external urban development interventions such as transportation improvements or improved walkability of neighborhoods (which is highly effective in developed countries) can have health benefits. Affordable housing options (including public housing) can make large contributions to both social determinants of health, as well as the local economy, and access to public natural areas -including green
Green is the color between cyan and yellow on the visible spectrum. It is evoked by light which has a dominant wavelength of roughly 495570 Nanometre, nm. In subtractive color systems, used in painting and color printing, it is created by ...
and blue space
Blue space (also referred to as blue infrastructure) in urban planning and design comprises all the areas dominated by surface waterbodies or watercourses. In conjunction with greenspace ( parks, gardens, etc. specifically: urban open spa ...
s- is also associated with improved health benefits.
The Commission on Social Determinants of Health made recommendations in 2005 for action to promote health equity based on three principles: "improve the circumstances in which people are born, grow, live, work, and age; tackle the inequitable distribution of power, money, and resources, the structural drivers of conditions of daily life, globally, nationally, and locally; and measure the problem, evaluate action, and expand the knowledge base." These recommendations would involve providing resources such as quality education, decent housing, access to affordable health care, access to healthy food, and safe places to exercise for everyone despite gaps in affluence. Expansion of knowledge of the social determinants of health, including among healthcare workers, can improve the quality and standard of care for people who are marginalized, poor or living in developing nations by preventing early death and disability while working to improve quality of life.
Challenges of measuring value of interventions
Many economic studies have been conducted to measure the effectiveness and value of social determinant interventions but are unable to accurately reflect effects on public health due to the multi-faceted nature of the topic. While neither cost-effectiveness
Cost-effectiveness analysis (CEA) is a form of economic analysis that compares the relative costs and outcomes (effects) of different courses of action. Cost-effectiveness analysis is distinct from cost–benefit analysis, which assigns a monetar ...
nor cost-utility analysis is able to be used on social determinant interventions, cost-benefit analysis is able to better capture the effects of an intervention on multiple sectors of the economy. For example, tobacco interventions have shown to decrease tobacco use, but also prolong lifespans, increasing lifetime healthcare costs and is therefore marked as a failed intervention by cost-effectiveness, but not cost-benefit. Another issue with research in this area is that most of the current scientific papers focus on rich, developed countries, and there is a lack of research in developing countries.
Policy changes that affect children also present the challenge that it takes a significant amount of time to gather this type of data. In addition, policies to reduce child poverty
Child poverty refers to the state of children living in poverty and applies to children from poor families and orphans being raised with limited or no state resources. UNICEF estimates that 356 million children live in extreme poverty. It's estima ...
are particularly important, as elevated stress hormones in children interfere with the development of brain circuitry and connections, causing long term chemical damage. In most wealthy countries, the relative child poverty rate is 10 percent or less; in the United States, it is 21.9 percent. The lowest poverty rates are more common in smaller well-developed and high-spending welfare states like Sweden and Finland, with about 5 or 6 percent. Middle-level rates are found in major European countries where unemployment compensation is more generous and social policies provide more generous support to single mothers and working women (through paid family leave, for example), and where social assistance minimums are high. For instance, the Netherlands, Austria, Belgium and Germany have poverty rates that are in the 7 to 8 percent range.
Within clinical settings
Connecting patients with the necessary social services during their visits to hospitals or medical clinics is an important factor in preventing patients from experiencing decreased health outcomes as a result of social or environmental factors.
A clinical study done by researchers at the University of California San Francisco, indicated that connecting patients with the resources to utilize and contact social services during clinical visits, significantly decreased families social needs and significantly improved children's overall health.
Public policy
The Rio Political Declaration on Social Determinants of Health embraces a transparent, participatory model of policy development that, among other things, addresses the social determinants of health leading to persistent health inequalities for indigenous peoples. In 2017, citing the need for accountability for the pledges made by countries in the Rio Political Declaration on Social Determinants of Health, the World Health Organization and United Nations Children's Fund called for the monitoring of intersectoral interventions on the social determinants of health that improve health equity.
The United States Department of Health and Human Services includes social determinants in its model of population health, and one of its missions is to strengthen policies which are backed by the best available evidence and knowledge in the field
Social determinants of health do not exist in a vacuum. Their quality and availability to the population are usually a result of public policy decisions made by governing authorities. For example, early life is shaped by availability of sufficient material resources that assure adequate educational opportunities, food, and housing among others. Much of this has to do with the employment security and the quality of working conditions and wages. The availability of quality, regulated childcare is an especially important policy option in support of early life. These are not issues that usually come under individual control but rather they are socially constructed conditions which require institutional responses. A policy-oriented approach places such findings within a broader policy context. In this context, Health in All Policies Health in All Policies (HiAP) was a term first used in Europe during the Finnish presidency of the European Union (EU), in 2006, with the aim of collaborating across sectors to achieve common goals. It is a strategy to include health considerations ...
has seen as a response to incorporate health and health equity into all public policies as means to foster synergy between sectors and ultimately promote health.
Yet it is not uncommon to see governmental and other authorities individualize these issues. Governments may view early life as being primarily about parental behaviors towards their children. They then focus upon promoting better parenting, assist in having parents read to their children, or urge schools to foster exercise among children rather than raising the amount of financial or housing resources available to families. Indeed, for every social determinant of health, an individualized manifestation of each is available. There is little evidence to suggest the efficacy of such approaches in improving the health status of those most vulnerable to illness in the absence of efforts to modify their adverse living conditions.
A team of the Cochrane Collaboration conducted the first comprehensive systematic review of the health impact of unconditional cash transfers, as an increasingly common up-stream, structural social determinant of health. The review of 21 studies, including 16 randomized controlled trials, found that unconditional cash transfers may not improve health services use. However, they lead to a large, clinically meaningful reduction in the likelihood of being sick by an estimated 27%. Unconditional cash transfers may also improve food security and dietary diversity. Children in recipient families are more likely to attend school, and the cash transfers may increase money spent on health care.
One of the recommendations by the Commission on the Social Determinants of Health is expanding knowledge – particularly to health care workers.
Although not addressed by the WHO Commission on Social Determinants of Health, sexual orientation and gender identity are increasingly recognized as social determinants of health.
With all the different health inequities and differences in quality of care addressed in social determinants of health, the American Hospital Association created the Value Initiative project which helps make healthcare more affordable to people of all types. It does this four different ways:
# It frames issues regarding the healthcare system and its pricing and affordability.
# It provides knowledge, resources, and tools for hospitals to supply affordable healthcare and increase value
# The initiative collects data of hospital experiences to develop new federal policy solutions
# Builds a platform for the American Hospital Association to discuss with policymakers to find solutions to the lack of affordable care.
This initiative educates the public and makes sure there is transparency in pricing of hospital bills, making sure patients are not billed more than they should be. It also addresses the cost drivers in the healthcare system, and urges for legislators to take action to make healthcare affordable and to prioritize health over profit. This organization asks congress to control the rising costs of pharmaceuticals by encouraging competition between manufacturers, and improving transparency in drug pricing. In this value initiative, they have started the Affordability Advocacy Agenda (AAA) which improves the ongoing policy and advocacy activities. With the Covid-19 pandemic health care spending increased and there was a rise in hospitalizations and therefore a rise in demand for health care providers. The price for care has increased and there aren't enough workers to meet the demand for care. The AAA and congress are working together to provide relief from the pandemic in order to make healthcare more affordable to all.
As of January 1, 2022 there are regulations placed for healthcare providers about no surprise billing. This is the "No Surprises Act" of division BB of the Consolidated Appropriations Act, 2021
The Consolidated Appropriations Act, 2021 () is a $2.3trillion spending bill that combines $900 billion in stimulus relief for the COVID-19 pandemic in the United States with a $1.4trillion omnibus spending bill for the 2021 federal fiscal yea ...
and this rule was made by the Biden-Harris administration. Patients should not be billed more than they expected to pay, it is often noticed with emergency services and this rule will stop patients from getting worried about any bills out of their budget, and they will be able to get the proper care they need for their health with peace of mind. The act was passed by congress at the end of 2020 and offers protection against insured Americans getting surprise bills from out-of-network providers They struggled to find an amount that an insurer should pay to the out-of-network provider, but eventually found an amount and the law is now in effect as of January 2022. When it comes to out-of-network providers, patients often rely on these services in an emergency and then get stuck with the bill afterwards. Air Ambulance bills are a big problem for consumers, not just because they are out of network and cost a lot, but also for their lack of billing transparency. Since the Airline Deregulation Act
The Airline Deregulation Act is a 1978 United States federal law that deregulated the airline industry in the United States, removing federal control over such areas as fares, routes, and market entry of new airlines. The Civil Aeronautics Boa ...
, which allows air ambulance to make their own prices, federal solutions to this increasing cost of emergency care is needed. A possible solution is to allow air ambulance services to be administered and financed in a way that combines competitive bidding and public utility regulation.
See also
* Adverse Childhood Experiences Study Adverse childhood experiences (ACEs) encompass various forms of physical and emotional abuse, neglect, and household dysfunction experienced in childhood. The harms of ACEs can be long-lasting, affecting people even in their adulthood. ACEs have be ...
* Causal inference
Causal inference is the process of determining the independent, actual effect of a particular phenomenon that is a component of a larger system. The main difference between causal inference and inference of association is that causal inference ana ...
* Center for Minority Health
The School of Public Health (sometimes shortened to Pitt Public Health) is one of 17 schools at the University of Pittsburgh. The school, founded in 1948, was first led by Thomas Parran, surgeon general of the U.S. Public Health Service. It is ...
* Diseases of affluence
Diseases of affluence, previously called diseases of rich people, is a term sometimes given to selected diseases and other health conditions which are commonly thought to be a result of increasing wealth in a society. Also referred to as the "Wes ...
* Diseases of poverty
Diseases of poverty (also known as poverty-related diseases) are diseases that are more prevalent in low-income populations. They include infectious diseases, as well as diseases related to malnutrition and poor health behaviour. Poverty is one o ...
* Environmental Racism in the United States Environmental racism is a form of institutional racism, in which people of colour experience environmental harms, such as pollution and the effects of natural disasters, at a disproportionately high rate. Some scholars have coined environmental raci ...
* Epidemiology
Epidemiology is the study and analysis of the distribution (who, when, and where), patterns and determinants of health and disease conditions in a defined population.
It is a cornerstone of public health, and shapes policy decisions and evidenc ...
* EuroHealthNet
EuroHealthNet is a non-profit partnership of organisations, agencies and statutory bodies working to contribute to a healthier Europe by promoting health and health equity between and within European countries. EuroHealthNet achieves this through ...
* Etiology
Etiology (pronounced ; alternatively: aetiology or ætiology) is the study of causation or origination. The word is derived from the Greek (''aitiología'') "giving a reason for" (, ''aitía'', "cause"); and ('' -logía''). More completely, e ...
* Exercise
Exercise is a body activity that enhances or maintains physical fitness and overall health and wellness.
It is performed for various reasons, to aid growth and improve strength, develop muscles and the cardiovascular system, hone athletic ...
* Global health
Global health is the health of the populations in the worldwide context; it has been defined as "the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide". Problem ...
* Health equity
Health equity arises from access to the social determinants of health, specifically from wealth, power and prestige. Individuals who have consistently been deprived of these three determinants are significantly disadvantaged from health inequitie ...
* Health behaviour
* Health literacy
Health literacy is the ability to obtain, read, understand, and use healthcare information in order to make appropriate health decisions and follow instructions for treatment. There are multiple definitions of health literacy, in part, because heal ...
* Healthy People
Healthy People is a program of a nationwide health-promotion and disease-prevention goals set by the United States Department of Health and Human Services. The goals were first set in 1979 "in response to an emerging consensus among scientists and ...
* Inequality in disease
Social epidemiology focuses on the patterns in morbidity and mortality rates that emerge as a result of social characteristics. While an individual's lifestyle choices or family history may place him or her at an increased risk for developing cer ...
* Hopkins Center for Health Disparities Solutions
The Hopkins Center for Health Disparities Solutions (HCHDS), a research center within the Johns Hopkins Bloomberg School of Public Health, strives to eradicate disparities in health and health care among racial and ethnic groups, socioeconomic ...
* Medical anthropology
Medical anthropology studies "human health and disease, health care systems, and biocultural adaptation". It views humans from multidimensional and ecological perspectives. It is one of the most highly developed areas of anthropology and applied ...
* Medical sociology
Medical sociology is the sociological analysis of medical organizations and institutions; the production of knowledge and selection of methods, the actions and interactions of healthcare professionals, and the social or cultural (rather than clin ...
* Molecular pathological epidemiology Molecular pathological epidemiology (MPE, also molecular pathologic epidemiology) is a discipline combining epidemiology and pathology. It is defined as "epidemiology of molecular pathology and heterogeneity of disease". Pathology and epidemiology s ...
* Pathogenesis
Pathogenesis is the process by which a disease or disorder develops. It can include factors which contribute not only to the onset of the disease or disorder, but also to its progression and maintenance. The word comes from Greek πάθος ''pat ...
* Pathology
Pathology is the study of the causes and effects of disease or injury. The word ''pathology'' also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in ...
* Population health
Population health has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group". It is an approach to health that aims to improve the health of an entire human population. It ha ...
* Population Health Forum The Population Health Forum is a group based at University of Washington in Seattle, Washington, and composed of academics, citizens, students, and activists from around North America.
Purpose and activities
Activities include development of acad ...
* Race and health
Race and health refers to how being identified with a specific race influences health. Race is a complex concept that has changed across chronological eras and depends on both self-identification and social recognition. In the study of race and ...
* Social determinants of health in Mexico
Social determinants of health in Mexico are factors that influence the status of health among certain populations in Mexico. These factors consist of circumstances in which people grow, live, work, and age, as well as the systems put in place to de ...
* Social determinants of obesity
While genetic influences are important to understanding obesity, they cannot explain the current dramatic increase seen within specific countries or globally. It is accepted that calorie consumption in excess of calorie expenditure leads to obes ...
* Social epidemiology
While epidemiology is "the study of the distribution and determinants of states of health in populations", social epidemiology is "that branch of epidemiology concerned with the way that social structures, institutions, and relationships influence ...
* Unnatural Causes: Is Inequality Making Us Sick?
* Whitehall Study
The Whitehall Studies investigated social determinants of health, specifically the cardiovascular disease prevalence and mortality rates among British civil servants. The initial prospective cohort study, the Whitehall I Study, examined over 17,5 ...
* Michael Marmot
Sir Michael Gideon Marmot (born 26 February 1945) is Professor of Epidemiology and Public Health at University College London. He is currently the Director of The UCL Institute of Health Equity. Marmot has led research groups on health inequa ...
* Richard G. Wilkinson
Richard Gerald Wilkinson (born 1943) is a British social epidemiologist, author, advocate, and left-wing political activist. He is Professor Emeritus of social epidemiology at the University of Nottingham, having retired in 2008. He is also Hon ...
* Dennis Raphael
Dennis Raphael is a professor of Health Policy and Management at York University in Toronto. Raphael received his Ph.D. from the University of Toronto in 1975.
Most of his over 300 scientific publications have focused on the health effects of inco ...
* Slavery hypertension hypothesis The slavery hypertension hypothesis proposes that disproportionately high rates of hypertension among black people in the New World are due to selection bias preferring individuals who retain more sodium among black slaves during the Middle Passage. ...
* Weathering hypothesis
The weathering hypothesis was proposed to account for early health deterioration as a result of cumulative exposure to experiences of social, economic and political adversity. It is well documented that minority groups and marginalized communities ...
Notes and references
External links
The determinants of health (World Health Organization)
HEALTH IS WEALTH – 7 REASONS CONVINCING WHY?
Commission on Social Determinants of Health (World Health Organization)
A glossary for social epidemiology - N Krieger
Key determinants of health (Public Health Agency of Canada)
NPTEL - Socio-economic Status and Health Income Inequality and Health
Social Determinants of Health: The Canadian Facts
The Social Context of Health Behaviors - Paula Braveman
World Health Organization: Equity, Social Determinants and Public Health Programmes
* ttp://health-gradient.eu/ Drivers for Health Equity
Olomouc University Social Health Institute
Research into Social Determinants of Health
{{DEFAULTSORT:Social Determinants Of Health
Public health
Social inequality
Determinants of health
Cultural competence
Social problems in medicine