Notes on Social Determinants of Health

Social Determinants of Health

  • Definition: Social determinants of health (SDoH) are the conditions in which people are born, grow, live, work and age that influence health, in addition to individual genetics and lifestyle choices. These conditions are shaped by the distribution of money, power (social class/position), and resources at global, national, and local levels. The SDoH encompass the full set of social conditions that impact a person’s health and wellbeing, summarized as "the social characteristics within which living takes place". (WHO Commission, 2005)
  • Importance: Understanding how population groups experience "place" or daily living and its impact on health is essential; SDoH explain health outcomes beyond individual choices.
  • Key takeaway: SDoH are not just individual factors but structural conditions that influence health equity and disparities.

Influential figures and institutions

  • Dr. Paul Farmer (founder of Partners In Health): "Illness has social roots and must be addressed through social structures." He argued that treating patients for diseases without addressing the desperate circumstances that contribute to sickness is insufficient. His work emphasizes linking medical care with social justice and community-based action.
  • University of Global Health Equity (UGHE): Established in Butaro, Rwanda in 2014. Rooted in Farmer’s belief that medical education should be inseparably linked to social justice and community service. Aims to develop health leaders to build and sustain equitable health systems in underserved regions.

Common social determinants of health

  • Income
  • Social status
  • Employment and working conditions
  • Access to health services
  • Education and literacy
  • Childhood experiences
  • Physical environments
  • Social supports
  • Health behaviors
  • Culture
  • Racism
  • Gender (not sex) – pervasive social, cultural, economic disparity

21st century: which determinant most affects life expectancy in developed countries?

  • Answer: Health technology improvements account for 75\% \text{ to } 90\% of the increase in life expectancy in developed countries; income growth accounts for the remainder. (Sandro Galea, 2007)

The Preston Curve: Wealth and life expectancy

  • Key idea: Wealth affects life expectancy up to a threshold and then levels off; additional wealth beyond the threshold yields diminishing returns on life expectancy.
  • Conceptual representation: Wealth-LE relationship shows initial steep gains in LE with increasing wealth, followed by plateauing gains as wealth grows beyond a certain point.
  • Conceptual formula (illustrative):
    LE(W) = \begin{cases} a\ \log(W) + b, & W < W* \ LE{\max}, & W \ge W_* \end{cases}
  • Implication: Economic growth improves health up to a point, after which other factors (e.g., behavioral, environmental, systemic) become comparatively more influential for further health gains.

Central Premise for SDOH (WHO)

  • In 2005, the WHO established a commission on Social Determinants of Health.
  • Premise: Economic systems, political processes, social structures, and legal arrangements can be as toxic to populations as any viral or bacterial pandemic.
  • Concept: Social inequalities can be thought of as a “macro-parasite” that undermines population health.
  • Reference: WHO SDOH framework and related resources (link provided in material).

Health People 2030 framework

  • Health People 2030 (as part of the Healthy People series) provides a framework for understanding and addressing SDOH.
  • Five Things to Know about Healthy People 2030’s Framework (referenced in the material).

Importance of SDOH

  • Health, disease distribution, and life expectancy vary across and within countries; patterns of disease and death cluster along social stratification.
  • Macro-determinants: Social justice, economic systems, and political arrangements influence health outcomes, supported by the concept of the social gradient.
  • European example: Comprehensive social and welfare reforms in housing, sanitation, nutrition, and education improved health outcomes (declining infant mortality, increasing life expectancy) even before modern medicine.

The main determinants of health (Dahlgren-Whitehead diagram, adapted)

  • Living and working conditions
  • General socio-economic, cultural, and environmental conditions
  • Work environment
  • Education
  • Agriculture and food production
  • Unemployment
  • Community networks
  • Social and individual lifestyle factors
  • Water and sanitation
  • Health care services
  • Housing
  • Age, sex, and constitutional factors
  • Visual reference: Figure 3-1 The Determinants of Health (Dahlgren, Whitehead, 1991)

Social Determinants of Health Framework (Healthy People)

  • A place-based organizing framework with five key areas of SDOH developed by Healthy People 2020, now updated to Healthy People 2030.

Other emerging determinants of health

  • Industry determinants: e.g., food and beverage industry influences on obesity; tobacco’s impact on cardiovascular and lung disease.
  • Political determinants: Political factors shape global health outcomes (e.g., PEPFAR since 2003); this area is studied in political epidemiology to identify institutions and factors that facilitate or impede public health decision-making (Kickbusch, Mackenbach).

Structural organizational determinants of health

  • Administrative decentralization: The process of distributing or delegating administrative, fiscal, and decision-making authority from a central government to sub-national levels (local governments, civil society, private sector).
  • Reported benefits: improved efficiency, service delivery innovation, increased equity, better infrastructure, increased accountability, and improved health outcomes. (Maharani & Tampubolon, 2014; Saltman et al., 2006)

Five Key Areas of SDOH

1) Economic Stability

  • Poverty
  • Employment
  • Food Security
  • Housing Stability
    2) Education
  • High School Graduation
  • Enrollment in Higher Education
  • Language and Literacy
  • Early Childhood Education and Development
    3) Social and Community Context
  • Social cohesion and connectedness
  • Civic Participation
  • Discrimination and segregation
  • Incarceration
    4) Health and Health Care
  • Access to Health Care
  • Access to Primary Care
  • Health Literacy
    5) Neighborhood and Built Environment
  • Access to Healthy Foods
  • Quality of Housing
  • Crime and Violence
  • Environmental Conditions

Social Determinants of TB disease (example)

  • Cause of TB: causative agent is Mycobacterium tuberculosis.
  • Host factors: nutrition and immune status influence progression from infection to active disease.
  • Environment: living conditions and exposure determine likelihood of infection.
  • Evidence: TB mortality declined from the 1900s to 1950s prior to widespread chemotherapy, coinciding with improvements in housing, sanitation, nutrition, and living conditions.
  • Visual example: A historical figure showing declines in TB mortality with the advent of better public health measures (BCG vaccination, tuberculin testing, and chemotherapy).

Social Determinants of Health Framework (another view)

  • Neighborhood and Built Environment
  • Economic Stability
  • Health and Health Care
  • Education
  • Social and Community Context
  • (Source: Healthy People framework)

In-class Exercise (concept)

  • Scenario: Develop a low-cost intervention to prevent obesity in school-age children (K-12) in a low-income country.
  • Approach: Use the 5 key SDOH areas to design a low-cost health intervention; briefly explain the program and identify the most practical approach for a low-income setting.

Health Inequality and Inequity

  • Important distinction: inequality vs inequity.
  • Both lead to disparities in health, but the terms have different implications for policy and justice.

What is Inequality?

  • Definition: Primarily refers to disparities in specific aspects (social, economic, etc.) between individuals or groups.
  • Examples: inequality in home ownership between married couples and single people; inequality in health insurance between college students and working adults with families.
  • Nature: Quantitative measure of societal imbalance/differences.
  • Systemic inequality: Perpetuated through social, political, economic institutions; creates a climate of unfairness.

What is Equity?

  • Definition: The principle of fairness and justice in a society.
  • Inequity: Often associated with groups that suffer from discrimination (gender, race, ethnicity, nationality, language, religion, social class, sexual orientation, disabilities).

What is Health Equity?

  • Definition: Equity in health is the absence of potentially remediable, systematic differences in health status across socially, economically, demographically, or geographically defined populations or subgroups.
  • Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health.
  • Health inequities: Unfair or unjust, avoidable differences arising from poor governance, policies, corruption, or social-cultural exclusion.
  • Inequities are potentially modifiable by government action, advocacy, changes in laws, or the structure of legal systems; they can lead to or cause inequalities (income, home ownership, graduation rates, etc.).

Inequality vs Equity (visual reference)

  • EQUALITY vs EQUITY: conceptually different; equality means equal distribution, equity means fairness by addressing specific needs to reach equal outcomes.

Importance of health inequality and inequity in global health

  • Benefits from health interventions are not evenly distributed across populations.
  • Universal interventions may not be equally effective for disadvantaged groups and can sometimes widen disparities if not designed with equity in mind.
  • Health differentials arise from complex interactions among factors relating to disadvantage.
  • Source: Macintyre (2003) on evaluating evidence to reduce inequalities in health; Health Equity Network.

The social health gradient

  • Health status correlates with social status: higher status associated with better health outcomes.
  • Indicators: life expectancy generally longer with higher social status; disease burden higher lower on the social ladder.

Implications of the social gradient for policymakers

  • General health improvements do not automatically reduce health inequities at the population level.
  • Universal interventions (e.g., high vaccination coverage, sanitation, clean water, better nutrition, improved housing) may benefit better-off groups more than poorer groups.
  • To reduce differential effects, equity-proofing of health programs is needed to minimize increases in health inequities.

Equity Proofing

  • Definition: A process that assesses intended and unintended equity consequences of a health action or policy.
  • Purpose: To inform how best to integrate measures into policies/programs that address SDOH and health equity; aims to close gaps in health experiences or outcomes and minimize inadvertent increases in inequities.

Example of Equity Proofing

  • Hybrid policies are often most appropriate for addressing health inequities: combine universal measures with targeted follow-up for subgroups (tailored programs).
  • Tobacco policy example: universal intervention such as a sin tax plus targeted health education on adverse effects of smoking.
  • Reproductive health example: programs including access to birth control, women empowerment, and male partner involvement.

Equity Proofing: policy development steps and tools

  • Steps: Identify, assess, and address potential health equity impacts within policy development.
  • Broad application: Should be applied to policies across sectors, not only in global health.
  • Recommended approach: Health Impact Assessment (HIA) to structure evaluation of positive/negative, intended/unintended health impacts.

Global Health, SDOH and Equity

  • Global health aims to advance health equity by addressing SDOH and promoting fair and just practices through science, programs, policies, and interventions.

Video on SDOH

  • Resources to explore: YouTube videos on SDOH (various national perspectives):
    • https://www.youtube.com/watch?v=neuQN6F7Io
    • https://www.youtube.com/watch?v=aS3-MZZYVNI
    • https://www.youtube.com/watch?v=PHvfjcuhAuQ