Social determinants of health

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Social determinants of health are the economic and social conditions – and their distribution among the population – that influence individual and group differences in health status. They are risk factors found in one's living and working conditions (such as the distribution of income, wealth, influence, and power), rather than individual factors (such as behavioural risk factors or genetics) that influence the risk for a disease, or vulnerability to disease or injury. According to some viewpoints, these distributions of social determinants are shaped by public policies that reflect the influence of prevailing political ideologies of those governing a jurisdiction.[1] The World Health Organisation says that “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 [where 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.”[2]

Contents

Improving Health Status

Profound improvements in health status have occurred in industrialized nations such as Canada since 1900. It has been hypothesized that access to improved medical care is responsible for these differences, but best estimates are that only 10–15 percent of increased longevity since 1900 in wealthy industrialized nations is due to improved health care.[3] As one illustration, the advent of vaccines and medical treatments are usually held responsible for the profound declines in mortality from infectious diseases in Canada since 1900. But by the time vaccines for diseases such as measles, influenza, and polio and treatments for scarlet fever, dramatic declines in mortality had already occurred.[3]

Improvements in behaviour (e.g., reductions in tobacco use, changes in diet, increased exercise, etc.) have also been hypothesized as responsible for improved longevity, but most analysts conclude that improvements in health are due to the improving material conditions of everyday life experienced by Canadians since 1900.[4][5] These improvements occurred in the areas of early childhood, education, food processing and availability, health and social services, housing, employment security and working conditions and every other social determinant of health.

International Health Differences

Between developed countries

Profound differences in overall health status exist between developed and developing nations. Much of this has to do with the lack of the basic necessities of life (food, water, sanitation, primary health care, etc.) common to developing nations. Yet among developed nations such as Canada, less profound but still highly significant differences in health status indicators such as life expectancy, infant mortality, incidence of disease, and death from injuries exist.[6] An excellent example is comparison of health status differences and the hypothesized social determinants of these health status differences among Canada, the United States, and Sweden.

Scholarship has noted that the USA takes an especially laissez-faire approach to providing various forms of security (employment, food, income, and housing) and health and social services while Sweden’s welfare state makes extraordinary efforts to provide security and services.[7][8] The sources of these differences in public policy appear to be in differing commitments to citizen support informed by the political ideologies of governing parties within each nation.[9][10]

Emerging scholarship is specifically focused on how national approaches to security provision to citizens influence health by shaping the quality of numerous social determinants of health. Nations such as Sweden whose policies reduce unemployment, minimize income and wealth inequality, and address numerous social determinants of health show evidence of improved population health using indicators such as infant mortality and life expectancy.[11] At the other end, nations with minimal commitments to such efforts such as the United States show rather worse indicators of population[further explanation needed] health.[12]

Finally, poverty is an especially important indicator of how various social determinants of health combine to influence health. Using child – that is family – poverty rates as an important social determinants of both child and eventual health, Canada does not fare well in relation to European nations.

Between developing and developed countries

People in rich countries live dramatically longer, healthier lives than people in poorer countries. It is argued by Labonte and Schrecker, as well as many NGOs and Global Health Organizations; like the WHO and OXFAM; that it is the huge wealth inequalities between rich and poor countries that is acting as a fundamental driver of poor global health.[13] Institutions like the OECD counter that advances in health have been primarily do to advances in research in technology and medicine--however, the demographic transition of many countries was due to simple advances in healthcare that had little to do with advanced research. The WHO advocates poverty reduction as an actionable method to increase global health outcomes.[13] The causes of wealth inequalities are discussed elsewhere, and groups have formed to lobby regarding these issues.[14][third-party source needed]

The USA

The United States has by far the most costly health care system in the world, both per person and as a percent of that nation’s total economic resources. Clearly, other countries have found effective mechanisms for keeping health care costs to a much lower share of their economic resources without putting financial barriers in the way of patients seeking care.[15] Susan Sered and Rushika Fernandopulle provide powerful insights due to the cost of healthcare in the United States which is visible, recognizable markers of caste membership on the bodies of the uninsured. Not being able to afford private healthcare, these individuals receive less and inadequate medical care, which leads to physical markers like rotten teeth, chronic cough, limping, etc. These physical markers also make it much more difficult for them to obtain a job that would provide salaries and benefits to move them out of their health insurance conundrum. Unable to escape, members of the caste are blamed for their own situation. Failure to make the “right choices” is seen as a personal failure rather than a failure of the system to provide adequate options.[16]

Cultural and Structuralist Approaches

To secure attention to the social determinants of health and build support for their strengthening, it is important to understand how social determinants of health come to influence health and cause disease. The very influential UK Black and The Health Divide reports considered two primary mechanisms for understanding this process: cultural/ behavioural and materialist/structuralist.[17]

The cultural/behavioural explanation was that individuals' behavioural choices (e.g., tobacco and alcohol use, diet, physical activity, etc.) were responsible for their developing and dying from a variety of diseases. Both the Black and Health divide reports however, showed that behavioural choices are heavily structured by one’s material conditions of life. And—consistent with mounting evidence—these behavioural risk factors account for a relatively small proportion of variation in the incidence and death from various diseases. The materialist/structuralist explanation emphasizes the material conditions under which people live their lives. These conditions include availability of resources to access the amenities of life, working conditions, and quality of available food and housing among others.

The author of the Health Divide concluded: The weight of evidence continues to point to explanations which suggest that socio-economic circumstances play the major part in subsequent health differences.[18] Despite this conclusion and increasing evidence in favour of this view, much of the Canadian public discourse on health and disease remains focused on “life-style” approaches to disease prevention.[19]

These materialist/structuralist conceptualizations have been refined such that analysis is now focused upon three frameworks by which social determinants of health come to influence health.[20] These frameworks are: (a) materialist; (b) neo-materialist; and (c) psychosocial comparison. The materialist explanation is about 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 come about. The psychosocial comparison explanation considers whether people compare themselves to others and how these comparisons affect health and wellbeing.

In this argument individuals experience varying degrees of positive and negative exposures over their lives that accumulate to produce adult health outcomes.[21] Overall wealth of nations is a strong indicator of population health. But within nations, socio-economic position is a powerful predictor of health as it is an indicator of material advantage or disadvantage over the lifespan.[22] 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, malnutrition, chronic disease, and injuries), developmental (delayed or impaired cognitive, personality, and social development), educational (learning disabilities, poor learning, early school leaving), and social (socialization, preparation for work, and family life) problems.[12][21]

Material conditions of life also lead to differences in psychosocial stress[23] The fight-or-flight reaction—chronically elicited in response to threats such as income, housing, and food insecurity, among others—weakens the immune system, leads to increased insulin resistance, greater incidence of lipid and clotting disorders, and other biomedical insults that are precursors to adult disease.

Adoption of health-threatening behaviours is a response to material deprivation and stress.[24] Environments determine whether individuals take up tobacco, use alcohol, experience poor diets, and have low levels of physical activity. Tobacco and excessive alcohol use, and carbohydrate-dense diets are also means of coping with difficult circumstances.[25][26] Materialist arguments help us understand the sources of health inequalities among individuals and nations and the role played by the social determinants of health.

Neo-materialist approach

Exposures to the material conditions of life are important for health, but why are these material conditions so unequally distributed among the Canadian population but less so elsewhere?[27][28] The neo-materialist approach is concerned with how nations, regions, and cities differ on how economic and other resources are distributed among the population.[29] Some jurisdictions have more equalitarian distribution of resources such that there are fewer poor people and the gaps that exist among the population in their exposures to the social determinants of health is narrower than places where there are more poor people and the gaps among the population are greater.

In the USA, states and cities with more unequal distributions of income have more low-income people and greater income gaps between rich and poor. They invest less in public infrastructure such as education, health and social services, health insurance, supports for the unemployed and those with disabilities, and spend less on education and libraries. All of these issues contribute to the quality of the social determinants of health to which people are exposed. Such unequal jurisdictions have much poorer health profiles[clarification needed] than more equalitarian places.[30][31]

Canada has a smaller proportion of lower-income people, a smaller gap between rich and poor, and spends relatively more on public infrastructure than the U.S.[32][verification needed] Canadians enjoy better health than Americans[clarification needed] as measured by infant mortality rates, life expectancy, and death rates from childhood injuries.[33] Neither nation does as well as Sweden where distribution of resources is much more equalitarian, low-income rates are very low, and health indicators are among the best in the world.

The neo-materialist view therefore, directs attention to both the effects of living conditions – the social determinants of health—on individuals' health and the societal factors that determine the quality of the distribution of these social determinants of health. How a society decides to distribute resources among citizens is especially important.

Social comparison approach

The argument here is that the social determinants of health play their role through citizens’ interpretations of their standings in the social hierarchy.[28][34] 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. Comparing their status, possessions, and other life circumstances to those better-off than themselves, individuals experience feelings of shame, worthlessness, and envy that have psychobiological effects upon health. These processes involve direct disease-producing effects upon neuro-endocrine, autonomic and metabolic, and immune systems.[23] These comparisons can also lead to attempts to alleviate such feelings by overspending, taking on additional employment that threaten health, and adopting health-threatening coping behaviours such as overeating and using alcohol and tobacco.[34]

At the communal level, widening and strengthening of hierarchy weakens social cohesion, a determinant of health.[35] Individuals become more distrusting and suspicious of others with direct stress-related effects on the body. Such attitudes can also weaken support for communal structures such as public education, health, and social programs. An exaggerated desire for tax reductions on the part of the public can weaken public infrastructure.

This approach directs attention to the psychosocial effects of public policies that weaken the social determinants of health. But these effects may be secondary to how societies distribute material resources and provide security to its citizens – processes described in the materialist and neo-materialist approaches. Material aspects may be paramount and the stresses associated with deprivation simply add to the toll on individuals’ bodies.

Health encompasses more than healthcare

Diseases are mediated by factors outside the clinical setting, such as personal behaviors that involve smoking, alcohol, obesity, and environmental exposures. Woolf states, "The degree to which social conditions affect health is illustrated by the association between education and mortality rates".[36] Reports in 2005 revealed the mortality rate 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 3 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 very much dependent on one another, but these social conditions also apply independent health influences.[36]

Richard Wilkinson suggested the social gradient in health within countries is primarily a gradient in relative income or social status, rather than a reflection of absolute material living standards. Also, Michael G. Marmot (2004) and others have argued that the relationship between health and social status may be primarily a reflection of the effects of social position itself.[37]

Michael Marmot and Ruth Bell have researched health issues in rich countries, such as the United States, where 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, access to good quality education, rewarding work with some degree of autonomy, decent housing, and a clean and safe living environment. The social condition of autonomy, control, and empowerment turns out to be a crucial influence on health and disease. Individuals who lack social participation and those who have little control over their lives are at a greater risk for heart disease, mental illness, absence from work, and are less productive in society. Research suggest social action should deal with the entire gradient, of all society, not only with those at the bottom.[38]

The WHO organization also reports that being poor is really bad for your health. Within countries, the evidence reveals that in general the lower an individual’s socioeconomic position the poorer their health. There is a social gradient in health that runs from top to bottom of the socioeconomic ladder. This is a worldwide phenomenon and has been seen in low, middle and high income countries. The social gradient in health means that health inequities affect everyone.[39]

Chronic Stress and Health

A self-destructive cycle develops from the enduring relatively disadvantageous socioeconomic situation and depressive symptoms. This cycle, which results in chronic stress, plays a significant role in the increase of morbidity and mortality rates in the lower socioeconomic groups of the population.[40] To compare most animal studies on social rank examine hierarchy, where social rank is the best predictor for quality of life and health. In an experiment performed by Dr. Carol Schively, she studies the physiological effect of stress in primates relative to their position of hierarchy. Results revealed the monkeys that are on the lowest step of the ladder in their society have the poorest health. These studies reveal how chronic stress has a physiological effect that increases the stress hormone cortisol. Cortisol is usually higher in the day, and then later in the evening decreases. But if one is under stress continually, the cortisol stays high, which is what Dr. Schively observed in the primates she studied and perhaps can apply to humans as well.[41]

John Mason’s studies in 1960 included measuring stress hormone levels in humans subjected to various stressful conditions to define specific psychological characteristics that would make a condition stressful. When the stress hormone is secreted in response to stress, they act on the body to create a fight or flight response with symptoms such as an increase in heart rate and blood pressure.[42] Chronic stress wears down the body suppressing the immune system. This makes the body more susceptible to contracting diseases, and accelerates the aging process. Biochemically, when the body is under constant stress it signals the body to continually pump out stress hormones such as cortisol, which in large quantities can be detrimental to the body. Large amounts of cortisol will result in excessive levels of glucose in the bloodstream, which in turn can result in plaque build-up in the arteries, increased heart rate, and high blood pressure.[43] Data from the Coronary Artery Risk Development in Young Adults Study (CARDIA), conducted in the United States of 35- to 45-year-old men and women, indicated that lower income and education were associated with higher cortisol levels in the late afternoon and evening. Furthermore, elevated levels among those with lower socioeconomic status could be mostly explained by differences in health behavior, such as smoking but also, to a lesser extent, by social network diversity, depression, perceived social support, and autonomy.[44]

Life-course perspective

Traditional approaches to health and disease prevention have a distinctly non-historical here-and-now emphasis. Usually adults, and increasingly adolescents and youth are urged to adopt “healthy lifestyles” as a means of preventing the development of chronic diseases such as heart disease and diabetes, among others.[45][46] In contrast to these approaches, life-course approaches emphasize the accumulated effects of experience across the life span in understanding the maintenance of health and the onset of disease. It has been argued:

“The prevailing aetiological model for adult disease which emphasizes adult risk factors, particularly aspects of adult life style, has been challenged in recent years by research that has shown that poor growth and development and adverse early environmental conditions are associated with an increased risk of adult chronic disease" Kuh, D., & Ben-Shilmo, Y. (Eds.). (1997). A life course approach to chronic disease epidemiology. Oxford, UK: Oxford University Press,p. 3.

More specifically, it is apparent that 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. This has been repeatedly demonstrated in longitudinal studies—the U.S. National Longitudinal Survey, the West of Scotland Collaborative Study, Norwegian and Finnish linked data—which follow individuals across their lives.[47] This has been most clearly demonstrated in the case of heart disease and stroke.[41][43] And most recently, studies into the childhood and adulthood antecedents of adult-onset diabetes show how adverse economic and social conditions across the life span predispose individuals to this disorder.[8][48][49]

A recent volume brings together some of the important work concerning the importance of a life-course perspective for understanding the importance of social determinants.[50] Adopting a life-course perspective directs attention to how social determinants of health operate at every level of development—early childhood, childhood, adolescence, and adulthood—to both immediately influence health as well as provide the basis for health or illness during later stages of the life course.

Hertzman outlines three health effects that have relevance for a life-course perspective.[51] Latent effects are biological or developmental early life experiences that influence health later in life. Low birth weight, for instance, is a reliable predictor of incidence of cardiovascular disease and adult-onset diabetes in later life. Experience of nutritional deprivation during childhood has lasting health effects.

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 neighbourhoods, 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. 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—early childhood, childhood, adolescence, and adulthood—to both immediately influence health and provide the basis for health or illness later in life.

Steps to improve conditions of health worldwide

Reducing the health gap in a generation requires that governments build systems that allow a healthy standard of living where no one should fall below due to circumstances beyond his or her control. Social protection schemes can be instrumental in realizing developmental goals rather than being dependent on achieving those goals. They can be effective ways to reduce poverty and local economies can benefit.[39]

Policies to reduce child poverty need to be enacted as an investment in the future of all countries. As a child, when stress levels go up and stay up as a result of constantly having to worry about shelter and food, high hormone levels interfere with the development of brain circuitry and connection causing long term chemical damage.[52] Studies showed that the immune system of participants were stronger if their parents had the security of home ownership while the participants were growing up.

Policies to reduce child poverty need to be enacted as an investment in the future of all countries. In most rich 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.[53] The Commission on Social Determinants of Health (CSDH) in 2005 made recommendations for action to promote health equity based on 3 principles of action: “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.”.[38] 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.

As one of the recommendations by the CSDH, expanding knowledge- particularly to health care workers- will improve understanding about how social factors play a role in acquiring diseases and improve the strategies to combat such diseases. looking into social medicine, there needs to be a global focus on improving knowledge about social determinants of health surrounding particular diseases for health care workers (nurses, physicians & clinicians). Greater knowledge and understanding of social factors will allow for greater success when implementing medical and public interventions. Thinking about improving education of health care workers about social determinants of diseases 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.[54]

Public policy

Much social determinants of health research simply focuses on determining the relationship between a social determinant of health and health status. So a researcher may document that lower income is associated with adverse health outcomes among parents and their children. Or a researcher may demonstrate that food insecurity is related to poor health status among parents and children as is living in crowded housing, and so on. This is what is termed a depoliticized approach in that it says little about how these poor-quality social determinants of health come about.[55]

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. As one example, consider the social determinant of health of early life. 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.[56] These are not issues that usually come under individual control. A policy-oriented approach places such findings within a broader policy context.

Yet it is not uncommon to see governmental and other authorities individualize these issues. Governments may choose to understand early life as being primarily about parental behaviours 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.[57]

As one of the recommendations by the CSDH, expanding knowledge- particularly to health care workers- will improve understanding about how social factors play a role in acquiring diseases and improve the strategies to combat such diseases. looking into social medicine, there needs to be a global focus on improving knowledge about social determinants of health surrounding particular diseases for health care workers (nurses, physicians & clinicians). Greater knowledge and understanding of social factors will allow for greater success when implementing medical and public interventions. Thinking about improving education of health care workers about social determinants of diseases 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.[54]

Politics and political ideology

One way to think about this is to consider the idea of the welfare state and the political ideologies that shape its form in Canada and elsewhere. The concept of the welfare state is about the extent to which governments – or the state – use their power to provide citizens with the means to live secure and satisfying[dubious ] lives. Every developed nation has some form of the welfare state.

Two literatures inform this analysis. The first concerns the three forms of the modern welfare state. Esping-Andersen identifies three distinct clusters of welfare regimes among wealthy developed nations: Social Democratic (e.g., Sweden, Norway, Denmark, and Finland), Liberal (USA, UK, Canada, Ireland), and Conservative (France, Germany, Netherlands, and Belgium, among others).[58][59] There is high government intervention and strong welfare systems in the social democratic countries and rather less in the liberal. Conservative nations fall midway between these others in service provision and citizen supports.

Social democratic nations have very well developed welfare states that provide a wide range of universal and generous benefits. They expend more of national wealth to supports and services. They are proactive in developing labour, family-friendly, and gender equity supporting policies. Liberal nations spend rather less on supports and services. They offer modest universal transfers and modest social-insurance plans. Benefits are provided primarily through means-tested assistance whereby these benefits are only provided to the least well-off.

Navarro and colleagues provide empirical support for the hypotheses that the social determinants of health are less unequal and health status outcomes are of higher quality.[further explanation needed] Infant mortality rates are lower, life expectancy is longer, and absolute health inequalities are smaller in the social democratic rather than the liberal nations.[10][60] Some of these indicators are spending on supports and services, equalization of incomes, and wealth and availability of services in support of families and individuals. Health indicators include life expectancy and infant mortality.

Could this general approach to welfare provision shape Canadian receptivity to the concepts developed in this volume? And if so, what can be done to improve receptivity to and implementation of these concepts?

A particularly important issue that is emerging is whether any particular analysis of social determinants of health is de-politicized or not. A de-politicized approach is one that fails to take account of the fact that the quality of the social determinants of health to which citizens in a jurisdiction are exposed to is shaped by public policy created by governments. And governments of course are controlled by political parties who come to power with a set of ideological beliefs concerning the nature of society and the role of governments.

Such analyses that recognize the role played by politics outline the particular importance of having social democratic political parties in power. Nations that have had longer periods of social democratic influence such as Norway, Finland, Sweden, and Denmark have government policymaking that is remarkably consistent with social determinants of health concepts. Nations such as the USA and Canada,dominated by liberal and neo-liberal governing parties, much less so.

Fig. 23 - Would you say your own health is excellent.JPG

A wealth of evidence from Canada and other countries supports the notion that the socioeconomic circumstances of individuals and groups are equally or more important to health status than medical care and personal health behaviours, such as smoking and eating patterns.[61][62]

An example of SDOH, applicable to the United States, is shown in the graph. It shows self-reported health as it relates to income level and political party identification (Democrat vs. Republican).[63]

The weight of the evidence suggests that the SDOH have a direct impact on the health of individuals and populations, are the best predictors of individual and population health, structure lifestyle choices, and interact with each other to produce health (Raphael, 2003). In terms of the health of populations, it is well known that disparities-the size of the gap or inequality in social and economic status between groups within a given population-greatly affect the health status of the whole. The larger the gap, the lower the health status of the overall population.[25][26]

Poverty

See Also : Social determinants of health in poverty

See also

References

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