Social Determinants of Health
by Abigail Silber
One concise explanation of the social determinants of health comes from the WHO and includes “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (1). This means that social constructs—not only biology—affect health outcomes. However, social determinants of health vary depending on the health topic. Take a hypothetical case of someone named John. He lives in subsidized housing, works at a local factory, and has health insurance. John learns that he has epilepsy when he is 35, after he has a seizure at work. His boss, not understanding this condition, thinks that John was taking drugs at work, which caused the seizure. John loses his job and is able to collect unemployment benefits. Because John has health insurance he goes to his primary care physician frequently, but he cannot afford the copay after five months and his medication has also become too expensive. John begins to have many more seizures per day, and becomes brain-damaged. John’s story is distinct from the story of someone named Mary, who has a job as an accountant, and is able to afford her doctor’s visits. John and Mary have different social determinants, and as a result there is a disparity between their health outcomes, even if they have the same biological conditions.
An understanding of the social determinants of health can help in creating meaningful public health interventions. If a doctor treats patients, then a public health practitioner treats a population. However, preventing illness will not help the entire population much if it does not address those things that have the potential to make health outcomes worse. Racial and ethnic oppression, income, housing, and education are commonly used examples of the social determinants of health seen in the US (2). The social determinants of health are why it is necessary to look at why disease affects different populations more severely.
Louis-René Villermé in Paris explored the idea of “social determinants of health” in the 1800s with regard to income. He conducted a study, which correlated the number of deaths in each neighborhood with the income ranking of the neighborhood. What he found was a strong negative correlation between mortality and income, shown below (3). This is the first study that was able to quantify the ability of money to buy health.
In the US, the federal government established a law recognizing health impact that seamen experienced in their profession. This gave these men access to healthcare, because they were not able to address their health needs at sea (4). As public health became a more sophisticated science, researchers and practitioners added more factors to income and occupation to become the social determinants of health.
Studies that include the social determinants of health have become relatively common. For example, in prospective studies, baseline assessments include questions about age, race, and sex. There are other social determinants of health that have yet to become streamlined like sexuality, gender preference (trans/cis), income, urban/rural dwelling, and education level to name a few. This is because people with different social determinants can produce vastly different data for any given intervention, or even clinical trial. Epidemiologists would be considered remiss if they did not include these items in their baseline assessments, because it would be as though they were looking at data that grouped apples and oranges, John and Mary.
Therefore the social determinants of health are crucial to address through public health interventions. Because of the gaps in health, interventions often target marginalized and impoverished populations to be able to improve the disparity between these groups and the general population. One example of a public health intervention that has incorporated the social determinants of health is the Affordable Care Act (ACA), which sought to increase the amount of people with insurance in the US. This gives more people access to the health system, especially those whose insurance is not provided by their employer. In this way, the ACA has attempted to limit the effects of income as a social determinant on health because it has given more people affordable healthcare.
The limitations of this public health theory include its lack of a framework for addressing and organizing social determinants of health. For this reason, this theory is closely tied to the socio-ecologic model because this provides public health professionals with a framework to organize different social determinants of health. This theory enables recognition and awareness of social issues, but must be considered in conjunction with other social approaches, frameworks, and theories.
1. Social determinants of health [Internet]. World Health Organization. 2016 [cited 24 October 2016]. Available from: http://www.who.int/social_determinants/en/
2. Wilkinson, R. and Marmot M. Social Determinants of Health: The Solid Facts [Internet]. World Health Organization. 2016 [cited 24 October 2016]. Available from: http://www.euro.who.int/__data/assets/pdf_file/0005/98438/e81384.pdf
3. Office of Teaching & Digital Learning. Villerme's Findings [Internet]. 2015 [cited 24 October 2016]. Available from: http://sphweb.bumc.bu.edu/otlt/MPH-Modules/PH/PublicHealthHistory/publichealthhistory7.html
4. Public Health in the United States [Internet]. Sphweb.bumc.bu.edu. 2016 [cited 24 October 2016]. Available from: http://sphweb.bumc.bu.edu/otlt/MPH-Modules/PH/PublicHealthHistory/publichealthhistory8.html