Social determinants and global health

Joyce L. Browne, MD MSc PhD fellowJulius Global Health, Julius Center for Health Sciences and Primary CareUMC Utrecht, The Netherlandswww.globalhealth.eu J.L.Browne@umcutrecht.nl

Fundamentals of Global Health Summer School 2014

1

Learning objectives

• To appreciate the historical context and evidence for a social gradient in morbidity and mortality

• To understand and discuss what social determinants are, and how they get under the skin

• Recognize and address the social gradients that occur in Global Health context

2

Understanding social determinants

3

Definitions

• Social determinants

• Health (in)equity

• Common measurements?

4

Definitions

Social DeterminantsThe social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.

Health inequitiesHealth inequities are avoidable inequalities in health between groups of people within countries and between countries. These inequities arise from inequalities within and between societies. Social and economic conditions and their effects on people’s lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs.

5

Why are we talking about social determinants?

http://www.kingsfund.org.uk/time-to-think-differently/trends/broader-determinants-health

Genetic 30%Social circumstances 15% environmental 5%

Historical context of the Social Determinants in Health

7

Historical context of the Social Determinants in Health (1)

1948

• WHO constitution: acknowledgement of “impact of social and political conditions on health” and need for intersectoral to achieve health gains.

1950s-1960s

• Little regard for social contexts, strong focus on technology and disease-specific campaigns.

1978

• Alma-Ata Declaration on Primary Health / Health for All.Asserted need to strengthen health equity by addressing social conditions through intersectoral programs

1980s

• Limited political will - Neoliberal governments in many European countries and the US with market-oriented reforms in health care- Structural Adjustment Programs for developing countries: reduced government’s social and public spending

• At the same time: biomedical paradigm was challenged: Black Report (UK)

8

• Published in 1980 by the Thatcher Government(over a Bank Holiday Weekend)

• Analysis of General Household Survey (GHS) data (collection started in 1970), by occupation as an indicator of SES

The Black Report

9Full report available at: http://www.sochealth.co.uk/resources/public-health-and-wellbeing/poverty-and-inequality/the-black-report-1980/

Consistent social class gradient in infant, child and adult mortality

10

Class differences were also observed for different causes of adult mortality

11

• Infectious and parasitic diseases• Endocrine, nutritional and

metabolic diseases• Diseases of the nervous system,

digestive system, genic-urinary tract

• Accidents, poisonings and violence

Historical context of the Social Determinants in Health (2)

1980s-1990s

• Increasing scientific evidence (e.g. Whitehall studies, UK)

• Political landscape: (social-)democrats within market systems

2004:

• Commission on Social Determinants of Health (CSDH)

2008:

• CSDH Report published

12

• British Civil Services• Prospective cohort

study (1967-1977)• 18 000 male servants

between 20-64

Conclusion:• Social gradient based

on seniority/occupation in overall mortality, but also for a range of specific diseases

Whitehall I

13

• British Civil Service, London offices

• Prospective cohort, start 1985

• 10,308 civil servants between 35-55 (33% female)

Conclusions:• Social gradient in

morbidity for men and women

• Causal factors identified: lifestyle (smoking, lack of physical activity, obesity, biometric markers), early life factors, the way work is organized, work climate, social influences

Whitehall II

14

Bosma et al, 1998

Historical context of the Social Determinants in Health (2)

1980s-

1990s

• Increasing scientific evidence (e.g. Whitehall studies, UK)

• Political landscape: (social-)democrats and continued market system approach

2004:

• Commission on Social Determinants of Health (CSDH)

2008:

• CSDH Report published

2013

• Statement of the UN Platform on Social Determinants in Health about the post-2015 development agenda

15

Theoretical explanations of disease distribution:• Psychosocial approach• Social production of

disease / political economic of health

• Eco-social and other multi-level frameworks

How do social factors get under the skin?

16

• Social stress resulting from (perception of) social status

• Hypthalamus-pituitary-adrenal axis (chronic)

• Sympatic nervous system/(nor)adrenatine (acute)

Psychosocial approach

17

• Economic and political determinants of health and disease, beyond the perception of inequalities– Lack of resources, but

also access to education, health services, transportation, environmental controls, availability of food, quality of housing, etc etc

Social production of disease / political economic of health

18

Krieger’s “embodiment”:

“we literally incorporate biological influences from the material and social world” and that “no aspect of our biology can be understood divorced from knowledge of history and individual and societal ways of living”

Eco-social and other multi-level frameworks

19

How is social economic position (social status) operationalized?

20

How is social economic position (social status) operationalized?

• Three levels: – Individual– Household– Neighborhood– Various time intervals

21

How is social economic position (social status) operationalized?

• Three levels: – Individual– Household– Neighborhood– Various time intervals

• Commonly used:– Education– Income– Occupation– Social class– Race/ethnicity – Gender

22

Bringing it together: a conceptual framework of social determinants of health

• Structural (or “distal” factors)• Intermediate factors (“proximal” factors)

..and their impact on health

23

Bringing it together: a conceptual framework of social determinants of health

24

Social determinants and global health

25

Social gradient in pre-mature death and life expectancy between countries

26

Marmot, 2005. LancetWorld Health Statistics 2013, WHO 2014

Social gradient in infant mortality between and within countries

27CSDH report, 2008

Social gradient in maternal mortality

Rosmans (2006)

• Eight key reproductive, maternal, newborn and child interventions:– Satisfied need for family

planning– ≥ 1 ANC – Skilled attendant at birth– Measles caffination– DPT vaccination– BCG vaccination– Oral rehydration and

continued feeding– Care seeking for

pneumonia

Social gradient in maternal health services coverage

Bhutta (2010) / Countdown to 2015 decade report

How to address the social inequalities in health?

30

Implementation of any policy or intervention requires involvement of various actors

• What actors/stakeholders should be involved?

31

Implementation of any policy or intervention requires involvement of various actors

32

Health Development

Strategies

Multilateral Organizations

Civil society

Bilateral organizations

National governments

Private sector

Philantropic organizations

CSDH report: an integral approach is necessary

33

Examples of intermediary approaches

• What could be examples?

34

• Structural determinants, socio-economic status:– Education, inter-

sectorial approach

• Material circumstances:– Housing,

intersectorial approach

Examples of intermediary approaches

35

Socio-economic status: SES

36Social determinants of health sectoral briefing series, 2

Material circumstances: housing

37Social determinants of health sectoral briefing series, 1

Examples of structural approaches?

• What could be examples?

38

1. Improve daily living conditions

2. Tackle inequitable distribution of power, money and resources

3. Measure and understand the problem and assess the impact of action

CSDH recommendations

39

1. Improve daily living conditionsEquity from the start (life course), fair employment, healthy living and work conditions, social protection, universal health care

2. Tackle inequitable distribution of power, money and resourcesHealth equity in all policies, fair financing, market responsibility, gender equity, potitical empowerment, good global governance

3. Measure and understand the problem and assess the impact of actionMonitoring, research, trainingGlobal movement

CSDH recommendations

40

• Social determinants play a major role in all aspects of health and disease, and can be categorized in structural and intermediate affects through various pathways.

• The importance of SDH and health equity is increasingly internationally recognized and applied.

In conclusion

41

Want to know more about social determinants?

• Online Social determinants gamewww.playspent.org

• Not about SHD, but VERY COOL!:www.thegreatflu.com