The classic principal determinants of health are behaviour factors, natural environmental impacts, genetic determinants and social determinants. These main groupings disguise the interactions between, and complexity and diversity of, health and disease drivers. Throughout history, these fundamental determinants of health have interacted and acted within populations in complex ways. For instance, in the sixteenth century, when the Europeans conquered the Americas, they subjugated and destroyed native American populations (social determinants) and confiscated land and associated food insecurity (social and environmental determinants). They spread infectious disease, such as smallpox and measles, that the Europeans had developed moderate resistance over generations (biological determinants) (1).
"Social determinants of health are
conditions in the social environment in which people are born, live, learn,
work, and play that affect a wide range of health, functioning, and
quality-of-life outcomes and risks" (2). The health and well-being at individual and population levels
are greatly influenced by individuals, communities, and societies' social and
demographic characteristics. Examples of an individual or population level of
social determinants are gender, race/ethnicity, socioeconomic status (SES),
social class, education, income, occupation, employment status, housing tenure,
immigrant status, language use, disability status, and social capital (2-4). Social determinants at the population levels,
which is considered more fundamental determinants of health and disease, can be
changed through public policy (2). In order to improve
health outcomes, the design, implementation and evaluation of effective
policies at local, state and federal levels can be improved through a deeper
understanding of the complexities of social and economic inequalities (4).
Former Director-General of the World Health Organisation
(WHO), the late J.W. Lee, set up the WHO Commission on Social Determinants of
Health ("the Commission") in 2005. The Commission aimed to collect
and synthesize global evidence on the social determinants of health and assess
their impact on health inequity and make recommendations for action to address these
inequalities (3). The Commission's work
was motivated and driven by [1] belief in social justice, [2] respect for
evidence, and [3] frustration that there was insufficient action on the social
determinates of ill health and health inequalities. The work of the Commission
and its consequential report, completed in 2008 (5), was meant to prompt
discussions among the institution and the public sphere, within countries and
internationally, and help promote social actions and policies to advance health
and health equity (3). Nations across the
globe have been called continuously, since the 1980s, to address health
inequities that are systematic, unfair, and avoidable differences in health
outcomes and their determinants between sections of the population based on SES,
demographics or geography (5).
The Commission recommended three main points (Table 1). First,
to improve daily living conditions, people are born, grow, live, and age.
Second, to handle the structural drivers of these conditions that arise from
unfair distributions of power, money and resources. Three, to build the capacity
to overcome the conditions by first measuring the problem and evaluating
actions, building a knowledge base, training an effective workforce, and
raising public awareness (3).
The Commission's recommendations are broad yet relevant to
and applicable to the different contexts in which people worldwide live their
lives. Contextual analysis across the areas identified by the Commission is
necessary to develop national and regional strategies for health equity
improvement. The resolution of the World Health Assembly in May 2009 reinforced
these recommendations by urging all member states to evaluate the impact of
policies and programs on health inequities and handle health inequities through
action on the social determinants of health(3).
Furthermore, in 1992, Margaret Whitehead (Head of the WHO Collaborating
Centre for Policy Research on the Social Determinants of Health) wrote a paper with
international influence. It urged governments and all sectors of society to
tackle differences in heath associated with social status - relative advantage
and disadvantage in social hierarchies. Since differences in health associated
with social status affect groups of people already at a disadvantage, it can be
considered unfair. All countries, rich and poor alike, have seen these dramatic
life changes (5).
Multiple and multi-level factors - such as individual
material circumstances, social cohesion and psychosocial, behavioural and
biological factors, and the functioning of the health care system - that
interact in a complex way bring about poor health and health inequalities
across individuals and social groups. People's position in the social hierarchy
– that is, their wealth and income, occupation, education, gender, race or ethnicity,
and geographical location of residence – determines how they interact with or
experience these complex factors. Moreover, all these factors are influenced by
a political, economic, social and cultural context that determines the unequal
distribution of power, prestige, and resource (3).
Race/Ethnicity as a determinant of health.
It is widely and commonly used "race/ethnicity"
and sometimes "minority" as a causal factor of social determinant of
health. However, this does not seem to be accurate despite the complex social
dynamics.
Ethnicity could be used to discriminate (5) against a group of
people in society to deny, for example, access to adequate health services. Due
to "ethnicity", a group of people may have a language (2,4) barrier, which hinders
them from requesting health interventions when needed. Cultural practices of ethnic
groups could compromise their health and well-being. Health consequences could arise
from a genetic or biological factor (4) related to a
particular ethnic group. However, none of these scenarios shows ethnicity as
the cause of poor health outcome.
These scenarios illustrate that the negative health
consequences are due to other factors linked to ethnicity and not ethnicity per
se. Some people in the population may be ethnic but not fall into any of the
scenarios mentioned above. Therefore, "ethnicity/race/minority" does
not cause poor health, hence could not be said is a factor of social
determinant of health.
|
No. |
3 Main points for the WHO Commission recommended |
No. |
Sub-areas the WHO Commission recommended for
actions |
|
1 |
To improve daily life
conditions. |
1 |
Early childhood
development and education |
|
2 |
To handle the structural drivers of these conditions. |
2 |
Health places – the living environment |
|
3 |
To Build capacity to
overcome these unjust conditions. |
3 |
Fair employment and decent work |
|
|
4 |
Social protection across the life course |
|
|
5 |
Universal health care |
||
|
6 |
Health equity in all policies |
||
|
7 |
Fair financing |
||
|
8 |
Market responsibility |
||
|
9 |
Gender equity |
||
|
10 |
Political empowerment |
||
|
11 |
Good global
governance |
||
|
12 |
Knowledge, Monitoring and Skills |
||
Table 1: Recommendation of the WHO Commission to overcome health inequalities in social determinants of health.
References
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Jackson, R. (2015-02). Determinants of health:
overview. In Oxford Textbook of Global Public Health. Oxford,
UK: Oxford University Press. Retrieved 22 Mar. 2021, from https://oxfordmedicine-com.iclibezp1.cc.ic.ac.uk/view/10.1093/med/9780199661756.001.0001/med-9780199661756-chapter-6.
(2) Singh GK, Daus GP, Allender M, Ramey CT, Martin EK, Perry C, et al. Social determinants of health in the United States: Addressing major health inequality trends for the nation, 1935–2016. International journal of MCH and AIDS. 2017; 6 (2): 139-164. Available from: doi: 10.21106/ijma.236 Available from: https://www.ncbi.nlm.nih.gov/pubmed/29367890 .
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