Social Determinants of Health

Social Determinants of Health (SDH)

• SDH are conditions in which people are born, grow, live, work, and age, inclusive of the health system
• These conditions are shaped by the distribution of money, power, and resources at global, national, and local levels
• SDH serves as the root causes of health and disease, influencing well-being and health risks

Understanding SDH and Health Outcomes

• Social determinants impact health trends and explain why health inequities exist
• Example: Higher prevalence of HIV/AIDS in low-income, marginalized communities occurs because of structural, socioeconomic, and environmental factors

Social Gradient in Health

• The social gradient refers to socially disadvantaged individuals experiencing worse health outcomes compared to more advantaged individuals
• The World Health Organization defines it as a progressive improvement in health outcomes as socioeconomic status rises

Data Examples

• Maternal mortality rates are increased among women with lower levels of education
• Under-5 mortality rates are highest amongst the poorest households in developing countries

Three Levels of Causes

• Distal (societal): Broad social, political, and cultural factors, such as education, income, housing, air quality, food security, and road safety
• Intermediate (community/relationships): Social contexts influencing health, such as work, school, peers, and family relationships
• Proximal (individual): Factors directly related to individual health, such as hygiene, disease exposure, smoking, and lifestyle behaviors

Addressing Distal Factors

• Addressing distal factors (e.g., poverty reduction policies) can have a greater impact on health than solely focusing on individual behaviors
• Example: Reducing poverty could lower coronary heart disease rates more effectively than providing medications alone

Determinants of Population Health (Public Agency of Canada)

• Income and social status
• Social support networks
• Education and literacy
• Employment and working conditions
• Social environments
• Physical environments
• Personal health practices
• Healthy child development
• Biology and genetic endowment
• Health services
• Gender
• Culture

Conceptual Frameworks for Understanding SDH

• Framework 1 visualizes SDH from the individual level (age, sex, biology) to broader societal factors (policies, economics, environmental conditions)
• Framework 2 attributes disease causation to 50% social and economic factors (income, education, race, social support), 25% health care access, 15% biology and genetics, 10% environmental factors (air quality, infrastructure
• Framework 3 highlights the interplay between structural (socioeconomic and political context) and intermediary determinants (social environments and healthcare systems)

Health Inequalities vs. Health Inequities

• Health inequalities are differences in health status between population groups that may or may not be avoidable
• Health inequities are systematic, avoidable, and unjust health differences due to social and economic policies
• Example: A child dying from an untreatable condition is unfortunate but not unfair, while dying due to a lack of affordable healthcare is unfair and unjust

Health Equity

• Health equity aims to ensure all people have an equal opportunity to attain full health potential regardless of social position

Inequalities and Social Justice

• Social justice refers to the fair distribution of society's benefits and responsibilities
• Addressing health inequalities requires policy changes that target broader social determinants rather than solely individual behaviors

Examples of Health Inequities in Canada

• Poorer health outcomes in populations such as people living in poverty, people with disabilities, LGBTQ+, indigenous peoples, rural and remote communities, immigrants and refugees
• Socioeconomic position directly affects health indicators such as chronic illness, psychiatric symptoms, obesity, low birth weight, and self-perceived health

Explanations for Socially Pronounced Inequalities in Health

• Natural and social selection: Unhealthy individuals may move down the socioeconomic ladder, while healthy individuals move up
• Materialist and structuralist explanations: Those in lower socioeconomic positions have fewer resources to maintain good health
• Neomaterialist mechanism: Health inequalities stem from differential access to resources, leading to disparities in housing, diet, and exposure to hazards
• Cultural and behavioral explanations: Differences in health behaviors (e.g., smoking, alcohol, diet, exercise) contribute to health disparities

Level of Analysis: Models of Health and Policy Implications

• Individual-level model of disease (risk factor model) focuses on individual characteristics such as age, sex, genetics, and behavior (e.g., smoking, alcohol use, diet, activity level)
• Biomedical model emphasizes the interaction between agent and host
• Behavioral model focuses on lifestyle choices and personal behaviors
• Policy Implications include healthcare services, health education, and behavior modification efforts
• Multi-Level Approach considers population attributes, geography, social, economic, cultural, and political structures
• Policy Implications calls for collective action and social reform

Origins of Population Health: Key People

• John Snow (1813-1858)
• Developed modern epidemiology and health geography, identifying contaminated water supply as the cause of cholera outbreaks
• Shifted focus from individual blame to environmental factors
• Friedrich Engels (1820-1895)
• Argued that poor working/living conditions determine health outcomes
• Showed that the urban poor had higher mortality rates than the rural poor
• Rudolf Virchow (1821-1902)
• Analyzed a typhus outbreak in Upper Silesia advocating for social, political, and economic reforms as solutions to health problems
• Emile Durkheim (1858-1917)
• Studied how social norms and structures shape health behaviors, arguing that choices are conditioned by social environments
• Thomas McKeown (1912-1988)
• He Argued that improved nutrition and social factors were more responsible for declining mortality than medical advancements
• Highly controversial due to lack of strong evidence that nutrition was the key factor

Demographic and Epidemiologic Transitions

• Demographic transition:

• Stage 1: High birth/death rates, leading to a stable population

• Stage 2: Declining death rates and high birth rates, resulting in rapid growth

• Stage 3: Declining birth rates, resulting in slower growth

• Stage 4: Low birth rate and death rate, which lead to a stable or declining population

• Epidemiologic transition (Abdel Omran 1971):

• Stage 1: Age of pestilence and famine, characterized by high mortality due to infectious diseases, malnutrition, and famine

• Stage 2: Age of receding pandemics, marked by declining mortality and rising life expectancy

• Stage 3: Age of degenerative and man-made diseases, with chronic illnesses like heart disease and cancer replacing infectious diseases as primary causes of death

• Stage 4: Age of delayed degenerative diseases, showing a decline in cardiovascular mortality but increased age-related diseases

Healthcare Services as a Health Determinant

• Healthcare ≠ health:
• Healthcare services focus on illness, injury, and disability rather than overall health
• Population health improvements are more influenced by social determinants than medical care
• Scope of healthcare system:
• Includes only conditions with known, and accepted medical treatments
• Many health needs are met outside the formal system (e.g., alternative medicine, self-care, social services)

Preventative Medicine and Knowledge Translation

• Preventative medicine:
  • Identifies and mitigates health risks (e.g., screening, lifestyle interventions)
  • Has has a limited impact on overall population health and can contribute to over-diagnoses
• Knowledge translation:
  • There is 17-year gap between research discoveries and clinical practice
• Choosing Wisely: Aims to reduce unnecessary medical intervention

Barriers to Healthcare Access

• Financial barriers:
  • Public healthcare covers 70% of costs with remaining costs (e.g., prescriptions, dental) requiring private insurance out-of-pocket payment
  • 1 in 10 Canadians cannot afford prescription medication
• Geographic barriers:
  • Rural/remote areas lack healthcare services leading to emergency response times that vary
• Cultural and social barriers:
  • Indigenous communities face discrimination, lack of culturally appropriate care
  • Stigma deters individuals (e.g., drug users, mental health patients) from seeking care

Health Equity and Policy Implications

• Health and social care gaps remain despite universal insurance

Issues of Equity:

• Poorer, rural, indigenous, and marginalized populations have worse access to care outsourcing surgeries to private clinics may increase privatization and deepen inequalities

Social Epidemiology

• Examines how social position and context influence health
• Aims to identify socio-environmental exposures that impact physical and mental health outcomes

Historical Developments

• 1970's Research: Studied the effects of bereavement ("broken heart syndrome") and social disintegration on health
• Highlighted the importance of social support, relationships, and social environments in determining health outcomes

Key Theories and Ideas

• Geoffrey Rose and the population health perspective:
  • Considered the father of population health
  • Most health issues arise within low-risk individuals, focusing only on high-risk groups fails to protect the majority
• Critique of the Individual-Level Risk Factor Approach:
  • Addresses only a small proportion of total disease incidence
  • Is a "downstream" approach that fails to address root causes
  • Ignores social/economic contexts that shape behavior
• Population Level Perspective: The risk of disease for individuals is influenced by the broader population context
• Social Context of Behavior: Social environments shape opportunities and constraints
• Multi-Level Analysis: Examines influences related to the individual, community, and societal domains. Health outcomes systematically improve with higher social status.

Whitehall Studies (Sir Michael Marmot)

• Whitehall I (1967): Studied 18,000 British civil servants and revealed that higher status jobs correlated with better health outcomes, independent of standard risk factors
• Whitehall II (1985): Extended findings to include women and emphasized that job control significantly affects health
• Key takeaway: a health gradient across all employment grades showing that health outcomes correlate with social and economic position

Key Features of Social Epidemiology

• Social Context of Behaviour: Social environments shape opportunities and constraints
• Multi-Level Analysis: Examines factors at individual, community and societal levels
• Life Course Perspective: Considers health impacts from early life through old age

The Black Report (Sir Douglas Black 1977)

• Commissioned by the UK Labour government
• Major Findings:
  • The health gap between social classes was large and growing
  • The death rate in the lowest class was two times as high as in the highest class
  • Found a distinct social gradient like the Whitehall findings

Government Reaction:

• Reaction : The UK Conservative government suppressed the report due to public policy implications
• Richard Wilkinson and Health Inequality
  • Studied inequality in societies and found that more equal places often have better health outcomes

Key Conclusion

• It is not just overall wealth (GDP) that determines health but the degree of inequality within a society
• Some researchers questioned his data selection and interpretation, but his work influenced further research into social determinants of health

Social epidemiology.

• Exists within affluent countries, not just between rich and poor nations
• Example: Even among privileged workers in the Whitehall studies, those in higher-status jobs had better health than those in lower status jobs

Important things to know

• Income is the most significant determinant of health
• Poverty has a long-Lasting impact on individuals and communities, making it difficult to escape the cycle of economic hardship

Current Issues Related to Poverty in Canada

• Food Insecurity and Food Bank Usage:

• There was a 60% increase in food bank usage in 2023

• Seniors, students, and low-income workers are particularly affected

• CBC 2024 reports record-breaking food bank usage, highlighting growing economic hardship

• Intergenerational Poverty:

• Poverty often persists across generations, making it difficult for people to escape

• (MAID) Poverty and Medical Assistance in Dying

• Economic hardship is forcing some disabled Canadians to consider MAID not bc of pain, but due to poverty

Theories Explaining the Link Between Income and Health

Materalist Hipothesis

Individual resources income, education, and social media directly affect health Limitations: Can't account for community resorses that combat incomeinequality

Neo materalist hipothesis:

Expands on the materialist view by including public goods and policies eg health care Key Idea: personal and communcal resources make up well being

Psychosocial theories

Supported by Wilingkinson Key idea: Status affects health

Wealth

• Wealth is distinct from income, primarily built through assets such as poverty, investments, and savings
• Wealth Inequality is growing faster than income inequality, largely due to the increasing value of assets like real estate
• The poorest in Canada have negative wealth (debt)
• In the USA the wealth of the top 1% increased by $6.5 trillion in 2021, mainly due to stock market gains, the top 1% own 53.9% of individually held shares
• The wealth gap is stark with the top 1% holding more than the entire middle class
• Reports such suggest the pandemic exacerbated wealth Inequality rather than equalizing opportunities

Generational Unfairness - Housing Wealth

• Housing affordability is a critical issue for younger canadians:
• Generation Squeeze 2019 found that it takes a young person 13 years to save 20% down payment on an average home, compared to 5 years in 1976
• The housing crisis worsened post-pandemic, with rising interest rates further reducing purchasing power
• Increasing Rental prices make saving more difficult
• Canadas slow response to the housing crisis reflects a systemic addiction rising home values, benefiting older generations at the expense of younger ones

Racial Wealth Gap

• The housing crisis disproportionally impacts racialized communities, especially black canadians

• Systemic barriers such as redlining policies have historically prevented racialized groups from accumulating Intergenerational wealth

• Discrimination in the housing market continues:

• Black Famillies reporting lower property appraisals and higher rejection rates from landlords

The Wealth Paradox

• Due to increasing the wealth gap, there are fewer opportunities that will move toward it.

  • The notion of meritocracy is called into question as social mobility becomes increasingly difficult

• Economic frustrations may have:

• Stagnant growth over the market.

• Rising costs of living

• The housing crisis

• Canadian tax policies have become less effective at reducing inequality due to lower tax rates and fewer savings of credits.

The Statistical Insights on the topic of gaps in race for wealth:

Black canadians do have rates less than those of white people. There is also an analysis that has been done which shows how racism has an impact on black home owners.

Government Solutions:

• a 10 million dollar incentive that shows a plan for more families of color to buy new homes in the future
• The shared equity Agreements now will help those of color who face extra problems such as the need for traditional mortgages.

Gender Pay Gap

Despite advancements in education and workforce participation, women continue to face wage disparities

Factors contributing to gender pay gap:

• Occupational segregation: Women are often funneled into lower-paying, service based or "pink collar" jobs (e.g. nursing, teaching, social work)
• Lack of job security
• The sandwich Generation; Women balance caregiving responsibilities

Explore the social determinants of health (SDH), which are the conditions in which people are born, grow, live, work, and age. These conditions, shaped by resource distribution, serve as root causes influencing well-being and health risks. Understand how SDH impacts health trends and contributes to health inequities, like the higher prevalence of HIV/AIDS in marginalized communities.