social determinants and global health
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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
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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
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Understanding social determinants
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Definitions
• Social determinants
• Health (in)equity
• Common measurements?
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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.
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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
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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)
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• 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
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Class differences were also observed for different causes of adult mortality
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• 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
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• 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
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• 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
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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
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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?
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• Social stress resulting from (perception of) social status
• Hypthalamus-pituitary-adrenal axis (chronic)
• Sympatic nervous system/(nor)adrenatine (acute)
Psychosocial approach
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• 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
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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
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How is social economic position (social status) operationalized?
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How is social economic position (social status) operationalized?
• Three levels: – Individual– Household– Neighborhood– Various time intervals
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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
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Bringing it together: a conceptual framework of social determinants of health
• Structural (or “distal” factors)• Intermediate factors (“proximal” factors)
..and their impact on health
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Bringing it together: a conceptual framework of social determinants of health
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Social determinants and global health
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Social gradient in pre-mature death and life expectancy between countries
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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?
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Implementation of any policy or intervention requires involvement of various actors
• What actors/stakeholders should be involved?
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Implementation of any policy or intervention requires involvement of various actors
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Health Development
Strategies
Multilateral Organizations
Civil society
Bilateral organizations
National governments
Private sector
Philantropic organizations
CSDH report: an integral approach is necessary
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Examples of intermediary approaches
• What could be examples?
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• Structural determinants, socio-economic status:– Education, inter-
sectorial approach
• Material circumstances:– Housing,
intersectorial approach
Examples of intermediary approaches
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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?
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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
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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
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• 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
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Want to know more about social determinants?
• Online Social determinants gamewww.playspent.org
• Not about SHD, but VERY COOL!:www.thegreatflu.com
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