Social Determinants of Health (September 30, 2002)

Overview of Social Determinants of Health

Dennis Raphael

School of Health Policy and ManagementYork University, Toronto, Canada

Poor conditions lead to poorer health. An

unhealthy material environment and

unhealthy behaviours have direct harmful

effects, but the worries and insecurities of

daily life and the lack of supportive

environments also have an influence.

Social Determinants of Health: The Solid Facts,

World Health Organization, 1999.

.

Social Determinants of Health: Literary Perspectives

We know what makes us ill. When we are ill we are told That it’s you who will heal us.

When we come to you Our rags are torn off us And you listen all over our naked body. As to the cause of our illness One glance at our rags would Tell you more. It is the same cause that wears out Our bodies and our clothes. -- Bertolt Brecht, A Worker’s Speech to a Doctor, 1938.

Social Determinants of Health: Academic Perspectives

It is one of the greatest of contemporary social injustices that people who live in the most disadvantaged circumstances have more illnesses, more disability and shorter lives than those who are more affluent.

-- Benzeval, Judge, & Whitehead, 1995, p.xxi, Tackling Inequalities in Health: An Agenda for Action.

Canadian Government Statements on Social Determinants of Health I

All policies which have a direct bearing on health need to be coordinated. The list is long and includes, among others, income security, employment, education, housing, business, agriculture, transportation, justice and technology.

-- Achieving Health For All: A Framework for Health Promotion, J. Epp. Ottawa: Health and Welfare Canada, 1986.

Canadian Government Statements on Social Determinants of Health II

There is strong evidence indicating that factors outside the health care system significantly affect health. These “determinants of health” include income and social status, social support networks, education, employment and working conditions, physical environments, social environments, biology and genetic endowment, personal health practices and coping skills, healthy child development, health services, gender and culture.

-- Taking Action on Population Health: A Position Paper for Health Promotion and Programs Branch Staff. Ottawa: Health Canada, 1998.

Canadian Government Statements on Social Determinants of Health III

In the case of poverty, unemployment, stress, and violence, the influence on health is direct, negative and often shocking for a country as wealthy and as highly regarded as Canada.

-- The Statistical Report on the Health of Canadians. Ottawa: Health Canada, 1998.

Social Determinants of Health:The Solid Facts

- social gradient - stress

- early life - social exclusion

- work - unemployment

- social support - addictions

- food - transport- World Health Organization, 1998

Ottawa Charter’s Prerequisites of Health• peace • shelter • education• food• income• a stable eco-system• sustainable resources• social justice• equity

World Health Organization, 1986

Health Canada’s Determinants of Health• Income and Social Status• Social Support Networks • Education • Employment/Working Conditions • Social Environments • Physical Environments • Personal Health Practices and Coping Skills • Healthy Child Development • Biology and Genetic Endowment • Health Services • Gender• Culture

Why Emphasize Social Determinants?

• Social determinants of health have a direct impact on health

• Social determinants predict the greatest proportion of health status variance

• Social determinants of health structure health behaviours

• Social determinants of health interact with each other to produce health

PYLL(0-74) by Cause, 1996

30.9

19.2

17.6

5.3

4.9

4.8

3.8

13.5

23.1

0 5 10 15 20 25 30 35

Neoplasms

Income-Related

Injuries

Circulatory

Infectious

Perinatal

Ill-defined

Congenital

All other

%

Excess PYLL(0-74) by Cause, 1996

21.6

16.9

14

12.2

8.3

7.1

5.4

14.5

0 5 10 15 20 25

Circulatory

Injuries

Neoplasms

Infectious

Ill-defined

Perinatal

Digestive

All other

%

203 218225 236

268

119 128 118143

Neighbourhoods by Income Quintile, Urban Canada

1st (Highest Income)

2nd 3rd 4th 5th (Lowest Income)

04080

120160200240280

Males Females

Figure 5: Cardiovascular Deaths Per 100,000, Urban Canada, 1996

127

4,614

8,090

11,837

13,93513,115

Neighbourhoods by Income Quintile, Ontario

1st (Highest Income)

2nd 3rd 4th 5th (Lowest Income)

0

3,000

6,000

9,000

12,000

Figure 7: Heart Attack Hospital Admissions by Area Income, Ontario, 1994-97

90%

160%

50%

90%

70%

90%

30%

50%60% 60%

40%

80%

White Males White Females Black Males Black Females

0%

40%

80%

120%

160%

Low Income Area - Adjusted for Age and Study Site

Low Income Area - Adjusted for Preceding and Individual Socioeconomic Characterist ics

Low Income Area - Adjusted for Preceding and All Behavioural and Medical Factors

Figure 9: Greater Risk of Heart Disease in Low Income Areas, USA, 1988-97

It was found that those living in lower income areas were much more likely to develop coronary heart disease than those in well-off neighbourhoods. These effects remained strong even after controlling for tobacco use, level of physical activity, presence of hypertension or diabetes, level of cholesterol, and body mass index.

- Summary of Neighbourhood of Residence and Incidence of Coronary Heart Disease, A. Roux, S. Merkin, D. Arnett, et al. New England Journal of Medicine, 2001, 345, 99-106.