Social determinants of health

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Social determinants of health are the economic and social conditions under which people live which determine their health. Virtually all major diseases are primarily determined by specific exposures to these conditions. And these conditions are a result of social, economic, and political forces. Social determinants of health have been recognized by several health organizations such as the Public Health Agency of Canada and the World Health Organization to greatly influence collective and personal well-being. A list of determinants of health -- only some of which are social determinants -- compiled by the Public Health Agency of Canada is below:

  1. Income and social status
  2. Social support networks
  3. Education and literacy, e.g. health literacy
  4. Employment/Working conditions
  5. Social environments
  6. Physical environments
  7. Personal health practices and coping skills
  8. Healthy child development
  9. Biology and genetic endowment
  10. Health services
  11. Gender
  12. Culture

The term social determinants of health grew out of the search by researchers to identify the specific exposures by which members of different socio-economic groups come to experience varying degrees of health and illness. While it was well documented that individuals in various socio-economic groups experienced differing health outcomes, the specific factors and means by which these factors led to illness remained to be identified. Overviews of the concept, recent findings, and an analysis of emerging issues are available. All these formulation share a concern with factors beyond those of biomedical and behavioural risk.

The SDOH National Conference list (see Raphael, below) is unique in that it specifically focuses on the public policy environment (e.g., income and its distribution) rather than characteristics associated with individuals (e.g. income and social status). These 11 social determinants of health are:

  1. Aboriginal status
  2. early life
  3. education
  4. employment and working conditions
  5. food security
  6. health care services
  7. housing
  8. income and its distribution
  9. social safety net
  10. social exclusion
  11. unemployment and employment security.

A particularly important issue that is emerging is whether any particular analysis of social determinants of health is de-politicized or not. A de-politicized approach is one that fails to take account of the fact that the quality of the social determinants of health to which citizens in a jurisdiction are exposed to is shaped by public policy created by governments. And governments of course are controlled by political parties who come to power with a set of ideological beliefs concerning the nature of society and the role of governments.

Such analyses that recognize the role played by politics outline the particular importance of having social democratic political parties in power. Nations that have had longer periods of social democratic influence such as Norway, Finland, Sweden, and Denmark have government policymaking that is remarkably consistent with social determiannts of health concepts. Nations such as the USA and Canada,dominated by liberal and neo-liberal governing parties, much less so. The work of David Coburn, Dennis Raphael, Toba Bryant, Clare Bambra, Richard Hofrichter, Carles Muntaner, and Vicente Navarro has been especially attentive to these issues.

An important development has been the Social Determinants of Health Listserv at York University. Its 1200 members represent every state and provincial health authority in the USA, Canada, and Australia and also boasts membership by researchers, advocates, and concerned citizens from around the world.

To subscribe to the SDOH list, send the following message to listserv@yorku.ca in the text section, NOT in the subject header.

SUBSCRIBE SDOH yourfirstname yourlastname

In spite of these development and the remarkable accumulation of evidence concerning the importance of living conditions on health, public health practice and government and media attention in North America remains firmly focused on promoting "healthy lifestyles" and "healthy choices." Why this is the case has been the focus of attention by Dennis Raphael at York University who has written extensively on this topic. Many of his writings and presentations can be found at: http://www.atkinson.yorku.ca/draphael

  • Bambra, C. (2004). The worlds of welfare: illusory and gender blind? Social Policy and Society, 3(3), 201-211.
  • Bambra, C., Fox, D., & Scott-Samuel, A. (2005). Towards a politics of health. Health Promot. International, 20(2), 187-193.
  • Bryant, T. (2006). Politics, public policy and population health. In D. Raphael, T. Bryant & M. Rioux (Eds.), Staying Alive: Critical Perspectives on Health, Illness, and Health Care (pp. 193-216). Toronto: Canadian Scholars
  • Coburn, D. (2006). Health and Health Care: A Political Economy Perspective. In D. Raphael, T. Bryant & M. Rioux (Eds.), Staying Alive: Critical Perspectives on Health, Illness and Health Care. Toronto: Canadian Scholars Press Inc.
  • Health Canada. (1998). Taking action on population health: A position paper for health promotion and programs branch staff. Ottawa: Health Canada. Available: http://www.phac-aspc.gc.ca/ph-sp/phdd/pdf/tad_e.pdf
  • Hofrichter, R. (Ed.). (2003). Health and Social Justice: A Reader on Politics, Ideology, and Inequity in the Distribution of Disease. San Francisco: Jossey Bass.
  • Navarro, V., & Muntaner, C. (Eds.). (2004). Political and Economic Determinants of Population Health and Well-being: Controversies and Developments. Amityville NY: Baywood Press.
  • Raphael, D. (Ed.). (2004). Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press: https://www.cspi.org/motion.asp?siteid=100366&lgid=1&menuid=5376&prodid=116644&cat=9869
  • Raphael, D., Bryant, T., and Rioux, M. (Eds. (2006). Staying alive: Critical perspectives on health, illness, and health care. Toronto: Canadian Scholars’ Press: https://www.cspi.org/motion.asp?siteid=100366&lgid=1&menuid=5376&prodid=116607&cat=9869
  • Raphael, D. (2007). Poverty and policy in Canada: Implications for health and quality of life.https://www.cspi.org/motion.asp?siteid=100366&lgid=1&menuid=5376&prodid=116963&cat=9869 Toronto: Canadian Scholars' Press.
  • Raphael, D. (2006). The social determinants of health: What are the three key roles for health promotion? Australian Health Promotion Journal, 17 (3), 167-170.
  • Raphael, D. (2006). Social determinants of health: Present status, unresolved questions, and future directions. International Journal of Health Services, 36, 651-677.
  • Raphael, D. (2003). Bridging the gap between knowledge and action on the societal determinants of cardiovascular disease: How one Canadian community effort hit -- and hurdled -- the lifestyle wall. Health Education, 103, 177-189.
  • Raphael, D., Anstice, S., Raine, K., et al. (2003). The social determinants of the incidence and management of Type 2 Diabetes Mellitus: Are we prepared to rethink our questions and redirect our research activities? Leadership in Health Services, 16, 10-20.
  • Raphael, D. (2006). Politics, political platforms, and child poverty in Canada. Policy Options, 7, (6), 99-103: http://www.irpp.org/po/archive/jul06/raphael.pdf
  • Raphael, D. (2003). Addressing the social determinants of health in Canada: Bridging the gap between research findings and public policy. Policy Options, 24, no. 3, 35-40: http://www.irpp.org/po/archive/mar03/raphael.pdf
  • Wilkinson, R., & Marmot, M. (2003). Social determinants of health: The solid facts. World Health Organization, European Office. Available: http://www.euro.who.int/document/e81384.pdf
  • World Health Organization. (1986). Ottawa charter for health promotion. World Health Organization European Office. Available: http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf
  • Zarcadoolas, C., Pleasant, A., & Greer, D. (2006) Advancing health literacy: A framework for understanding and action. Jossey-Bass:San Francisco, CA. Available at http://www.amazon.com/dp/0787984337/


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