Social Determinants to Watch

Part Two of the IFMSA Primer

Prepared by
Anna Klicpera and Ramon Lorenzo Luis R. Guinto
on behalf of the IFMSA Small Working Group on Health Inequities




Social Determinants to Watch

In the framework adopted by the 2008 WHO Commission on Social Determinants of Health,
social determinants of health are categorized into two the structural determinants, which
are rooted in the key institutions and policies of the socioeconomic and political context;
and the intermediary determinants which directly link the structural determinants to
health outcomes. The illustration below illustrates the dynamics between socioeconomic
and political context, the structural determinants, the intermediary determinants, and the
effect which is the distribution of health and well-being in a population.


The most important structural stratifiers investigated by the Commission include:
1. Income
2. Education
3. Occupation
4. Social Class
5. Gender
6. Race/Ethnicity

On the other hand, the Commission also explored the following intermediary determinants:
1. Material circumstances
2. Psychosocial circumstances
3. Behavioral and/or biological factors
4. Health system as a social determinant of health




Even before the Commission Report was released, the European Regional Office of WHO
published its Social Determinants of Health: The Solid Facts in 2003, listing ten social
determinants that have impact on health, particularly in Europe:

1. The Social Gradient
Life expectancy is shorter and most diseases are more common further down the
social ladder in each society.
2. Stress
Stressful circumstances, making people feel worried, anxious and unable to cope, are
damaging to health and may lead to premature death.
3. Early Life
A good start in life means supporting mothers and young children: the health impact
of early development and education lasts a lifetime.
4. Social Exclusion
Life is short where its quality is poor. But causing hardship and resentment, poverty,
and social exclusion and discrimination cost lives.
5. Work
Stress in the workplace increases the risk of disease. People who have more control
over their work have better health.
6. Unemployment
Job security increases health, well-being and job satisfaction. Higher rates of
unemployment cause more illness and premature death.
7. Social Support
Friendship, good social relations and strong supportive networks improve health at
home, at work and in the community.
8. Addiction
Individuals turn to alcohol, drugs and tobacco and suffer from their use, but use is
influenced by the wider social setting.
9. Food
Because global market forces control the food supply, healthy food is a political issue.
10. Transport
Healthy transport means less driving and more walking and cycling, backed up by
better public transport.

Lets take a look at some concrete evidence showing how social determinants make an
impact on peoples health and on widening health inequities between and within countries.












Income

Looking at health (measured as life expectancy) globally, we can see that it is very much
directly related to the national income of the countries. In general, poorer the country, the
poorer is its health.


Income per person versus life expectancy



From Marmot M, et al. Executive Summary: Fair Society, Healthy Lives. London: The
Marmot Review, 2010.















But also within countries, we can see that life expectancy depends on the average income.
The following graph shows that the richer and poorer neighbourhood in England differs
seven years in terms of life expectancy and even seventeen years in terms of disability-free
life expectancy.


Life expectancy and disability-free life expectancy (DFLE) at birth, persons by neighbourhood
income level, England, 1999-2003



From Marmot M, et al. Executive Summary: Fair Society, Healthy Lives. London: The
Marmot Review, 2010.

















Social Class

Studies also showed a strong correlation between health measures and social classes. In the
next figure you can see how mortality depends on socio-economic status. It is remarkable
that there is not only a difference between the highest and lowest class, but also there is a
constant gradient. Therefore, differences can also be seen even between the highest social
classes.


Age standardised mortality rates by socioeconomic classification (NS-SEC) in the North East
and South West regions, men aged 25-64, 2001-2003




From Marmot M, et al. Executive Summary: Fair Society, Healthy Lives. London: The
Marmot Review, 2010.









One of the first studies depicting social determinants of health the Whitehall Studies
showed that the employment grade of civil servants influence the risk of death from
coronary heart disease.


Relative risk of death from coronary heart disease among civil servants according to
employment grade (Proportions of differences explained by risk factors)



From Rose G and M Marmot. Social class and coronary heart disease. British Heart Journal.
1981: 13-19.















Ethnicity

In many countries, health outcomes also differ between ethnic groups. A study done in the
US shows that infant mortality in black people is twice as high as in white people.


Infant mortality in USA by mothers education and race/ethnicity



From the United States Center for Disease Control and Prevention, National linked file of live
births and infant deaths, 1998, table 21.Available from http://www.cdc.gov/nchs/linked.htm














Education

The next figure illustrates how educational attainment affects health. In Korea for example,
men who finished elementary education are five times more at risk for mortality than men
with university education.


Age-adjusted mortality among men and women of the Republic of Korea by educational
attainment, 1993-1997


From Commission on Social Determinants of Health. Final Report: Closing the Gap in a
Generation: health equity through action on the social determinants of health. Geneva:
World Health Organization, 2008.



















Work

It is not just a matter of being employed or not the conditions under which we work also
influence our health. This does not only relate to the amount of stress workers have to
endure but also to the amount of job control (decision-making capability) a worker feels he
possesses. The next figure shows that the less control an employee has over his work, the
greater the risk of cardiovascular disease.


Self-reported level of job control and incidence of coronary heart disease in men and women



From Wilkinson R and M Marmot, editors. Social determinants of health: the solid facts.
Second edition. Geneva: World Health Organization, 2003.













Furthermore, our health is badly influenced not just by unemployment but also by insecure
employment. See the evidence from Spain.


Prevalence of poor mental health among manual workers in Spain by type of contract




From Commission on Social Determinants of Health. Final Report: Closing the Gap in a
Generation: health equity through action on the social determinants of health. Geneva:
World Health Organization, 2008.























Psychosocial factors

Social support and good social relations improve our health status. Through friends and
social network of communication, people gain not just practical but also emotional
resources that they need. The next figure illustrates how the level of social integration
correlates with mortality. Social isolation and exclusion are associated with increased rates
of premature death and poorer chances of survival after a heart attack.


Level of social integration and mortality in five prospective studies



From Wilkinson R and M Marmot, editors. Social determinants of health: the solid facts.
Second edition. Geneva: World Health Organization, 2003.





















Socioeconomic deprivation is also related to unhealthy lifestyle, such as drug addiction. Drug
use is both a response to social breakdown and an important marker of worsening social
inequalities.


Socioeconomic deprivation and risk of dependence on alcohol, nicotine and drugs, Great
Britain, 1993



From Wilkinson R and M Marmot, editors. Social determinants of health: the solid facts.
Second edition. Geneva: World Health Organization, 2003.


















The following graph shows how psychosocial stimulation (along with nutritional support) can
positively influence the development of children.


Effects of combined nutritional supplementation and psychosocial stimulation on stunted
children in a 2-year intervention study in Jamaica
a




From Commission on Social Determinants of Health. Final Report: Closing the Gap in a
Generation: health equity through action on the social determinants of health. Geneva:
World Health Organization, 2008.







IFMSA Week of Global Action on the Social Determinants of Health (Oct 17-23rd 2011) by IFMSA
Small Working Group on Health Inequity is licensed under a Creative Commons Attribution-
NonCommercial-NoDerivs 3.0 Unported License.