1205MED Health Challenges for the 21st Century

Week 6: Social determinants: Key social determinants and their link to health 2
1205MED Health Challenges for the 21st Century
Topic 6.1: Proximal vs distal determinants
Lecture learning outcomes:

Understand the proximal vs distal determinants

In week 1
Determinants of Health

“A factor or characteristic that

brings about a change in
health, either for the better or
the worse”

(Reidpath in
Keleher and
Murphy 2004:4)
 A person’s health and wellbeing results from a complex
interplay between biological, lifestyle, socioeconomic,
societal and environmental factors, many of which can be
modified to some extent by health and other
interventions.

Determinants
of health
Ways to think about determinants
Determinants of health
Proximal determinants of health
• Refers to “any determinant of health that is readily and
directly associated with the change in health status”
• Close, immediate connection

Distal determinants of health

• Refers to “a determinant that is distant in time or place from
the change in health status”
• Therefore connection between determinant and health
status may be indirect or more difficult to identify
(Keleher and Murphy 2004:10)
Proximal determinants
• The proximal determinants, which act on both micro and macro
levels, often include lifestyle or behaviour (e.g. alcohol, fat, tobacco,
fruit and vegetable consumption), and
• demography (e.g. elderly proportion of the total population), local
physical environment (e.g. air pollution by oxides of sulphur, nitrogen
or carbon) and host constitution.
• The health system mostly operates at this proximal level.
• Many of the proximal non-medical determinants can avert or
minimize the need for expensive medical care.
Distal determinants
Distal determinants of health include the national, institutional,
political, legal, and cultural factors that indirectly influence health by
acting on the more proximal factors, their interrelated mechanisms,
levels, trends, and distributions.
These distal factors are usually more stable than proximal
determinants. E.g.
• The socioeconomic environment (including macro-economic
measures such as wealth of society),
• Culture that shapes behavioural choices
Case Study
Ama, a small, three-year-old child, was playing with her siblings on the road outside her home in a
small, semi-urban, slum area. While chasing her older brothers she trod on a nail. Her mother
washed the wound and bandaged it. The wound remained red and ‘angry’.

Over a week the wound did not heal, the area remained red and ‘angry’, with flaring up the leg.
Ama began to complain that she had pain in her groin, she became weak and febrile. Ama was
taken to hospital when her mother could not control her fever and she died within a few days of
admission.

P10, Keleher & Murphy, 2004

Case Study

• What are the possible determinants of Ama’s health?

• Proximal vs distal

• Solutions/interventions?
 Proximal Distal
Knowledge of wounds Education

Ama case Footwear

No transport
Income

study: Delayed access to health

care
proximal vs Playing on road Living conditions
distal Rusty nail - housing

determinants Wound care

Host protection
Access to health
services -
Vaccinations
No safe place to play Community
resources
Determinants of health

• The way that we think about determinants impacts on the types of interventions
that are considered to improve individual or population health.

• What does this mean?

Summary

• Social determinants of health

• Overview
• Definition
• Proximal vs Distal determinants….
• Linked with health

• This week – workshop is on SDoH: proximal vs distal determinants

1205MED Health Challenges for the 21st Century
Topic 6.2: Corporations as a social determinant
 The ‘commercial
determinants of health’
Defined as “factors that influence health which
stem from the profit motive.” WHO, 2017

Kosinska and Ostlin (2016) provided a broader

definition: “a good or a service where there is an
inherent tension between the commercial and the
public health objective”
 Commercial
determinants
of health?
This is reflected in the Vienna Declaration on Public Health, a
30-year renewal of the Ottawa Charter, which notes that:

“it is essential to recognize the growing role of diverse non-state actors, and
especially the importance of distinguishing those that pursue public interest
objectives from those that pursue commercial interests, paying particular
attention to the difficulties that can arise with activities promoted as corporate
social responsibility.”
Influence on behaviours & ‘Profit driven’
epidemics
• Commercial determinants have a large
influence over the health behaviours of
populations and the environments that we live
in.
• Corporate activities shape our environments
and determine the availability, promotion and
pricing of consumables >>>

All of which involve decision-making by private

sector actors to further business interests.
 • Premature death & disability associated
with NCDs and chronic diseases
Downstream • ‘industrial epidemics’ and ‘profit driven’
health epidemics
• Cancers including lung cancer, obesity
consequences and overweight, cardiovascular
diseases, chronic obstructive pulmonary
of CDoH disease, high cholesterol, diabetes,
cirrhosis, and others were highlighted,
as well as injuries
Drivers
• Globalisation
• Capitalism
• Internationalisation, and corporate
growth and expansion
• We see them reflected in trade
relations, the outsourcing of labour to
countries with lower wages and fewer
worker protections, and multinational
corporates that move profits offshore
to avoid taxes
Power
Power imbalances:
a) Between corporations and governments with
conflicting interests, and between corporations and
b) Individual citizens, driving behaviours that harm
health.
Corporate power is said to influence decision making,
with corporations sometimes directly involved in
public health policymaking.
Transnational corporations can impact trade
agreements, drive consumer demand, provide
employment, shape working conditions or influence
policies and regulations.
The world’s top 100 economies: 31 countries; 69 corporations
The environment
To achieve elevated profits, corporations may externalize costs
(environmental, health-related and oherwise) to avoid capturing
the true aggregate ‘cost’ of their products
Consequences for physical environments and planetary health
associated production and trade:
• Land clearing
• Lost biodiversity
• Air pollution
• Climate change
• Respiratory and cardiovascular diseases
• Labor practices including child labor and inadequate
maternity protections
Groups targeted by corporate action
Groups described as being targeted by
corporate actions within CDoH systems
included:

• Groups living in vulnerable circumstances

• Children
 • The WHO’s ‘Health in All Policies’
• Uses examples of the pitfalls for health policy associated with ‘Better Regulation’
Possible solutions: processes, conflicts of interest in the areas of food production, weak voluntary
putting agreements to combat obesity, and marketing
• Health in All Policies (HiAP) is an approach to public policies across sectors that
commercial systematically takes into account the health and health systems implications of
influences back in decisions, seeks synergies and avoids harmful health impacts, in order to improve
population health and health equity.
the picture • It includes examples of successful initiatives to prevent undue corporate influence,
such as tobacco directives (WHO, 2006) of unhealthy products to children.
1205MED Health Challenges for the 21st Century
Topic 6.3: SDGs and social determinants
Lecture 6.3 Lecture learning
outcome:

Identify SDGs linked with social determinants

What is being done to address
social determinants globally?
PROGRESS OF GOAL 1 IN 2019
The decline of global extreme poverty continues, but has slowed.

Deceleration indicates the world is not on track to achieve target of less than 3 per cent of
the world living in extreme poverty by 2030.

The share of the world population living in extreme poverty declined t:

• 10% in 2015, down from 16% in 2010 and 36% in 1990.
• However, the pace of poverty reduction is decelerating, with a “nowcast” of 8.6% per
cent in 2018.

Social protection systems help prevent and reduce poverty

Disasters often lead to a downturn in the trajectory of socioeconomic development and
exacerbate poverty.
 Hunger is on the rise again globally and undernutrition
continues to affect millions of children.

An estimated 821 million people – approximately 1 in 9

PROGRESS people in the world – were undernourished in 2017, up
from 784 million in 2015.
OF GOAL 2
IN 2019 Public investment in agriculture globally is declining,
small scale food producers and family farmers require
much greater support and increased investment in
infrastructure and technology for sustainable agriculture
is urgently needed.
 Despite the considerable progress on
education access and participation over the
past years, 262 million children and youth
aged 6 to 17 were still out of school in 2017.

PROGRESS More than half of children and adolescents are

not meeting minimum proficiency standards in
OF GOAL 4 IN reading and mathematics.

2019 Rapid technological changes present

opportunities and challenges.

The learning environment, the capacities of

teachers and the quality of education have not
kept pace.
While some indicators of gender equality are
progressing, e.g. early marriage (Declined by
25%), the overall numbers continue to be
high. PROGRESS
Insufficient progress on structural issues at OF GOAL 5 IN
the root of gender inequality, such as legal
discrimination, unfair social norms and
2019
attitudes, decision-making on sexual and
reproductive issues and low levels of
political participation, are undermining the
ability to achieve Sustainable Development
Goal 5.
PROGRESS OF GOAL 10 IN 2019

Income inequality continues to

rise in many parts of the world,
even as the bottom 40 per cent of
the population in many countries
has experienced positive growth
rates.

Greater emphasis will need to be

placed on reducing inequalities
in income
All SDGs are
interconnected
& indivisible