🧑‍⚕️Public Health Social Sciences Unit 3 – Social Determinants of Health

What's This Unit About?

• Explores the social, economic, and environmental factors that influence health outcomes and disparities
• Examines how social determinants of health (SDOH) shape individual and population health across the life course
• Investigates the complex interplay between social structures, policies, and health inequities
• Discusses the historical context and development of the SDOH framework in public health research and practice
• Highlights the importance of addressing SDOH to promote health equity and social justice
• Introduces key concepts, definitions, and theoretical frameworks related to SDOH
• Provides real-world applications and case studies to illustrate the impact of SDOH on health outcomes

Key Concepts and Definitions

• Social determinants of health (SDOH): The conditions in which people are born, grow, live, work, and age that shape health outcomes
  • Includes factors such as income, education, housing, employment, social support, and access to healthcare
• Health equity: The absence of unfair and avoidable differences in health outcomes across population groups
• Health disparities: Differences in health outcomes and access to healthcare services between population groups
  • Often related to social, economic, and environmental disadvantages
• Social gradient: The stepwise relationship between socioeconomic position and health outcomes, with those in higher positions experiencing better health
• Intersectionality: The interconnected nature of social categorizations (race, class, gender) that create overlapping systems of discrimination or disadvantage
• Life course approach: Recognizes the cumulative impact of social, economic, and environmental exposures on health across the lifespan
• Upstream factors: The fundamental social, economic, and political determinants that influence downstream health outcomes
• Downstream factors: The proximal, individual-level factors (health behaviors, access to care) that directly impact health outcomes

Historical Context and Development

• Early recognition of the link between social conditions and health in the 19th century (Rudolf Virchow, Friedrich Engels)
• Development of social medicine and social epidemiology in the 20th century (Salvador Allende, Geoffrey Rose)
• Release of the Black Report in the UK (1980) highlighting the persistent health inequalities despite the establishment of the National Health Service
• Publication of the Whitehall Studies (1960s-1980s) demonstrating the social gradient in health outcomes among British civil servants
• Emergence of the SDOH framework in the 1990s and 2000s (Dahlgren and Whitehead, WHO Commission on Social Determinants of Health)
• Growing recognition of the need to address SDOH in public health research, policy, and practice in the 21st century
• Increased focus on health equity and social justice in global health agendas (Sustainable Development Goals, Health in All Policies)

Major Social Determinants of Health

• Socioeconomic factors: Income, education, occupation, and wealth
  • Higher socioeconomic position associated with better health outcomes and longer life expectancy
• Neighborhood and built environment: Housing quality, access to green spaces, transportation, and community safety
  • Poor housing conditions (overcrowding, dampness) linked to respiratory illnesses and mental health problems
• Social and community context: Social cohesion, discrimination, incarceration, and social support
  • Discrimination and social exclusion associated with higher rates of chronic stress and adverse health outcomes
• Health and healthcare: Access to and quality of healthcare services, health insurance coverage, and health literacy
  • Lack of access to preventive care and treatment contributes to health disparities
• Education: Early childhood development, high school graduation, and higher education attainment
  • Higher levels of education associated with better health outcomes and health-promoting behaviors
• Economic stability: Employment, job security, and financial stress
  • Unemployment and job insecurity linked to poor mental health and increased risk of chronic diseases
• Food environment: Access to healthy and affordable food options, food insecurity, and nutrition
  • Food deserts and food insecurity associated with higher rates of obesity and diet-related chronic diseases

Health Inequities and Disparities

• Racial and ethnic disparities: Differences in health outcomes and access to care across racial and ethnic groups
  • Structural racism and discrimination contribute to persistent health disparities (higher rates of chronic diseases, maternal mortality among Black Americans)
• Socioeconomic disparities: Differences in health outcomes and life expectancy across income and education levels
  • Lower socioeconomic position associated with higher rates of chronic diseases, mental health problems, and premature mortality
• Gender disparities: Differences in health outcomes and healthcare experiences between men and women
  • Women face unique health challenges (reproductive health, gender-based violence) and barriers to care (lack of comprehensive services, discrimination)
• Geographic disparities: Differences in health outcomes and access to care across urban, rural, and remote areas
  • Rural populations face challenges such as limited healthcare infrastructure, transportation barriers, and provider shortages
• Disparities across the life course: Cumulative impact of social and economic disadvantages on health outcomes from childhood to older age
  • Adverse childhood experiences (ACEs) linked to higher risk of chronic diseases and mental health problems in adulthood
• Intersectional disparities: Compounded impact of multiple forms of disadvantage (race, class, gender) on health outcomes
  • Black women face disproportionate rates of maternal mortality and breast cancer mortality due to the intersection of racial and gender inequities

Measurement and Data Collection

• Social determinants of health indicators: Measures of social, economic, and environmental factors that influence health outcomes
  • Examples include poverty rates, high school graduation rates, housing affordability, and food insecurity rates
• Health equity indicators: Measures of differences in health outcomes and access to care across population groups
  • Examples include life expectancy gaps, preventable hospitalization rates, and uninsured rates by race/ethnicity
• Data sources for SDOH research: Population health surveys, administrative data, electronic health records, and qualitative data
  • Behavioral Risk Factor Surveillance System (BRFSS), National Health Interview Survey (NHIS), and American Community Survey (ACS) provide valuable data on SDOH
• Challenges in SDOH data collection: Lack of standardized measures, limited granularity, and data gaps for marginalized populations
  • Need for improved data collection and disaggregation to identify and address health inequities
• Importance of community engagement and participatory research methods in SDOH data collection
  • Engaging community members in the research process can improve data quality, relevance, and trust
• Geospatial analysis and mapping of SDOH data to identify hotspots of health inequities and target interventions
  • Using geographic information systems (GIS) to map the distribution of SDOH and health outcomes across neighborhoods and regions

Interventions and Policies

• Upstream interventions: Addressing the fundamental social, economic, and political determinants of health
  • Examples include policies to reduce poverty, improve education, and promote affordable housing
• Midstream interventions: Targeting the intermediate pathways through which SDOH influence health outcomes
  • Examples include community-based programs to improve access to healthy food, transportation, and social support
• Downstream interventions: Addressing the proximal, individual-level factors that directly impact health outcomes
  • Examples include healthcare services, health education, and behavior change interventions
• Health in All Policies (HiAP) approach: Integrating health considerations into decision-making across sectors and policy areas
  • Recognizes the importance of cross-sectoral collaboration to address SDOH and promote health equity
• Place-based initiatives: Targeting interventions and investments to specific geographic areas with high levels of health inequities
  • Examples include community development initiatives, neighborhood revitalization programs, and health enterprise zones
• Policies to address structural racism and discrimination: Dismantling systems and practices that perpetuate health inequities
  • Examples include fair housing policies, criminal justice reform, and anti-discrimination laws in healthcare settings

Real-World Applications and Case Studies

• Affordable Care Act (ACA) and Medicaid expansion in the United States
  • Expanded access to healthcare coverage and reduced uninsured rates, particularly among low-income and minority populations
• Healthy Cities movement and the WHO European Healthy Cities Network
  • Promotes cross-sectoral collaboration and community engagement to create health-promoting urban environments
• Conditional cash transfer programs (e.g., Bolsa Família in Brazil, Oportunidades in Mexico)
  • Provide financial incentives for low-income families to invest in health, education, and nutrition
• Housing First initiatives for individuals experiencing homelessness
  • Prioritize providing stable housing as a foundation for improving health outcomes and reducing healthcare costs
• Early childhood development programs (e.g., Head Start in the United States)
  • Provide comprehensive services (education, nutrition, health screenings) to promote healthy development and reduce disparities
• Community health worker (CHW) programs in low- and middle-income countries
  • Train local community members to provide health education, outreach, and navigation services to improve access to care and address SDOH
• Health impact assessments (HIAs) to evaluate the potential health consequences of policies and projects
  • Systematically assesses the health impacts of non-health sectors (transportation, housing, urban planning) to inform decision-making and mitigate adverse effects