Social Determinants of Health
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"What good does it do to treat people's illness, and then to send them back to.."
The determinants of health cover social, environment, individual capacity, personal health practices, and the health care system.
The Determinants of Health
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Measuring only health outcomes misses the majority of the population and how they are doing. These health issues are important for whole society and for the world, and it is a mistake to focus only on the bottom 10%.
Wellbeing needs to be a global development outcome. Society development needs to be judged by population health and its fair distribution.
The determinants have been written about extensively by the Public Health Agency of Canada and the World Health Organization.
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- education and literacy
- physical environment
Education and Literacy
What we're most interested in is functional literacy - can people
SES makes a BIG difference; of an age cohort, only 27% of poor kids pass the grade 12 test, while over 70% of rich kids do.
Assessing Literacy
A point-blank question can be helpful:
- do you have any trouble with reading or writing?
Having
Teaching Literacy
There are many programs available..
Physical Environment
As an important determinant of health, our physical environments have tremendous impact on how we feel and live.
Richness = socioeconomic steroids
The Political System
"Show me your budget and I'll show you what you value."
Improving the Determinants of Health in Society
The WHO has been active in setting the global agenda, equipping members countries to tackle their population's wellbeing by launching a report in September 2008. The report will cover the conditions in which people are born, grow, live, work, age, the structural drivers of conditions at global, national, and local levels, and monitoring, training, research.
Health Equity: the absence of unfair and avoidable or remiadble differences in health among population or groups defined socially, economically... (Solar and)
Murray, 2006.
Swedish PH
participation in society
The policy makers have in their hands the capacity to set levels of poverty through resource distribution. (Fritzell and... )
Tobacco taxes are a way of taking money from the poor and giving it to the rich.
Woolf et al, AJPH 2007
medical advances - 180k deaths averted
educational inequalities, 1.4m deaths averted
US 1996-2002
Grantha-McGregor et al, 1991
stunted kids:
nutrition + stimulation restores growth; neither does on its own.
stress and work
iso-strain: social isolation + strain
big deal.
ageing
Three waves of GH research
1 biomedical disciplines to offer clin
2 health systems, PH interventions
3 sDOH as effected by social and economic policy and upstream political choices
- must go beyond behavioural and ither individual determinants of illness
- examine intersections among i
- examine connections between proximal and distal health
dlp: these resources need to be permeated with:
- ethics
- compassion
- explicitly within SDoH, millenium development goals
- clear desire for foundational KT
will prevention save money? debatable. But should it matter? We should prevent disease and illness because health and well-being.
Health systems do matter
- Rannan-Eliya, 2009 low-income countries which
major obstacles to third wave: complexity of causal pathways, biological or epidemiolgocial orientation of many clinicians or researchers; many governments are quite cautious
Child Health Initiative Project
CMA, CPS, CFPC
charter
- a place with a safe and secure environment
- a place for good health and development
- a full range of health resoucres to all
a place with a safe and secure environment
- clean water and air
- protection from injury
- safe home and communities
a place for good health and development
- prenatal and maternal care
- nutrition
- early learning
- physical activity
- mental health
child and youth challenge
- stop doing things TO children; statr doing them WITH children
Morris et al, 2007 IJE
minimum income for healthy living - our pensions are insufficient
people drink the same amounts; its vulnerability to it that is linked with death
Kenya - participatory approach to nutrition
problem was social breakdown
Havemann and Pridmore, 2005
60 cents per person per year
Social isolation
one of the biggest problems in health care is very poor customer service.
we need to feel we have control and purpose; we need to love and be loved.
Socioeconomic Status and Early Child Development
- interactions with biology
Income correlates with all-cause mortality, with the majority of the impact being unexplained by traditional risk factors such as blood pressure, smoking, etc (Whitehall Study).
This gradient is ubiquitous across wealthy countries, with SES. It cuts across a wide range of disease processes.
This income-health gradient becomes replicated as new conditions emerge - ie post WWII, HIV/AIDS, etc.
This impact appears distinct from biology. How does SES then impact health? Social, emotional, and language development, especially at an early age, are profound.
Sensitive periods in early brain development
get graph from Council from Early Child Development
Nurture is a substantial indicator.
The easiest time to do something is early on.
Problems known to be related to early life include:
- school failure, teen pregnancy, criminality
- obesity, HTN, depression
- CAD, diabetes
- premature aging and memory loss
Hart and Risley, 1995
Disparities in Early Vocabulary Growth are profiund by 36 months, and appears to be connected to the number of words spoken to them. (30 million word gap).
The words parents use, and the way they are used, are also very important. Disparaging words, or commands, are not great.
The Bill Cosby Show made an effort to model effective household language.
National Long. Study in children and youth:
- 13.7% kids from well-off families are vulnerable
- 31% kids from very poor families are vulnerable
Can seek the impact of ECD at the level of the population
can seek to understand how biology interacts with development
Interactions with Biology
Biological embedding occurs when experience has a permanent role on human biology.
Need to have a breakdown of experiences and behabviours, neural circuitry, synapses, and molecular biology.
Low SES has an impact on prefrontal cortex, whereby attention is constantly on guard (perhaps a product of chronic disorganized lifestyle). It makes focused attention more difficult. You can train kids to focus better, but at what age is neural circuitry locked in? Is it?
A Capsi. Science. 2004. Serotonin transporter gene potentiates depression, but only in areas of severe abuse. There are now 5-10 very important studies reinforcing gene-environment interactions.
Epigenetics: methylation. This guy has shown methylation can continue not only during fetal development, but also after birth.
Meaney M, Szuf, 2004-2008 - rats who lick their babies more - babies have a better functioning HPA axis (cortisol fine-tuning). Can see methylation of the GR promoter - 'Meaney-Szuf Paradigm' between days 9-16 of rats; not before, not after. And then the mother passes on this behaviour to their babies!
Now doing human genome studies: can find over 1500 loci of differential methylation in children from different SES.
Resources and References
The Canadian Facts - Social Determinants of Health, May 2010
Health Care Without Harm - the Campaign for Environmentally Responsible Health Care
Great journals include Social Science and Medicine and Health and Place
Robin Kearns has done much work on people in place. Some of his publications include:
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