The document discusses social determinants of health, which are defined as the circumstances in which people are born, grow, live, work and age that impact health outcomes. These circumstances are shaped by wider social, economic and political forces. Historical evidence from studies like the Black Report and Whitehall studies showed social gradients in health according to factors like socioeconomic status and occupation. Theoretical frameworks explain how social factors influence health through pathways like psychosocial stress and limited access to resources. A conceptual framework outlines how structural factors like income and education act through intermediate factors like housing and healthcare access to impact health. Addressing social determinants requires multisectoral approaches and involvement of various stakeholders.

1. Social determinants and global
health
Joyce L. Browne, MD MSc
PhD fellow
Julius Global Health, Julius Center
for Health Sciences and Primary Care
UMC Utrecht, The Netherlands
www.globalhealth.eu
J.L.Browne@umcutrecht.nl
Fundamentals of Global Health Summer School 2014
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2. Learning objectives
• To appreciate the historical context and
evidence for a social gradient in morbidity
and mortality
• To understand and discuss what social
determinants are, and how they get under
the skin
• Recognize and address the social gradients
that occur in Global Health context
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3. Understanding social determinants
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4. Definitions
• Social determinants
• Health (in)equity
• Common measurements?
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5. Definitions
Social Determinants
The social determinants of health are the circumstances in
which people are born, grow up, live, work and age, and
the systems put in place to deal with illness. These
circumstances are in turn shaped by a wider set of forces:
economics, social policies, and politics.
Health inequities
Health inequities are avoidable inequalities in health
between groups of people within countries and between
countries. These inequities arise from inequalities within and
between societies. Social and economic conditions and their
effects on people’s lives determine their risk of illness and the
actions taken to prevent them becoming ill or treat illness
when it occurs.
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6. Why are we talking about social determinants?
http://www.kingsfund.org.uk/time-to-think-differently/trends/broader-determinants-health
Genetic 30%
Social circumstances 15%
environmental 5%

7. Historical context of the Social Determinants
in Health
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8. Historical context of the Social Determinants in
Health (1)
1948
• WHO constitution: acknowledgement of “impact of social and political
conditions on health” and need for intersectoral to achieve health gains.
1950s-
1960s
• Little regard for social contexts, strong focus on technology and disease-
specific campaigns.
1978
• Alma-Ata Declaration on Primary Health / Health for All.
Asserted need to strengthen health equity by addressing social conditions
through intersectoral programs
1980s
• Limited political will
- Neoliberal governments in many European countries and the US with
market-oriented reforms in health care
- Structural Adjustment Programs for developing countries: reduced
government’s social and public spending
• At the same time: biomedical paradigm was challenged: Black Report (UK)
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9. • Published in 1980 by the
Thatcher Government
(over a Bank Holiday
Weekend)
• Analysis of General
Household Survey (GHS)
data (collection started
in 1970), by occupation
as an indicator of SES
The Black Report
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Full report available at: http://www.sochealth.co.uk/resources/public-health-and-wellbeing/poverty-and-inequality/the-
black-report-1980/

10. Consistent social class gradient in infant,
child and adult mortality
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11. Class differences were
also observed for
different causes of
adult mortality
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• Infectious and parasitic diseases
• Endocrine, nutritional and
metabolic diseases
• Diseases of the nervous system,
digestive system, genic-urinary
tract
• Accidents, poisonings and
violence

12. Historical context of the Social Determinants in
Health (2)
1980s-
1990s
• Increasing scientific evidence (e.g.
Whitehall studies, UK)
• Political landscape: (social-
)democrats within market systems
2004:
• Commission on Social Determinants
of Health (CSDH)
2008:
• CSDH Report published
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13. • British Civil Services
• Prospective cohort study
(1967-1977)
• 18 000 male servants
between 20-64
Conclusion:
• Social gradient based
on seniority/occupation
in overall mortality, but
also for a range of
specific diseases
Whitehall I
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14. • British Civil Service, London
offices
• Prospective cohort, start
1985
• 10,308 civil servants
between 35-55 (33%
female)
Conclusions:
• Social gradient in
morbidity for men and
women
• Causal factors identified:
lifestyle (smoking, lack of physical
activity, obesity, biometric markers),
early life factors, the way work is
organized, work climate, social
influences
Whitehall II
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Bosma et al, 1998

15. Historical context of the Social Determinants in
Health (2)
1980s-
1990s
• Increasing scientific evidence (e.g.
Whitehall studies, UK)
• Political landscape: (social-)democrats
and continued market system approach
2004:
• Commission on Social Determinants of
Health (CSDH)
2008:
• CSDH Report published
2013
• Statement of the UN Platform on Social
Determinants in Health about the post-
2015 development agenda
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16. Theoretical explanations of
disease distribution:
• Psychosocial approach
• Social production of
disease / political economic
of health
• Eco-social and other multi-
level frameworks
How do social factors get under the skin?
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17. • Social stress resulting
from (perception of)
social status
• Hypthalamus-pituitary-
adrenal axis (chronic)
• Sympatic nervous
system/(nor)adrenatine
(acute)
Psychosocial approach
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18. • Economic and political
determinants of health
and disease, beyond the
perception of inequalities
– Lack of resources, but also
access to education, health
services, transportation,
environmental controls,
availability of food, quality
of housing, etc etc
Social production of disease / political economic
of health
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19. Krieger’s “embodiment”:
“we literally incorporate
biological influences from the
material and social world” and
that “no aspect of our biology
can be understood divorced
from knowledge of history and
individual and societal ways of
living”
Eco-social and other multi-level frameworks
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20. How is social economic position (social status)
operationalized?
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21. How is social economic position (social status)
operationalized?
• Three levels:
– Individual
– Household
– Neighborhood
– Various time intervals
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22. How is social economic position (social status)
operationalized?
• Three levels:
– Individual
– Household
– Neighborhood
– Various time intervals
• Commonly used:
– Education
– Income
– Occupation
– Social class
– Race/ethnicity
– Gender
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23. Bringing it together: a conceptual framework
of social determinants of health
• Structural (or “distal” factors)
• Intermediate factors (“proximal” factors)
..and their impact on health
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24. Bringing it together: a conceptual
framework of social determinants of health
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25. Social determinants and global health
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26. Social gradient in pre-mature death and life
expectancy between countries
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Marmot, 2005. Lancet
World Health Statistics 2013, WHO 2014

27. Social gradient in infant mortality between and
within countries
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CSDH report, 2008

28. Social gradient in maternal mortality
Rosmans (2006)

29. • Eight key reproductive,
maternal, newborn and
child interventions:
– Satisfied need for family
planning
– ≥ 1 ANC
– Skilled attendant at birth
– Measles caffination
– DPT vaccination
– BCG vaccination
– Oral rehydration and
continued feeding
– Care seeking for pneumonia
Social gradient in maternal health services
coverage
Bhutta (2010) / Countdown to 2015 decade report

30. How to address the social inequalities in
health?
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31. Implementation of any policy or intervention
requires involvement of various actors
• What actors/stakeholders should be involved?
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32. Implementation of any policy or
intervention requires involvement of
various actors
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Health
Development
Strategies
Multilateral
Organizations
Civil society
Bilateral organizations
National governments
Private sector
Philantropic
organizations

33. CSDH report: an integral approach is necessary
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34. Examples of intermediary approaches
• What could be examples?
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35. • Structural determinants,
socio-economic status:
– Education, inter-
sectorial approach
• Material circumstances:
– Housing, intersectorial
approach
Examples of intermediary approaches
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36. Socio-economic status: SES
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Social determinants of health sectoral briefing series, 2

37. Material circumstances: housing
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Social determinants of health sectoral briefing series, 1

38. Examples of structural approaches?
• What could be examples?
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39. 1. Improve daily living conditions
2. Tackle inequitable distribution
of power, money and resources
3. Measure and understand the
problem and assess the impact
of action
CSDH recommendations
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40. 1. Improve daily living conditions
Equity from the start (life course), fair
employment, healthy living and work
conditions, social protection, universal health
care
2. Tackle inequitable distribution of
power, money and resources
Health equity in all policies, fair financing,
market responsibility, gender equity, potitical
empowerment, good global governance
3. Measure and understand the
problem and assess the impact
of action
Monitoring, research, training
Global movement
CSDH recommendations
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41. • Social determinants play a
major role in all aspects of
health and disease, and can
be categorized in structural
and intermediate affects
through various pathways.
• The importance of SDH and
health equity is increasingly
internationally recognized
and applied.
In conclusion
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42. Want to know more about social
determinants?
• Online Social determinants game
www.playspent.org
• Not about SHD, but VERY COOL!:
www.thegreatflu.com