Social Determinants of Health
The Conceptual Framework for the One Healthy Reason Conference
by Dr. Jonathan Spikes
Populations are stratified by income, education, occupation, race/ethnicity, and other factors through social, economic, and political mechanisms, which in turn shape certain health status determinants (intermediary determinants) that are indicative of people’s positions within social hierarchies (World Health Organization, 2010). Individuals experience varying levels of exposure and vulnerability depending on their respective social status (World Health Organization, 2010).
For example, in an urban community context, exposure to firearm-related violence can “feedback” on a given individual’s social position by compromising educational attainment and employment opportunities and reducing income.
Educational attainment, employment opportunities, and income are structural mechanisms that generate:
- Stratification (privilege/positionality)
- Social class divisions in society
- Individual socioeconomic positions
Structural mechanisms generate structural stratifiers (World Health Organization, 2010) in urban communities that contribute to social stratification and inequalities within the population. These stratifiers can significantly impact people’s access to resources, opportunities, and well-being. Some of the most important structural stratifiers in urban communities and their proxy indicators include:
Income and Wealth
- Proxy Indicators: Median household income, poverty rate, and access to basic amenities, such as housing, healthcare, and political representation (World Health Organization, 2010).
Education
- Proxy Indicators: Literacy rates, high school graduation rates, college enrollment rates, and availability of quality educational institutions (World Health Organization, 2010).
Occupation and Employment
- Proxy Indicators: Unemployment rate, job opportunities, occupational segregation (unequal distribution of jobs based on gender, race, etc.), and access to formal employment (World Health Organization, 2010).
Race and Ethnicity
- Proxy Indicators: Demographic composition represents housing, representation in different sectors, access to social services, educational disparities, and income based on racial or ethnic background (World Health Organization, 2010).
Housing and Residential Segregation
- Proxy Indicators: Housing affordability, quality of housing, levels of residential segregation (separation of different racial or socio-economic groups in different neighborhoods) (World Health Organization, 2010).
Health and Healthcare
- Proxy Indicators: Life expectancy, access to healthcare facilities, health insurance coverage, and the prevalence of diseases in different areas (World Health Organization, 2010).
Social Class
- Proxy Indicators: Ownership of assets (e.g., property, vehicles), access to recreational facilities, and access to networking opportunities (World Health Organization, 2010).
Social Networks and Social Capital
- Proxy Indicators: Participation in community organizations, access to social support systems, and level of community engagement (World Health Organization, 2010).
These structural stratifiers often interact and reinforce each other, leading to complex and multifaceted patterns of inequality within urban communities and, in effect, forming structural determinants of health. Structural determinants, such as social, economic, and environmental factors, create conditions that directly influence intermediary determinants of health (World Health Organization, 2010). Intermediary determinants of health are the factors that directly influence health outcomes and are influenced by the broader structural determinants of health (World Health Organization, 2010). Intermediate determinants act as a link between social, economic, and environmental conditions and individual health status (World Health Organization, 2010).
For example:
- Income inequality (structural determinant) can lead to housing affordability (intermediate determinant), which in turn, can result in living in communities with high exposure to firearm-related violence, high levels of racial segregation, and lower consumption potential (e.g. the financial means to buy healthy food, the resources to pay for an increase in electricity bills due to global warming, etc.).
- Lack of educational attainment (structural determinant) can impact health by reducing formal employment (intermediary determinant), affecting an individual’s stressful living circumstances, poverty rates, and adverse coping mechanisms such as the use and availability of illegal drugs and increased exposure to and perpetration of crime.
- Lack of social networks and social capital (structural determinant) can reduce access to influence public policies (intermediary determinant), which, in turn, affects political power and the allocation of resources, which can have direct or indirect impacts on health outcomes.
Social Determinants of Health
A Demographic Approach to Understanding the experiences of Black children in the United States
- World Health Organization (WHO) defines social determinants of health as circumstances or conditions in which people are born, grow up, live, work and age, and systems put into place to deal with illness; affect health, functioning, and quality-of-life outcomes and risks
- patterns of social engagement and sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes
- Circumstances can affect anyone’s health, regardless of age, race, ethnicity; however, health inequities work illustrates importance of identifying intersectional identities and relevance social justice and power when exploring social determinants of health
- List Item
why america's black mothers and babies are in a life-or-death crisis
– LINDA VILLAROSA April 11, 2018
- Intergenerational and socio historical disadvantage corrodes health; biological response to product of lived experience via weathering (e.g. Geronimus et al., 2010; Simons et al., 2016)
- Cultures of exclusion create chronic stress that just happens all the time, never a period where there's rest from it, affecting everything; type of stress for which education and class provide no protection (e.g. Geronimus, 2001; Geronimus et al., 2010; Simons et al., 2016)
- allostatic load is physiological stress response to threats causing hormones cascade through the body, sending blood flowing to muscles and heart to help body run faster and fight harder; fight-or-flight response (e.g. Duru et al., 2012; Wallace & Harville, 2013
- Leads to younger age chronic conditions (e.g. hypertension and type 2 diabetes), depression, sleep deprivation, and increased risky coping behaviors (e.g. overeating, drinking, and smoking)