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Social determinants of health

In this video we ask why are poorer people suffering worse health outcomes than people who are more advantaged in terms of socio-economic position?
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So, we can ask ourselves why is this? Why are people who are poorer suffering worse health outcomes than people who are more advantaged in terms of socio-economic position. The answers lie in the circumstances in which people are born, grow, live, work, and age in, the social determinants of health, ‘the causes of the causes’. A person’s opportunity for health is influenced by factors outside the health system. The social determinants of health are the conditions in which people are born, grow, live, work and age in and these circumstances are shaped by the distribution of money, power and resources at global, national and local levels.
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The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries (WHO, 2020). The social determinants of health is an overarching term for several social factors that serve as the root causes of health and disease. These social factors may not seem directly relevant to health but these social factors form the conditions in which people live, work and age and that can be conducive to good health and wellbeing, or not. This figure is what we describe as the famous rainbow model by Dahlgren and Whitehead. Although this was developed quite some time ago, this is still very relevant and widely used.
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Dame Margaret Whitehead is Professor of Public Health at the University of Liverpool, which you can be proud of! Professor Dame Margaret Whitehead holds the W.H. Duncan Chair of Public Health in the Department of Public Health and Policy, where she leads the ‘Policy Research on Social Determinants and Health Inequalities’ research group. This Dahlgren and Whitehead rainbow model describes the intricate interaction between the determinants of health. At the core of the model we have the personal characteristics such as age, gender, ethnicity or hereditary factors. Then in the next layer we have the individual lifestyle factors, including behaviours such as smoking, alcohol use, and physical activity.
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Then we have in yellow the next layer of the social and community networks, including family and wider social circles. Then in green we have the living and working conditions and that includes access and opportunities in relation to jobs, housing, education and welfare services. Then right at the top the overarching and underpinning factors of the general social, economic, cultural, and environmental conditions, including factors such as disposable income, taxation, and opportunity of good employment. The layers are dynamic, interconnected and interrelated. None of the layers can stand by themselves and all are important in determining our health.

So, we can ask ourselves why are people who are poorer suffering worse health outcomes than people who are more advantaged in terms of socio-economic position?

The answers lie in the circumstances in which people are born, grow, live, work, and age in, the social determinants of health, ‘the causes of the causes’. We can therefore say that there are several social determinants of health. Watch the video above, before reading more about the social determinants of health below.

the social determinants of health

Poverty 

Poverty is a social determinant of health and ultimately underpinning all of these factors. When we talk around the sort of lifestyle choices that people make, it’s really around opportunities and chances. Poverty underpin much of these. It is important to realise this is across the life course. For example, experiencing adverse circumstances early in life can heave a long term negative impact on our health. Children who thrive in early childhood have a higher chance of positive health outcomes later on in life. All the factors are connected, for example, good relationships can encourage good communication skills in early life, which will help to attain success in education, which can lead to better or more qualifications, which in turn can result in a better income, which can result in better access to healthcare, and better health. And vice versa.

Social network

Social networks, family, friends and communities are also a social determinant of health and this is so strong that social isolation and loneliness are associated with a 30% increase risk of heart disease and stroke (Hakulinen, et al 2019).This is an incredible figure. People who are more socially connected to family, friends or their communities are happier and live longer. They have better health outcomes with fewer physical and mental health problems than people who are less well connected, says The Health Foundation (2018). We can then also think further about the concept of social exclusion and individuals becoming disconnected from their social networks, and the negative impact this can have on their health and wellbeing. Again, do try to think about how these factors are interconnected. Poverty plays a role again, you do need to have the funds to be able to connect and engage with friends.

Housing

It is probably not difficult to imagine how housing can impact our health. Marmot (2020) states that children living in cold homes are more than twice as likely to suffer from respiratory problems than children living in warm homes. Housing is important for our overall health and wellbeing. It is also a place where we want to feel safe and at home, and if we can’t feel this, that could impact our health. Does housing allow the individual to connect with their social networks, or are they isolated because of the location? Or is the housing leading to overcrowding, which can put someone at risk of poor health, for example because of stress, or in the case of Covid the lack of opportunity to socially distance puts a direct risk of people’s health. Are children able to do their homework in a quiet place in the home?

Education

Education is an important Social determinant of health. Marmot states that people with the lowest healthy life expectancy are three times more likely to have no qualifications compared with those with the highest life expectancy. Marmot also states that there would be about 202,000 fewer premature deaths each year if everyone in Britain had the low level of mortality of those with university education. That is about 500 deaths a day.   Qualifications and education are significantly associated with health behaviours and health outcomes. People who are educated to a higher degree are less likely to suffer from poorer mental health and less likely to suffer from poor health outcomes. Good education is linked to other skills that can help us in life, for example education helps us to develop skills needed to build social connections, or education helps us to access opportunities for good employment, and feeling more empowered and having a sense of control of one’s life.

Marmot also says had the price of good education is simple: healthier, happier, wealthier people and stronger families, communities and businesses so investing in education is actually a very clever thing to do for a country.

Employment

Having employment is important. Employments provides an income and therefore is essential to afford the basics in life, such as food, housing, gas and electricity, as well as the opportunity to engage with social network. But just having employment is not enough to protect our health, having good employment is very important. This means having work in which we feel valued, feel fulfilled and have a sense of control, which are important for our self-esteem and mental wellbeing. Not having these experiences can cause a great deal of stress and which has a significant negative impact on our health. The Marmot report 2020 highlights that the incidence of stress has increased since 2010 in the UK, that there is now in increase in poor quality employment with more insecurity and pressure. Zero hour contracts are an example of this. Employment also needs to be in a safe environment that protects an employee’s safety and wellbeing. Low income may be associated with work that carries greater occupational hazards.

Transport 

Transport is another social determinant of health. The Health Foundation (2018) highlights that there are nine times as many fatal and serious injuries among pedestrians age 5 to 9 in the most deprived areas than the least deprived areas. Transport provides access to opportunities and jobs, as well as social networks and essential services such as healthcare. There are differences in health outcomes between rural and urban communities, with rural communities having worse health outcomes. Good and accessible public transport systems are conducive to healthier lives. A good public health system is also important for air pollution, another factor that impacts our health

Our environment

That brings us to the environment, another social determinant of health and public health experts call for much more action on the environment as a public health emergency. But here we also mean our direct environment, our surroundings that we live in. Do we feel good and safe in our environment? Living in and having access to green spaces is beneficial to our health. Having easy access to green spaces allows people an opportunity to engage in physical activity, or for children to play. Being in nature and enjoying green spaces in itself is also beneficial to our health and makes us feel good. During Covid-19 we also saw large inequalities there with some people have considerable less access to green spaces. Does our environment help us to stay connected to others and our social networks, or does our environment contribute to social isolation? All important factors to consider, and all related to our health.

Nutrition

Nutrition is the final social determinant of health that we will discuss. The healthy choice should really be the easy choice, but unfortunately it is not. Poor diet is one of the biggest risk factors for preventable ill health however it is more expensive to get the energy we need from healthy food than from unhealthy food (The Health Foundation, 2018). Marmot (2020) highlights that the poor diet of people is very largely to result of poverty and not of poor choices. Remember that all the factors are interrelated and intertwined. Healthy food should be affordable but also accessible and factors in our environment can make it difficult to access healthy foods. We find a higher density of fast food chains in deprived areas, than in more affluent areas and healthy foods are more difficult to buy in deprived areas.

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