Understanding social determinants of health.
In 2008 the World Health Organization (WHO) defined social determinants of health as “the non-medical factors that influence health outcomes” including “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (World Health Organization [WHO], n.d.). These include (as a preliminary but not exhaustive list) education, employment and job security, income, early childhood development, social inclusion and freedom from discrimination, and access to decent and affordable housing, nutrition, and health care (WHO, n.d.). These determinants drive health inequity and contribute to poorer health outcomes and higher mortality of socially disadvantaged individuals, communities, and populations across the globe (Andermann, 2016; Mikkonen & Raphael, 2010; WHO, n.d.).
In Canada, most Canadians identify themselves as in good health. However, health inequities persist in the country, and, in recent years, have shown evidence of growth (Jackson & Huston, 2016; Mikkonen & Raphael, 2010). These inequities require immediate action within and across sectors to address social determinants, improve individual and community health, and achieve lasting structural change (Andermann, 2016; Jackson & Huston, 2016; WHO, n.d.). Critical to this is the need to understand and measure social determinants and assess the impact of current and proposed action towards their elimination (Andermann, 2016; Mikkonen & Raphael, 2010; Ministry of Health and Long-Term Care [MOHLTC], 2015; WHO, n.d.).
Since WHO’s call to action in 2008, significant efforts have been undertaken to investigate the impact of social determinants of health worldwide. Unfortunately, despite great interest in the topic, little change has been seen at a systems level (Mikkonen & Raphael, 2010). Upon review of current literature, an interesting theme began to emerge: the belief that a redefinition of and (re)narrowed focus on social determinants is required if progress is to be made in the reduction and eradication of (global) health inequity. Several authors identify missteps in the current approach and suggest that by taking a step back, greater understanding can be created and spur necessary public and political motivation to act.
Where is the current approach going wrong?
As a starting point, Lundberg (2020) suggests that the current definition of social determinants of health may be difficult (for the lay public) to grasp and appreciate. Unlike the physical effects of disease or obvious damage from a motor vehicle collision, the impact of social determinants is not as easily seen and, as such, risks ignorance and apathy (Lundberg, 2020). Redefinition (simplified?) and reframing may better communicate how inequities are created, what these look like, and how best to reduce or eliminate them (Lundberg, 2020). Such redefinition will be useful to medical practitioners, who Andermann (2016) suggests, “operate under a ‘risk factor’ paradigm, focus[ing] on behaviour modification for high-risk groups…”, which ignores the reality that these individuals may not be in control of the structural factors that impact their individual health.
Also in support of re-examination and a simplified approach, Islam (2019) suggests that public and political understanding of social determinants has been complicated in recent years due to a (too) broad use of the term. This has fuelled confusion and misdirected intervention across sectors, especially at the political level. A growing body of literature regularly contributes new determinants to the original WHO list, many of which are culturally and context specific (Islam, 2019). And, while each new addition has merit and importance, the growing list creates a lack of clarity, leaving policymakers questioning which determinants to address and where to target intervention to create the greatest impact (Islam, 2019). This confusion is further complicated by a shallow body of definitive research from which to draw (Islam, 2019; Lundberg, 2020). The result: ill-responsive policy and programs that continue to invest in individual-level intervention but fail to address the underlying systems and structures that contribute to wider inequity (Castrucci & Auerbach, 2019). This confusion also creates challenges in intersectoral collaboration, fundamental to effectively addressing social determinants and creating sustainable societal change (Lundberg, 2020).
I liken these challenges to being presented with a 10-page menu when dining at a new restaurant. You are hungry, and want to eat, but having so many options from which to choose makes it overwhelming and difficult to order. You look to the opinions of waitstaff and other patrons, but receive 10 different answers, all which account more for individual taste than reliable, measurable data. Needing to satisfy your hunger and move forward, you ignore the suggestions of others and choose the same old club sandwich and fries that you’ve had elsewhere many times. While doing nothing to expand your culinary repertoire, this option is tried and tested, and gets the job done.
A final criticism comes from Castrucci and Auerbach (2019) who assert that, despite WHO prioritizing a community-level focus, most current policy and programs created to address health inequity focus on individual-level intervention. These policies target short-term, immediate solutions for acute issues, rather than addressing social determinants at the community-level and endeavouring to achieve systemic change. This is (again) driven (in part) by a limited pool of available research, as well as data which tends to emphasize the impact of social factors on individual health. This research is complemented by the provision of practice examples which focus on the success of individual rather than community-level programs, again resulting in misdirected attention and resource distribution (Castrucci & Auerbach, 2019; Islam, 2019; Lundberg, 2020). Intervention at the individual level is necessary and important, but often only serves a small percentage of the population, usually the sickest or most frequent users of emergency care (Castrucci & Auerbach, 2019). It is instead suggested that advocates clearly position individual circumstance as embedded into social structures so that both (equally important) concepts garner similar political attention and investment (Lundberg, 2020; Mikkonen & Raphael, 2010). This will prioritize the creation of policies that promote universal access, but differential treatment, based on individual need and clearly distinguish that programs addressing acute (individual) social challenges are not the same as community level progress when addressing social determinants of health (Castrucci & Auerbach, 2019; Lundberg, 2020, WHO, n.d.).
Where do we go from here?
Improved understanding and policy change will be some of the greatest drivers of progress in the continued calls to address social determinants of health and reduce and eliminate health inequity in Canada, and across the globe (Mikkonen & Raphael, 2010). A (re)narrowed focus and redefinition will serve to create greater public understanding and interest and provide clarity and enhance community intervention, especially at the policy level, where targeted investment and sustainable change is lacking (Castrucci & Auerbach, 2019; Islam, 2019; Mikkonen & Raphael, 2010). Additionally, renewed focus can improve the collection of relevant, timely, consistent, inclusive, and affordable data, and ease confusion that surrounds proposed intervention and potential impact (Jackson & Huston, 2016; MOHLTC, 2015). Such improved research risks only to further inform understanding of health and determinants, increase information sharing and cross-sectoral collaboration and clinical-community partnerships, and better target investment and equitable resource distribution; strengthening individuals and communities, and the taking steps towards the overall reduction of health inequities (Andermann, 2016; Jackson & Huston, 2016; Mikkonen & Raphael, 2010; MOHLTC, 2015).
References
Andermann, A. (2016). Taking action on the social determinants of health in clinical practice: A framework for health professionals. Canadian Medical Association Journal, 188(17-18), E474–E483. https://doi.org/10.1503/cmaj.160177
Castrucci, B., & Auerbach, J. (2019, January 16). Meeting individual social needs falls short of addressing social determinants of health. Health Affairs. https://www.healthaffairs.org/do/10.1377/forefront.20190115.234942/full
Islam, M. (2019). Social determinants of health and related inequalities: Confusion and implications. Frontiers in Public Health, 7(11). https://doi.org/10.3389/fpubh.2019.00011
Jackson, B., & Huston, P. (2016). Advancing health equity to improve health: The time is now. Canada Communicable Disease Report, 42(S1), S1–1-S1-6. https://doi.org/10.14745/ccdr.v42is1a01
Lundberg, O. (2020). Next steps in the development of the social determinants of health approach: The need for a new narrative. Scandinavian Journal of Public Health, 48(5), 473–479. https://doi.org/10.1177/1403494819894789
Mikkonen, J., & Raphael, D. (2010). Social determinants of health - The Canadian facts. Wellesley Institute. https://thecanadianfacts.org/the_canadian_facts.pdf
Ministry of Health and Long-Term Care (2015). Mapping wellness: Ontario’s route to healthier communities. https://www.health.gov.on.ca/en/common/ministry/publications/reports/cmoh_15/docs/cmoh_15.pdf
World Health Organization (n.d.). Social determinants of health. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
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