Braveman et al (2011) L1: Social determinants - KEY Flashcards
What are the social determinants of health? (Upstream/downstream)
The term social determinant of health is often used to refer broadly to any nonmedical factors influencing health, including health-related knowledge, attitudes, beliefs, or behaviors (such as smoking). These factors, however, represent only the most downstream determinants in the causal pathways influencing health; they are shaped by more upstream determinants.
To illustrate the upstream/downstream metaphor, consider people living near a river who become ill from drinking water contaminated by toxic chemicals originating from a factory located upstream. Although drinking the contaminated water is the most proximate or downstream cause of illness, the more fundamental (yet potentially less evident, given its temporal and physical distance from those affected) cause is the upstream dumping of chemicals. A downstream remedy might recommend that individuals buy filters to treat the contaminated water before drinking; because more affluent individuals could better afford the filters or bottled water, socioeconomic disparities in illness would be expected.
The upstream solution, focused on the source of contamination, would end the factory’s dumping. Although these concepts may make intuitive sense, the causal pathways linking upstream determinants with downstream determinants, and ultimately with health, are typically long and complex, often involving multiple intervening and potentially interacting factors along the way. This complexity generally makes it easier to study— and address—downstream determinants, at the risk of failing to address fundamental causes.
Define downstream social determinants
factors that are temporally and spatially close to health effects (and hence relatively apparent), but are influenced by upstream factors
Define upstream social determinants
fundamental causes that set in motion causal pathways leading to (often temporally and spatially distant) health effects through downstream factors
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This article focuses on the more upstream social determinants of health—the factors that play a more fundamental causal role and represent the most important opportunities for improving health and reducing health disparities. Figure 2 illustrates the conceptual framework for the RWJF Commission’s work. Although the relationships are more complex, this simplified schema highlights several important concepts. First, it shows that health- related behaviors and receipt of recommended medical care (key downstream determinants of an individual’s health) do not occur in a vacuum. Rather, these factors are shaped by more upstream determinants related to the living and working conditions that can influence health both directly (e.g., through toxic exposures or stressful experiences) and indirectly (by shaping the health-related choices that individuals have and make for themselves and their families). The diagram highlights how health is shaped not only by living and working conditions, but also by even more upstream determinants that reflect the economic and social resources and opportunities that influence an individual’s access to health-promoting living and working conditions and to healthy choices.
What do we know about the association between social factors and health?
Evidence from decades of research examining associations between key social factors— primarily educational attainment and income in the United States and occupational grade (ranking) in Europe—and health outcomes throughout the life course overwhelmingly links greater social disadvantage with poorer health
What is the social gradient?
(US data) - education - social gradient
Although the most disadvantaged—those with below- poverty-level incomes or without high-school completion—typically experience the worst health, even those with intermediate income or education levels appear less healthy than the most affluent/educated
What are the potential implications of a social gradient?
The social gradients in health provide clues to understanding the SDOH. Although other research is needed to clarify the underlying pathways, the dose-response relationship suggested by the gradient patterns supports the biological plausibility of a fundamental causal role for one or more upstream SDOH. Gradients by income, education, or occupational grade could reflect relatively direct health benefits of having more economic resources (e.g., healthier nutrition, housing, or neighborhood conditions, or less stress due to more resources to cope with daily challenges), unmeasured socioeconomic factors, and/or associated psychosocial/ behavioral factors, such as health-related behaviors, self-perceived social status, or perceived control. Reverse causation as an alternative explanation is discussed below.
Pathways through which Social Factors Shape Health: Neighbourhood Conditions - How can it shape health? Outline theory
Neighborhoods can influence health through their physical characteristics, such as air and water quality and proximity to facilities that produce or store hazardous substances; exposures to lead paint, mold, dust, or pest infestation in housing; access to nutritious foods and safe places to exercise; or risk of pedestrian accidents.
The availability and quality of neighborhood services— including schools, transportation, medical care, and employment resources—can also influence health, e.g., by shaping residents’ opportunities to earn a living. Neighborhoods’ physical and service characteristics can create and reinforce socioeconomic and racial/ethnic disparities in health. Health is also shaped by social relationships.
What is evidence for association between neighbourhood characteristics and health?
For example, neighborhoods where residents express mutual trust and are willing to intervene for the public good have been linked with lower homicide rates; conversely, less closely knit neighborhoods and more social disorder have been related to anxiety and depression.
Many—but not all—studies have found that neighborhood features are associated with health even after considering residents’ individual-level characteristics. Surprisingly, some researchers—albeit not many— have found poorer health among disadvantaged individuals living in relatively advantaged neighborhoods, possibly because of adverse psychological effects of feeling worse off than one’s neighbors and/or stronger social ties or reduced exposure to discrimination associated with a greater geographic concentration of one’s own group.
How can working conditions shape health?
The physical aspects of work—the traditional domain of occupational health and safety—represent an obvious pathway through which work influences health. For example, jobs requiring repetitive movements and/or high physical workload put workers at higher risk for musculoskeletal injuries and disorders, whereas physically inactive workers in sedentary jobs are at increased risk of obesity and chronic diseases such as diabetes and heart disease; physical conditions in the workplace such as inadequate ventilation, high noise levels, and hazardous chemical exposures can also harm health.
Psychosocial aspects of work represent another pathway to health. For example, working overtime has been associated with injury, illness, and mortality. Workers in jobs characterized by high demands coupled with low control or by perceived imbalance of efforts and rewards are at higher risk of poor health; control at work may be a major contributor to socioeconomic differences in health among employed persons.
Social support at work has also been linked with health; environments facilitating mutual support among coworkers may buffer against physical and mental health stressors.
Work-related opportunities and resources can also influence health. Employment-related earnings represent most Americans’ primary economic resource, shaping health-related decisions made for themselves and their families; work-related benefits—including medical insurance, paid leave, schedule flexibility, work- place wellness programs, child- and elder-care resources and retirement benefits—could also be important. Well-paying jobs are more likely to provide benefits, greater financial security, and ability to afford healthier living conditions
In contrast, the working poor—estimated at 7.4 million U.S. workers in 2006 —generally do not earn enough to cover basic necessities and are less likely to have health-related benefits. Different pathways linking work and health may interact to exacerbate social disparities in health: Socially disadvantaged groups. are more likely to have health-harming physical and psychosocial working conditions, along with disadvantaged living conditions associated with lower pay
How may education levels impact health?
SEE GRAPH ON PATHWAYS
It is widely recognized that education can lead to improved health by increasing health knowledge and healthy behaviours. This may be explained in part by literacy, allowing more-educated individuals to make better-informed, health-related decisions—including about receipt and management of medical care—for themselves and their families
Greater educational attainment has been associated with health-promoting behaviours and earlier adoption of health-related recommendations
Education also plays an important role in health by shaping employment opportunities, which are major determinants of economic re- sources. More-educated individuals experience lower rates of unemployment, which is strongly associated with worse health and higher mortality; they are more likely to have jobs with healthier physical and psychosocial working conditions, better health-related benefits, and higher compensation (which determines affordability of health-promoting living conditions)
Education may also affect health by influencing social and psychological factors. More education has been associated with greater perceived personal control, which has frequently been linked with better health and health-related behaviors. Greater educational attainment is generally associated with higher relative social standing; subjective social status (an individual’s perception of his or her ranking in a social hierarchy) may predict health even after controlling for more objective indicators of social status. More education also has been linked with increased social support, which is associated with better physical and mental health; social support may buffer the health-damaging effects of stress, influence health-related behaviors, and if one’s social networks are socially advantaged, enhance access to employment, housing, and other opportunities and resources that can influence health.
The role of educational quality—e.g., the employment opportunities, prestige, social networks, and other advantages accompanying a degree from an elite institution—is rarely considered in health studies. Educational attainment thus can underestimate health-related differences related to education
What are pathways through which income and wealth can impact health?
Economic resources reflect access to material goods and services, including income (monetary earnings during a specified time period) and wealth (ac- cumulated material assets, such as the value of one’s home, household possessions, vehicles and other property, bank accounts, and investments). Theoretically, wealth may better reflect economic resources overall, but it is more difficult to measure than income and hence less frequently measured in health studies. Among studies that have included both, many (but not all) have found links between wealth and health after considering income. Racial/ethnic differences in income markedly underestimate differences in wealth
Reverse causation (income loss due to poor health) occurs but does not fully account for the observed associations of income/wealth and health. Many longitudinal studies show that economic resources predict health or its proximate determinants, even after adjustment for education [although education is a stronger predictor for other outcomes and both are likely to matter]. Health effects of increasing income have been observed in randomized and natural experiments
Several researchers have observed health effects of income/wealth even after adjusting for many other relevant factors. Particularly when other socioeconomic factors are inadequately measured, however, observed associations between income/wealth and health may reflect effects of other socioeconomically linked factors such as educational attainment and quality, childhood socioeconomic circum- stances, neighborhood characteristics, physical and psychosocial working conditions, and subjective social status. The health effects of low economic resources may be ameliorated by access to other resources and opportunities; for example, some relatively low-income countries/states (e.g., Cuba, Costa Rica, and Kerala, India) have favorable health indicators that may be explained by long-standing societal investments in education, social safety nets, and/or prevention-oriented medical care .
How can income inequality impact health?
Income inequality (measured at an aggregate level) has often been linked with health, although a causal link is debated. Income inequality could affect health by eroding social cohesion. The link could also be explained by other factors strongly associated with both income inequality and health, such as lack of social solidarity, which could be both a cause and an effect of income inequality.
How can race and racism impact health?
In the United States and many other societies, race or ethnic group is another important social factor that influences health, primarily because of racism. Racism refers not only to overt, intentionally discriminatory actions and attitudes, but also to deep-seated societal structures that—even without intent to discriminate—systematically constrain some individuals’ opportunities and resources on the basis of their race or ethnic group.
Racial residential segregation is a key mechanism through which racism produces and perpetuates social disadvantage. Blacks and Latinos are more likely to reside in disadvantaged neighborhoods with inadequately resourced schools and hence to have lower educational attainment and quality with resultant health effects through pathways discussed above.
Racism may also affect health more directly through pathways involving stress; chronic stress related to experiences of racial/ethnic bias, including relatively subtle experiences arising even without consciously prejudicial intent, may contribute to racial/ethnic disparities in health, regardless of one’s neighborhood, income, or education. More education or income may paradoxically expose blacks or Latinos to more discrimination because of more contact with (non-Latino) whites.
Race-health links could also be shaped by perceptions of how one’s race—and its associations with social influence, prestige, and acceptance—affects one’s relative place in social hierarchies. Associations between discrimination and health similar to those observed in the United States are being found in other countries
How can stress impact health?
Coping with daily challenges can be particularly stressful when one’s financial and social resources are limited. Recent evidence implicates chronic stress in the causal pathways linking multiple upstream social determinants with health, through neuroendocrine, inflammatory, immune, and/or vascular mechanisms
Stressful experiences—such as those associated with social disadvantage, including economic hardship and racial discrimination—may trigger the release of cortisol, cytokines, and other substances that can damage immune defenses, vital organs, and physiologic systems . This mechanism can lead to more rapid onset or progression of chronic illnesses, including cardiovascular disease, and the bodily wear and tear associated with chronic stress may accelerate aging. The accumulated strain from trying, with inadequate resources, to cope with daily challenges may, over time, lead to more physiological damage than would a single dramatically stressful event. A recent collection of papers summarizes current knowledge of pathways and biological mechanisms likely to be involved in the health effects of stress and other psychosocial factors— including perceived control, subjective social status, and social support
How important are early childhood experiences?
Among the strongest bodies of SDOH evidence is work considering adverse health effects of early childhood experiences associated with family social disadvantage. Many studies have shown that early experiences affect children’s cognitive, behavioral, and physical development which predicts health; developmental differences have been associated with socioeconomically linked differences in children’s home environments, including differences in stimulation from parents/caregivers
Biological changes due to adverse socioeconomic conditions in in- fancy and toddler years appear to become “embedded” in children’s bodies, determining their developmental capacity
Several longitudinal studies following children from early childhood through young adulthood have linked childhood developmental outcomes with subsequent educational attainment, which is strongly associated with adult health
Substantial evidence indicates that pathways initiated by childhood adversity can be interrupted. Studies show that high-quality early childhood development interventions— including center-based programs to nurture and stimulate children and to support and educate parents—greatly ameliorate the effects of social disadvantage on children’s cognitive, emotional/behavioral, and physical development; the first five years of life appear to be most crucial, although opportunities for intervention continue throughout childhood and adolescence .
