Social Determination of Health
“Minnesota ranks, on average, among the healthiest states in the nation. But the averages do not tell the whole story. Too many people in Minnesota are not as healthy as they could and should be, and the health disparities that exist are significant, persistent and cannot be explained by bio-genetic factors. Minnesota has these disparities in health outcomes because the opportunity to be healthy is not equally available everywhere or for everyone in the state.
“Health is a state of complete physical, social, and mental well-being and not merely the absence of disease or infirmity. Health is created in the community through social, economic and environmental factors as well as individual behaviors and biology. When groups face serious social, economic and environmental disadvantages, such as structural racism and a widespread lack of economic and educational opportunities, health inequities are the result.”
Photo 1: Learners in the Global-Local Course cooking together over open fires at the Hmong Agape Farm of Xong Mouacheupao, where students make connections between culture and health. Photo courtesy of Jnanendra V.
Factors which influence health can be understood schematically through four “rings” of influence. Biological factors are those inherent to an individual person, found in DNA. Behavioral factors are those related to the actions that an individual takes throughout their life—some common behavioral factors might be related to exercise, healthy eating, smoking, going to the dentist, etc.
Societal factors are those that shape the space in which you live, work, school, and play—examples might include size of a family, safety in your neighborhood, the quality of housing or schooling, access to healthy food, or the environmental conditions of one’s lived environment. Societal factors are also often referred to as the social determinants of health.
Finally structural factors are those at the highest level which affect the societal factors. For example, when considering a societal factor such as access to food, one then asks what are the factors that affect access to food. These factors are closely connected to power and are social forces such as racism, patriarchy, colonialism, and unfair economic systems that influence things like socioeconomic status and opportunity through social policy, government action, and our lived environments.
| We advocate thinking about these processes as the social “determination” of health rather than “determinants” of health to acknowledge that these are dynamic forces that come from somewhere and don’t just exist in a static, natural fashion. |
The above diagram comes from a publication by Myers and Naledi (2007) Links to an external site. on a project related to burden of disease reduction. The publication shares an example of using the “rings” model:
“The term 'upstream causes' refers to those socio-structural factors that are considered to be the 'root causes' of illness, while 'downstream causes' typically refer to the 'final,' proximal, or direct cause in a causal pathway. So, for example, poverty (upstream) may lead to food insecurity (upstream) which leads to poor nutrition (downstream) which can result in B12 deficiency (downstream), which causes mental illness” (page 10).
How could this framework be used to understand other biological conditions?
Think about a disease or condition such as malaria, hypertension, lung cancer, etc. How could we understand these conditions within the ring diagram? What are the causes of these conditions, and which ring do they fit within?
Resources
Healthy People 2020 approach to Social Determinants of Health Links to an external site. – website. US Office of Disease Prevention and Health Promotion
This framework for social determinants of health looks at varying societal and structural factors that can influence health outcomes:
| Economic stability | Education | Social and community context | Health and Health Care | Neighborhood and Built Environment |
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Fast Facts on Health Inequities Links to an external site. – video. World Health Organization
This video fact file looks at what health inequities are, provides examples and shows their cost to society. In all countries – whether low-, middle- or high-income – there are wide disparities in the health status of different social groups. There is ample evidence that addressing equity in societal factors is critical to improving health equity and influencing population health in a positive way.
Structural Racism and Supporting Black Lives — The Role of Health Professionals Links to an external site.– article. Hardeman, 2016.
“The term “racism” is rarely used in the medical literature. Most physicians are not explicitly racist and are committed to treating all patients equally. However, they operate in an inherently racist system.
“Structural racism, the systems-level factors related to, yet distinct from, interpersonal racism, leads to increased rates of premature death and reduced levels of overall health and well-being. Like other epidemics, structural racism is causing widespread suffering, not only for black people and other communities of color but for our society as a whole. It is a threat to the physical, emotional, and social well-being of every person in a society that allocates privilege on the basis of race. We believe that as clinicians and researchers, we wield power, privilege, and responsibility for dismantling structural racism — and we have a few recommendations for clinicians and researchers who wish to do so.”
Additional Articles:
Four Social Theories for Global Health Links to an external site. – article. Arthur Kleinman, 2010
Social Conditions as Fundamental Causes of Disease Links to an external site. – article. Bruce G. Link and Jo Phelan, 1995
Inaction is Not an Option: Using Antiracism Approaches to Address Health Inequities and Racism and Respond to Current Challenges Affecting Youth Links to an external site. – article. Maria Veronica Svetaz et al., 2020