Читать книгу New Horizons in Modeling and Simulation for Social Epidemiology and Public Health - Daniel Kim - Страница 15

In 2005, the World Health Organization (WHO) established a Commission on the Social Determinants of Health that was tasked with the job of supporting countries to address the upstream social factors that shape population health and health inequities (WHO Commission on the Social Determinants of Health 2008). The overall goal of the Commission was to draw the attention of governments and society to the social determinants of health and to create better social conditions for health, particularly amongst the most vulnerable populations. The commission delivered its final report to the WHO in 2008 (WHO Commission on the Social Determinants of Health 2008).

As defined by the WHO Commission, the social determinants of health are “the conditions in which people are born, grow, live, work, and age” (WHO Commission on the Social Determinants of Health 2008). These social determinants extend well beyond the confines of the health care system and include aspects of our neighborhood and workplace environments (e.g. the food, built, and social environments) and the social and economic policies (e.g. tax policies) that govern the regions in which we live. It is these “upstream” nonmedical social determinants that are increasingly understood as the root causes of population health inequalities, even within rich nations (Marmot and Bell 2009; Woolf and Braveman 2011). Such social determinants offer a critical lens to explain why the average life expectancy in America has lagged well behind other nations, despite the fact that the United States remains one of the richest nations in the world and spends more on a per‐capita basis on health care than all other developed nations globally (Marmot and Bell 2009). Identifying what impacts various social determinants have on population health is now the central focus of the growing public health field known as social epidemiology.

The WHO Commission on the Social Determinants of Health developed a conceptual framework of the social determinants of health (Solar and Irwin 2007; WHO Commission on the Social Determinants of Health 2008). Figure 1.2 shows an adaptation of this conceptual framework. As illustrated in this figure, the social determinants of health are composed of the material living and working conditions and social environmental conditions in which people are born, live, work, and age, along with the structural drivers of these conditions. These structural drivers include individual‐ and area‐level socioeconomic status (SES), race/ethnicity, residential segregation, gender, social capital/cohesion, and the macroeconomic and macrosocial contexts, e.g. macroeconomic and social policies including labor market regulations (Muntaner et al. 2012), political factors including governance and political rights (Chung and Muntaner 2006; Bezo et al. 2012), and cultural factors. Examples of macroeconomic determinants include the gross domestic product (GDP) per capita and income inequality—the gap between the rich and the poor within societies.

Figure 1.2 A social determinants of health conceptual framework.

Source: Adapted from Kim and Saada (2013) and Solar and Irwin (2007).

The broader macroeconomic and social context generates social stratification, that is, the sorting of people into dominant and subordinate SES, racial/ethnic, and gender groups (Figure 1.2). Through social stratification and differential exposures of individuals to levels of material factors/social resources, social determinants such as individual/area‐level SES, race/ethnicity, and social capital shape individual‐level intermediary determinants, including behavioral factors (e.g. maternal smoking), biological factors, and psychosocial factors (e.g. social support), which in turn produce differential risks of, and inequities in, health outcomes (Figure 1.2). Access to health care and the quality of health care are also determinants of these outcomes, yet health care factors are believed to play lesser roles compared to societal factors (Figure 1.2). This is supported by cross‐national evidence on health care spending and life expectancy. Moreover, even in societies with a national health system in place (e.g. Canada and the United Kingdom), socioeconomic disparities and gradients in health are salient and well established.