Social determinants of health (SDOH) are the factors that fall outside of biological or genetic, that impact upon health (Bambra et al., 2010). They are the also the driving force of health inequalities (Lynch, 2017). SDOH account for one third of premature deaths in the United Kingdom (Lacobucci, 2019). Social determinants of health include: position within the social hierarchy, income, level of education, living and working conditions, access to healthcare, social isolation, adverse childhood experiences, race and gender. Health inequalities happen when subgroups of the population have a less equal chance of being healthy due to the SDOH. Health is impacted by where someone is born, where they grow up, where they live and the conditions in which they work and grow old (Marmot, 2015). Health inequalities are avoidable. It is possible to reduce health gaps by addressing the underlying, wider determinants that are causing ill health rather than targeting individual symptoms. The drivers for this change are social policy that filters down through healthcare structures.
To demonstrate the SDOH, illustrated, is the example of a 15 year old girl. Kerri was raised in care after losing her mother and experiencing abuse and neglect from her father. She became pregnant at 15, never finished school and had 3 children by 18. At home, the father was an alcoholic and violent. He also has experienced physical abuse at the hands of his father. In danger, the family moved to a new town, cutting contact with family. Kerri made attempts to gain employment, but each time was faced with a conundrum: it was more financially viable to remain unemployed and receive benefits than it was to work and pay for childcare. The family often lived in poverty, in unsafe areas which prompted several house moves. When Kerri did work, it was in a low paid and low skilled environment where bullying was experienced. Kerri’s children moved out of the family home at a young age and did not pursue ongoing education. These issues demonstrate the social determinants of health.
This live scenario evidences the complex interplay between the social determinants of health. All combined, these factors are mutually reinforcing and have a far reaching, negative impact upon health (Lovell & Bibby, 2018). The mother and children were in a low socioeconomic position. Health and life expectancy can be seen on a gradient from the lowest to the highest within the social hierarchy (Marmot, 2017a). The lowest on the social gradient have poorer health and health improves for each increased stage of the gradient. They were also victims of adverse childhood experiences (ACEs). Children who have experienced trauma such as domestic violence, alcoholism, divorce or death, are more likely to experience low mental wellbeing and ACEs correlate with heart disease and cancer. More respiratory and gastrointestinal disturbances are also seen in the adulthood of children who have had ACEs (Bellis et al., 2014). They are also more likely to adopt health offensive behaviours and are less likely to engage in health improvement behaviours (Bartley, 2017).
Lifestyle factors such as smoking, drinking excessive alcohol, poor diet and lack of physical activity are all causes of non-communicable diseases such as heart disease, obesity, type 2 diabetes and some cancers (Arena et al., 2016). Poor lifestyle factors are more prevalent in people in low socioeconomic positions and ACEs (Bellis et al., 2014; Lakshman et al., 2011). At first glance, this suggests that health issues within these populations are behavioural and is it the individual behaviours that must be targeted (Crinson, 2009). These behaviours, however, can be a way of seeking relief for those in dire circumstances (Baum & Fisher, 2014) and may also be culturally adopted (Kriznik et al., 2018). Marmot (2015), argues however, that poor lifestyle behaviours are adopted due to the conditions that people live in as opposed to the free choices one is able to make.
Sufficient opportunity must first exist in order for people to adopt healthy behaviours. (Lovell & Bibby, 2018). For example, Kerri would be unlikely to leave the house for a daily run when it was unsafe to be outside. She would also be unlikely to exercise due to lack of social support and time (Marmot, 2015). With time being and money being an issue, the gym and healthy food may not at the top of the priority list (Lovell & Bibby, 2018). Additionally, education may not be at the top of the priority list for a family who is struggling to survive. Education, however, impacts upon life chances (Braveman et al., 2011).
Higher levels of education are associated with improved health literacy and, in turn, higher levels of positive health management. Although domestic violence occurs at all stages of the social gradient, it is more concentrated in less educated, socially deprived areas. Education level can result in female empowerment: women who are well educated are more likely to seek help earlier. (Michael Marmot, 2017b). Education is also linked with better rates of employment and higher levels of income. Greater income would enable the family to acquire housing in a safer area. Deprived areas are typically more built up so have more light and noise pollution which can impact sleep as well as fear of inherent dangers (Davies & Pearson-Stuttard, 2020). Research by (Bambra et al., 2010) showed that urban regeneration has the potential to improve health but only if the social issues within the area are also addressed.Therefore, housing quality is impacted by income (Braveman et al., 2011). With more money, people may be able to move to a safer area that has access to green space for exercise and where it is safe to do so. Education, therefore, impacts upon socioeconomic position.
Position in the social hierarchy has an independent effect on health (Bambra & Schrecker, 2014). Those who are lower in the social hierarchy in all areas, experience poorer health outcomes. The mother was unable to work. Unemployment impacts health on multiple levels. It increases psychosocial stress and risk of poverty which increases the risk of malnutrition (Marmot, 2017b). Psychosocial stress increases the risk of cardiovascular disease (Marmot et al., 2013).The stress also impacts upon children’s socio-emotional behaviour which can impact upon engagement within education settings and perpetuate more social isolation (Marmot, 2017b). Social isolation negatively impacts upon health (Haslam et al., 2018). It correlates with increased risk of heart disease and strokes (Lovell & Bibby, 2018). However, being in employment but in low skilled, unsupported, emotionally toxic work, with lack of autonomy and control also impacts upon health (Marmot & Brunner, 2005). This makes clear, the need for social interventions in order to improve overall health.
Healthcare provision is largely biomedical. For example, if someone visited the general practitioner’s office for depression, they are likely to be prescribed anti-depressants – medicine. Medicine will not solve the underlying social issues the individual is facing. This is changing. It is being recognised that people need non-medical interventions and social prescribing, whilst it has been around since the 1980’s, has more recently caught the attention of the National Health Service (NHS) and was included within the 5 year plan in 2014 (National Health Service, 2019). Social prescribing provides help to patients who are experiencing social difficulties. As those social difficulties can result in poor health, the aim is to increase social health with a view of improving overall health (South et al., 2008). Social prescribing has been driven by policy (Kilgarriff-Foster & O’Cathain, 2015).
Policy drives healthcare. Policy is a set of laws, frameworks and guidelines, set to achieve particular goals (British Ecological Society, 2017). Prior to the war, inequalities were largely accepted (Crinson, 2009). After World War II a need for social justice was highlighted and this drove the inception of the NHS in 1948, for the purpose of improving health and reducing social differences in health. Whilst general health improved and life expectancy increased (Dorling, 2013), health inequalities also continued to increase; the dominant governmental belief at the time was that it was due to individual behaviours (Crinson, 2009). However, Marmot et al. (1978) found that individual behaviours explained only a portion of the rates of mortality in the civil service workers who were studied and this lead to the commission of the black report by the Labour government (McIntosh Gray, 1982). The black report provided compelling evidence of health inequalities. This coincided Margaret Thatcher coming into power for the Conservative government and the report was subsequently ignored in favour of pushing the individual behaviour narrative (Crinson, 2009). What is demonstrated here, is that policy is unstable and healthcare provision is controlled by political agendas. Regardless of whether or not a policy is working, politicians hold the trump card.
Labour came back into power in 1997 and commissioned the Acheson report which served as an update to the black report and corroborated the original findings (Crinson, 2009). The initial evasion of this undeniable data is responsible for the public health policies that are directed at improving individual behaviour. It has been shown however, that health promotion, is unlikely to drive health improvements in low socioeconomic position populations (Baum & Fisher, 2014). Over time, changing governments also saw the cancellation of policies such as the Sure Start program (Melhuish et al., 2008) which was evidenced to improve the social problems and life chances for children in low socioeconomic groups. The National service framework for children, young people and maternity services which aimed to intervene and provide additional care to children who were exposed to domestic violence, was abolished due to an organisational change within the NHS (Department of Health, 2004).
Nonetheless, policy is responsible for substantial improvements in population health. Fiscal policy or tax on tobacco, alcohol and sugar has shown to be successful. By increasing tax by ten per cent it induced four percent of smokers, largely from low social position groups, to quit (Chaloupka & Powell, 2018; Thomson et al., 2018). However, the tobacco industry seeks to undermine this effort by promoting cheaper ways to smoke such as ‘roll your own’ so policy needs to go further to address this (Hiscock et al., 2018). Via social prescribing, smokers have access to healthier activities that may honour the relief they seek from smoking ,by obtaining additional social support (Kilgarriff-Foster & O’Cathain, 2015).
Creating policy that supports these issues is more conducive to health and a healthier society creates a more fruitful economy (Lovell & Bibby, 2018). Woolf (2019) argues that investments made in education and housing will do more for life expectancy than care provided by health services. Domestic violence is not caused by policy makers, but policy can be produced to address the cascade of social determinants that drive the health inequalities that keep generations in a vicious cycle of poor health (Bellis et al., 2014; Gill & Theriault, 2005; Department of Health, 2015). It is in the interest of policy makers to address these issues. Lovell & Bibby, (2018) argue that good health is the basic right of everyone in society. It is the moral obligation of the state to provide this. If governments, rather than pushing their own agendas would take heed of the data and provide continuity in the policies written to reduce inequalities, then it is a possibility that the health gaps and social gradient would reduce in a timelier fashion.
There are a multitude social issues that have a negative impact upon health. These issues drive inequalities but if the SDOH and health inequalities are addressed, it would benefit the economy as a whole, as well as reducing the costs to healthcare services. Ultimately, the life expectancy of Kerri and her children, according to the social gradient, will be lower. Currently, they have a higher probability of spending more time in their lives with illness, disease or disability. People are generally aware of the risks of smoking, drinking and poor diet so individualistic policies that target behaviours ignore the wider determinants of health. (Baum & Fisher, 2014). Change needs to come from the top to create a fairer society. Policy must address the underlying determinants, the deeper causes of these behaviours, alongside or even ahead of behaviour change, in order for change to be effective. Good health starts with political and organisational continuity of the policies that have proven fruitful in addressing the issues. Social determinants of health and health inequalities are likely to always exist, but if the gradient is tackled it would go a long way to reducing these issues, to the benefit of society as a whole.
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