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Case Study 1
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5 I F P E P S F $ P P Q F S·
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Case Study 2
?Countries such as Poland, Hungary, Bulgaria, and
Russia experienced steady improvements in life expectancy
after World War II.
?These increases ceased and life expectancies began to
decline as the economies of these countries have faltered.
?In Russia life expectancy has fallen from 65 years in 1987
to 59 years in 1993.
The experience of Eastern Europe
Case Study 3
Economic growth and prosperity
?Japan best illustrates the relationship between
narrow income spreads and improved overall
health status. Between 1965 and 1990 it leaped
ahead of all other industrialized countries despite
increased dietary fat and increased smoking rates.
?Life expectancy was 63.6 years for males and
67.8 years for females in 1955.
?By 1991 it had increased to 76.1 for males and
82.1 years for females.
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HEALTH DETERMINANTS. Frenk (1991)
Health is a crossroad, where social and biological factors
come together.
S
O
C
I
A
L
O
R
G
N
I
Z
A
T
I
O
N
P O P U L A T I O N
Structure &
Function of
Body
Culture
&
Ideologi
e
Sciencie &
Technologi
e
Political
Institutions
Economic
Structure
Level of
Wealth
Ocupational
Structure
Social
Stratificat.
R
e
d
i
s
t
r
i
b
u
t
i
o
n
M
e
c.
HEALTH CARE
SYSTEM
Family Planning
E N V I R O N M E N T
W
o
r
k
i
n
g
C
o
n.
O
c
c
u
p
a
t
i
o
n
R
i
k
s
Living
Conditions
---------
Publicity
Education
Social
Security
Market
Comida
H
o
u
s
Individual
Susceptibility
HEALTH
STATUS
DISEASE
AGENTS
(Biolog,
Chemical
Physical)
Pollution
(Environmental
Risks)
LIFESTYLES
F
a
m
i
l
y
S
t
r
u
c
t
Occupational Health
Serv
Environm. Health
Serv
Diagnosis
&
Treatment
Genetic counseling
Prevention
Health
Promotion
B
I
O
L
O
G
I
C
A
L
R
I
S
k
S
Social Determinants of Health
What Matters?
Why We Should Be Concerned About
the Social Determinants of Health
?
Why should Be Concerned about the
Social Determinants of Health?
? Social determinants of health have a direct
impact on health
? Social determinants are the best predictors
of population and individual health status
? Social determinants of health structure
health behaviours
? Social determinants of health interact with
each other to produce health
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Relative Risk of Traumatic Death
and Suicide
0
1
2
3
4
Not married No close relatives Not belong to church
Relative Risk
[Kawachi et al. 1996]
Domains of Social Relations
Marriage
Children
Close friends
Relatives
Community
Groups
Church
Groups
Social Networks Index
? Marital status
? Presence/contact with children
? Presence/contact with close
friends/relatives
? Voluntary group membership
? Church membership
Social Networks and Cardiovascular
Disease Incidence in Men
' V M M Z J O U F H S B U F E 4 P D J B M M Z
J T P M B U F E
Adjusted RR
P trend 0.006
Level of social integration
Kawachi et al, 1996
Types of Social Support
? Emotional support – expressions of
empathy, love, trust, and caring
? Instrumental support – tangible aid
and service
? Informational support – advice,
suggestions, and information
? Appraisal support – information that
is useful for self-evaluation
Forms of Capital
? Financial
?Human
?Social
Social Capital
' F B U V S F T P G T P D J B M
S F M B U J P O T I J Q T –
T V D I B T M F W F M T P G
J O U F S Q F S T P O B M U S V T U
B O E
O P S N T P G S F D J Q S P D J U Z B O E
N V U V B M B J E
– X I J D I G B D J M J U B U F
D P M M F D U J W F B D U J P O
Measures of Social Capital
? Structural dimensions:
- Civic engagement
- Community voluntarism
? Cognitive dimensions:
- Social trust
- Collective efficacy
Spheres and Settings of Social Capital
Formal
Organizations
Informal
Connections
Norms of Trust,
Reciprocity
Settings –
Family/Kin
Communities
Schools
Firms
Religion
Politics
Benefits of Social Capital
? Economic Development
– Reduce transaction costs
– Develop norms of cooperation, mutual aid
? Functioning of Democracy
– Encourage politically active citizenry
? Enhanced Community Quality of Life
– Crime Prevention
– Protection of individuals from becoming
socially isolated
Social Capital and Health
Neighborhood mechanisms
? Provides social connection
? Norms of healthy behavior
? Informal social control over deviant
behavior
? Lobbying for amenities and services
Downsides of Social Capital
? Exclusion of “out” groups
? Excess claims made on “in” groups (role
strain)
? Restrictions on individual freedom
? Negative externalities
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Income Influences Health
? People in the top income bracket are
healthier than middle income earners.
? Middle income earners are, in turn,
healthier than people with low incomes.
? This means that the poorer people are,
the less healthy they are likely to be.
Wilkinson, Richard, ed. Class and Health (London: Tavistock, 1986), as cited in
Nurturing Health: A Framework on the Determinants of Health (Toronto: Government
of Ontario, 1991).
Death Rates, Men in Richest and Poorest
Neighborhoods, Urban Canada, 1991
The relationship between health and income is not just a matter of being rich or
very poor. There is also a gradient in health status. A gap between the rich and
the poor exists for most types of illnesses and for almost all causes of death.
$ J S D V M B U P S Z % J T F B T F - V O H D B O D F S * O K V S J F T 4 V J D J E F
1 P P S F T U
3 J D I F T U
Population Health Promotion Model: A Resource Binder, Saskatchewan Health, 1997
People’s perception of how healthy
they are
Percentage of Canadians Reporting Excellent or Very
Good Health, by Income
Low Income Middle
Income
Next to
Highest
Highest
Pe
r
c
e
n
t
Strategies for Population Health: Investing in the Health of Canadians. 1994.
p.13. (From: Statistics Canada General Social Survey, 1991.)
Why Higher Income = Better Health?
With higher income, one has the ability to:
? purchase adequate housing, food and other basic
needs.
? make more choices and feel more in control over
decisions in life.
This feeling of being in control is basic to good health.
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How does Social Status*
affect Health ?
? It affects health by determining the
degree of control people have over
life circumstances.
? It affects their capacity to act and
make choices for themselves.
? Higher social position and income
somehow act as a shield against
disease.
s?a?
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s
p
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deat
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a
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Mortality rates (per 1000 person years) of lower & higher
educated groups, women aged 60-69
Source: unpublished data based on paper by M. Huisman, A.E. Kunst and J.P. Mackenbach for the
EU Working Group on Socioeconomic Inequalities in Health, to be published in JECH
high
low
0
5
10
15
20
25
30
35
au
st
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a
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e
Mortality rates (per 1000 person years) of lower & higher
educated groups, men aged 60-69
Source: unpublished data based on paper by M. Huisman, A.E. Kunst and J.P. Mackenbach for the
EU Working Group on Socioeconomic Inequalities in Health, to be published in JECH
high
low
ü<?yTHq
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??
> ?yT
?á?f￥ |
ì?μ÷r B￥
&8
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From: Social Determinants of Health: The Solid Facts. WHO 2003
= a
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Cigarette smoking among women aged 16 and over by
socioeconomic group 1958-2000, Britain
0
10
20
30
40
50
60
1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
year
%
smokers
professional
unskilled manual
all women
Sources: Wald and Nicolaides-Bouman, 1993; Bridgewood et al, 2000
?ü6y
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Healthy Child Development
?The effect of prenatal and early childhood experiences
on subsequent coping skills, competence and future
well-being is very powerful.
?Children born in low income families are
more likely to have low birth weights, to eat
less nutritious food
and to have difficulties
with health and social
problems throughout
their lives.
Healthy Child Development Means:
? good physical health, including good nutrition
? age-appropriate physical, mental and social development
? the ability to make effective social connections with others
? competence in culturally valuable skills and the opportunity to
use them
? good coping skills, including handling stress
? control over one’s life choices
? a sense of being loved and belonging
? healthy self-esteem
The Progress of Canada’s Children 1996. Canadian Council on Social Development.
Studies of Early Intervention Programs
Head Start Programs - U.S.A.
Preschool Enrichment for High Risk Children
Intervention Group vs. Control Group
? Employment Twice as good
? High school completion 1/3 higher
? Crime 40% less
? Teenage pregnancies 40% less
? Drug use substantially less
Child Development and Resiliency
? Resiliency is the ability to
adapt and bounce back
in spite of severe stress
or adversity.
Resiliency Research Shows:
? All people have resiliency
? Local champions (e.g. a teacher, a big sister)
can and do transform lives
?It’s how we do what we do that counts
? Your belief in your own capacity starts the
change process
Adapted from: Benard B. (March 3, 1998). Videoconference Presentation
Fostering Resiliency in Families. Schools and Communities. Edmonton, Alberta.
SENSE OF
PURPOSE & FUTURE
AUTONOMY
PROBLEM
SOLVING
SKILLS
SOCIAL
COMPETENCE
RESILIENT
CHILD
Benard B. (March 3, 1998).
Videoconference Presentation Fostering
Resiliency in Families. Schools and
Communities. Edmonton, Alberta.
Critical
Factors
? Leading neuroscientists have shown that the quality
of stimulation and nurturing received by a child
between birth and three years of age has a major
effect on his/her knowledge capacity, competence,
and coping skills in later life.
? The evidence on youth violence, crime and antisocial
behavior clearly indicates that prevention is much
more economical and effective that later “acute care”
intervention.
[Growing up in Canada: National Longitudinal Survey of Children and Youth, Statistics Canada,
Human Resources Development Canada 1996. (Taylor, Allan R.) p.140]
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?1 Anderson LM, et al. Am J Pre Med 2003;24(3S):32-41
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Unemployment is a risk factor for
cardiovascular disease (RR= 1.54).
Multiple Pathways of Causality
? Mediation: the relationship between a factor
and an outcome can be explained by an
intermediate factor.
? What might explain this relationship?
Cardiovascular
Disease
Unemployment
Multiple Pathways of Causality:
Mediation
Cardiovascular
Disease
Unemployment Stress
*
Multiple Pathways of Causality:
Mediation
Unemployment Stress
Cardiovascular
Reactivity
Cardiovascular
Disease
Multiple Pathways of Causality:
Mediation
Loss of
Income &
Health Care
Cardiovascular
Disease
Unemployment
Multiple Pathways of Causality:
Mediation
*
Loss of
Income &
Health Care
Unemployment
Unable to
pay for blood
pressure
meds
Cardiovascular
Disease
Multiple Pathways of Causality
? Moderation: The presence of one factor
modifies the relationship between another
factor and an outcome.
? What might change this relationship?
Cardiovascular
Disease
Unemployment
Multiple Pathways of Causality:
Moderation
X
Cardiovascular
Disease
Social
Support
+
*
Unemployment
Multiple Pathways of Causality:
Moderation
Cardiovascular
Disease
+
Unemployment
Type A
Personality
*
Multiple Pathways of Causality:
Moderation
Cardiovascular
Disease
+
Unemployment
Type A
Personality
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KG Sherman January 2002
Former Director General
Swedish Social Insurance Board
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Traditional Ten Tips For Better Health
1. Don't smoke. If you can, stop. If you can't, cut down.
2. Follow a balanced diet with plenty of fruit and vegetables.
3. Keep physically active.
4. Manage stress by, for example, talking things through and making
time to relax.
5. If you drink alcohol, do so in moderation.
6. Cover up in the sun, and protect children from sunburn.
7. Practise safer sex.
8. Take up cancer screening opportunities.
9. Be safe on the roads: follow the Highway Code.
10. Learn the First Aid ABC : airways, breathing, circulation.
Source: Donaldson, 1999
An Alternative Ten Tips for Better Health
1. Don't be poor. If you can, stop. If you can't, try not to be poor for long.
2. Don't have poor parents.
3. Own a car.
4. Don't work in a stressful, low paid manual job.
5. Don't live in damp, low quality housing.
6. Be able to afford to go on a foreign holiday and sunbathe.
7. Practice not losing your job and don't become unemployed.
8. Take up all benefits you are entitled to, if you are unemployed, retired or sick or
disabled.
9. Don't live next to a busy major road or near a polluting factory.
10. Learn how to fill in the complex housing benefit/ asylum application forms before
you become homeless and destitute.
Source: Gordon, 1998
Society and Health:
Where are We Now?
Social Determinants of Health
Individual Health and Illness
“Individual Lifestyle Choices”
Raphael, 2003
Iceberg(s) Model
Observe and Measure
Seat belts
Tobacco
Alcohol
Context and Determinants
Dovell, RA
Population Health Conference, 2002
Iceberg(s) Model
Observe and Measure
Seat belts
Tobacco
Alcohol
Dovell, RA
Population Health Conference, 2002
Patterns of
determinants
Distinguishing between the
determinants of health and
health inequalities…
The main determinants of health
The main determinants of health inequalities
inequalities in..
inequalities in..
inequalities
in..
Conclusions
Tackling health inequalities by
tackling their social determinants
