W3 - Intro To SDH (1) Disbowelment

Week 3 – Introduction to
socioeconomic determinants of
health
Associate Professor Linda Selvey
School of Public Health
The University of Queensland
Learning objectives
• Describe a framework for understanding socioeconomic determinants
of health
• Understand how political decisions influence health inequities
• Appraise potential management of chronic conditions according to
individuals’ socioeconomic status (Tutorial)
Question
What does the ‘social determinants of health’ mean to you?
Word cloud
apps.elearning.uq.edu.au/wordcloud/56998
Definition – socioeconomic determinants of
health
WHO definition
“The conditions in which people are born, grow, live, work and age.
These circumstances are shaped by the distribution of money, power
and resources at global, national and local levels. The social
determinants of health are mostly responsible for health inequities –
the unfair and avoidable differences in health status seen within and
between countries”
https://www.who.int/social_determinants/sdh_definition/en/
Mortality and life expectancy
AIHW, 2016. Australia’s Health 2016. 4.1 - Social determinants of health, pp 7 & 8
Tobacco
AIHW 2017 – Risk factors to health, tobacco smoking

https://www.aihw.gov.au/reports/biomedical-risk-factors/risk-factors-to-
health/contents/tobacco-smoking
PNAS 2019, 116(43) 21864-21873, www.pnas.org/cgi/doi/10.1073/pnas.1910242116
UK mortality inequality quantified
Figure 1, pg e35
Findings
• UK mortality data from 2003-2018
• Two indicators – Mortality attributable to socioeconomic inequality and years of life
lost due to inequality
• 35.6% of premature deaths (before 75 years) are attributable to inequality
• Biggest contributors – ischaemic heart disease, COPD, respiratory cancers
• Highest proportion of contribution of inequality to death is for deaths due
to a range of causes including TB, HIV and obesity
• Proportion of deaths due to inequality increased over the study period
• Peak inequality in early years and aged 40-49
• Average of 14.4 months of life before 75 due to inequality
What are some potential reasons for these
differences in life expectancy, health behaviours?
Individual, society and environment levels?
Padlet: https://padletuq.padlet.org/l_selvey/5ppzrx850u48
Three main theoretical frameworks
1. Psychosocial
• Inequalities cause psychological stress that undermines health
2. Social production of disease/political economy of health
• Economic and political determinants – structural causes (lack of resources for
individuals and under-investment in community infrastructure – education,
food, services, etc)
3. Ecosocial – multi-level frameworks
• Incorporates biological, ecological and social organisation
Framework
WHO Commission on Social Determinants of Health 2010: A conceptual framework for action on the social determinants of health, pg 6
https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf
Socioeconomic and political context
• Global, regional and national levels
Governance – democracy, corruption, decision
making
Macroeconomic policies – eg taxation, trade &
protectionism
Social Policies – how is labour organised, housing
policies, land distribution/ownership, incarceration
rates
Public Policies – distribution of services
Culture and societal values – underpin the above
Socioeconomic position
Social class CONTROL!
• Status, access, influence and control
• Economic position
Professor Sir Michael Marmot – Status Syndrome
• Whitehall studies (British civil servants) – the higher the
rank, the lower the mortality, independent of health
risk factors
• Promotion led to better health (not vice versa)
• Oscar winners live 5 years longer than other actors!
• Not just about income
• Relative position is important
• Steepness of the gradient in health is not uniform
M Marmot, 2004, Significance; December:150-155
Socioeconomic position
Gender
• Social and economic impacts
Ethnicity
• Social and economic impacts of racism
Social Class
• Is social class just about economic status?
• How might status impact on health?
• How might influence and control impact on health?
• How do race, gender and social class intersect?
• How might unions affect health?
https://padletuq.padlet.org/l_selvey/ytabwjwiedsk
Social cohesion and social capital
• Social support and participation in society is protective for health
• Can improve material impacts of inequalities
• Increases agency and reduces stress
Intermediary determinants
Putting it all together
PADLET:
What is the role of the
health system in
addressing health
inequity?
Health equity is key
• Addressing some intermediary determinants (particularly
behavioural) without structural determinants may not address
inequity and may increase it
• Eg Smoking, many health promotion campaigns, UK study (CV disease)
• Need to address both structural and intermediary determinants to
address inequity.
Increasing inequalities in childhood obesity
(UK)
M Marmot, 2017 The health gap, Scand J Public Health; 45:686-693, pg 689
Addressing structural determinants
The role of doctors
Doctors for health equity (World Medical Association)
http://www.instituteofhealthequity.org/resources-reports/doctors-for-health-equity-world-
medical-association-report
Six areas for action:
• Workforce education and training
• Monitoring and evaluation
• Working with individuals and communities, seeing the patients in the
broader perspective
• The health sector as employers
• Working in partnerships
• Advocacy
Health inequality is a problem for us all
Activity
View the following video: ‘Confronting the Health Gap’, Sir Michael
Marmot
https://www.youtube.com/watch?v=4uDFO-46Jjs
In this video, Sir Marmot discusses health inequalities in the USA and
the UK, with comparisons to many European countries. How do you
think Australia would compare? What data would you look for?
Readings
Required
• Anne Anderman, Taking action on the social determinants of health in clinical practice: a
framework for health professionals. CMAJ 2016; 188:17-18, DOI:10.1503/cmaj.160177
Recommended
• Michael Marmot, The health gap: Doctors and the social determinants of health. Scand J
Public Health, 2017; 45: 686-694
• World Medical Association Doctors for Health Equity report
http://www.instituteofhealthequity.org/resources-reports/doctors-for-health-equity-
world-medical-association-report
• CLEAR collaboration: The CLEAR Toolkit. Training frontline health workers to ask about
and act upon the social causes underlying poor health.
https://www.mcgill.ca/clear/download

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Week 3 – Introduction to

AIHW 2017 – Risk factors to health, tobacco smoking

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