1. The Social Determinants of Health
Diane Ashton, MD, MPH
Vice President, Health Equity & Deputy Medical Director
March of Dimes Foundation
Presentation to the Secretary’s Advisory Committee on Infant Mortality
March 26, 2015

2. Definition
The social determinants of health are 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.
- WHO

3. Health inequities are avoidable inequalities in health between groups of people within countries and between countries. These inequities arise from inequalities within and between societies. Social and economic conditions and their effects on people’s lives determine their risk of illness and the actions taken to prevent them becoming ill or treat illness when it occurs.
- WHO

4. Many factors combine together to affect the health of individuals and communities. Whether people are healthy or not, is determined by their circumstances and environment. To a large extent, factors such as where we live, the state of our environment, genetics, our income and education level, and our relationships with friends and family all have considerable impacts on health, whereas the more commonly considered factors such as access and use of health care services often have less of an impact.
The determinants of health include:
the social and economic environment,
the physical environment, and
the person’s individual characteristics and behaviours.
The context of people’s lives determine their health, and so blaming individuals for having poor health or crediting them for good health is inappropriate. Individuals are unlikely to be able to directly control many of the determinants of health. These determinants—or things that make people healthy or not—include the above factors, and many others:

6. The Social Gradient
Life expectancy is shorter and most diseases are more common the further down the social ladder in each society
Health policy must tackle the social and economic determinants of health
Policy implications
Good health requires reducing levels of educational failure,
reducing insecurity & unemployment, and improving housing
standards

7. Stress
Stressful circumstances that make people feel worried, anxious, and unable to cope are damaging to health and may lead to premature death
Policy Implication
Government should recognize that welfare programs need to address both psychosocial & material needs. In particular, support families with young children, encourage community activity, combat social isolation, reduce material & financial insecurity, and promote coping skills in education and rehabilitation

8. Biobehavioral Model Wadhwa, P., 2005
Biobehavioral Model of Prenatal Stress, Human Fetal Developmental &Health Outcomes
Depicted here is the biobehavioral model of prenatal stress, human development and health outcomes which serves as the conceptual framework for a neurobiological model of prenatal stress (proposed by Wadhwa). This model proposes that:
Maternal psychosocial stress exerts a significant & independent negative influence on fetal development outcomes
That these effects are mediated, in part, via maternal-placental-fetal neuroendocrine mechanisms, with a central role for Corticotrophin Releasing Hormone
The effects of prenatal stress are outcome-specific, & are moderated by the nature, timing & duration of stress.
Individual differences in maternal stress appraisals exert a larger impact than exposure per se to stressful events
Prenatal stress in early gestation exerts a larger impact on outcomes related to the length of gestation and fetal growth than stress in the latter part of gestation
Experimental studies with rodent models provide convincing evidence supporting a causal role for prenatal stress to alter the baseline & stress-induced responsivity of the HPA axis and the levels and distribution of regulatory neurotransmitters – norepinephrine, dopamine, serotonin & acetylcholine. These prenatal stress induced alterations affect cognition (decreased learning), emotionality (increased anxiety) and social behavior (increased withdrawal)
Similarly, the application of prenatal stress in non-human primates has been shown to alter endocrine, immune and neurobehavioral outcomes in offspring.
Wadhwa, P., 2005

9. Early Life
A good start in life means supporting mothers and young children: the health impact of early development and education lasts a lifetime
Policy Implications
Increase the general level of education and provide equal opportunity of access to education
Provide good nutrition, health education, and health &
preventive care facilities, before first pregnancies, during
pregnancy, and throughout infancy
Ensure that parent-child relationships are supported from
birth through home visiting and the encouragement of good
parental relations with schools

10. Social Exclusion
Life is short where quality is poor. By causing hardship and resentment, poverty, social exclusion and discrimination cost lives
Policy implications
All citizens should be protected by minimum wage guarantees, minimum wages legislation and access to services
Interventions to reduce poverty & social exclusion are needed at both the individual and neighborhood levels
Legislation can help protect minorities and vulnerable groups from discrimination and social isolation
Public health policies should remove barriers to health care, social services and affordable housing
Labor market, education and family welfare policies should aim to reduce social stratification

11. Work
Stress in the workplace increases the risk of disease. People who have more control over their work have better health
Policy implications
Good management involves ensuring appropriate rewards – in terms of money, status and self-esteem - for all employees
Workplaces must be ergonomically appropriate
Workplace health protection should provide effective
infrastructure with legal controls & powers of
inspection and also include workplace health
services with staff trained in the early detection of
mental health problems & appropriate interventions

12. Unemployment
Job security increases health, well-being and job satisfaction. Higher rates of unemployment cause more illness and premature death
Policy implications
Government management of the economy to reduce the highs and lows of the business cycle can make an important contribution
to job security & the reduction on unemployment
Provide high standards of education and good retraining
schemes
Unemployment benefits set at a higher proportion of
wages are likely to have a protective effect

13. Social Support
Friendship, good social relations and strong supportive networks improve health at home, at work and in the community
Policy implications
Reducing social & economic inequalities and reducing social exclusion can lead to greater social cohesiveness and better standards of health
Improving the social environment in schools, at work and in the community will help people feel valued & supported and will contribute to their health, especially their mental health
In all areas of both personal and institutional life, practices that cast some as socially inferior or less valuable should be avoided because they are socially divisive

14. Addiction
Individuals turn to alcohol, drugs & tobacco and suffer from their use, but use is influenced by the wider social setting
Policy implications
Addressing problems of both legal and illicit drug use needs to not only support & treat people who have developed addictive patterns of use, but also to address the social patterns of deprivation in which the problem is rooted
Policies to regulate availability, use health education to
reduce the recruitment of young people and provide
effective treatment services for the addicted
Effective drug policy must be supported by the broad
framework of social and economic policy that address
the underlying social issues

15. Food
Because global market forces control the food supply, healthy food is a political issue
Policy implications
The integration of public health perspectives into the food system to provide affordable & nutritious fresh food for all, especially the most vulnerable
Support for sustainable agriculture and food production methods that conserve natural resources & the environment
A stronger food culture for health, especially through school education, to foster people’s knowledge of food & nutrition, cooking skills, growing food and the social value of preparing food and eating together
The availability of useful information about food, diet and health especially aimed at children

16. Transport
Healthy transport means less driving and more walking and cycling, backed up by better public transport
Policy implications
Roads should give precedence to cycling and walking for short trips
Public transportation should be improved for longer journeys
with regular & frequent connections for rural areas
Reduce state subsidies for road building, increasing financial
support for public transport & creating disincentives for business
use of cars
Convert road space into green spaces & increase bus and cycle lanes

17. Social Determinants of Infant Mortality
- Adapted from Solar & Irwin

18. Health in All Policies
“In keeping with the recent Adelaide Statement on Health in All Policies, at a societal level, both health and non-health policies that address the social determinants of health are needed to tackle infant mortality / birth outcome disparities. Implementing such policies while addressing key research gaps for the social determinants of infant mortality / birth outcomes may optimally reduce inequities in these vital health outcomes across and within the western industrialized world.”
Kim & Saada, 2013