In 2007, the World Health Organization released a seminal paper entitled, “A Conceptual Framework for Action on the Social Determinants of Health.” The original 79 page document can be viewed at this link. My own synopsis of the paper follows.
The previous paradigm of improving health was a strictly biomedical health model. Stakeholders and medical leaders erroneously believed that improvements in medical care alone would generate major gains in population. This paradigm assumed, for example, that scientific improvements in surgeries or medicine would make all of a population healthier. However, this strictly biomedical health paradigm has been debunked.
Instead, the World Health Organization (WHO) presented A Conceptual Framework for Action on the Social Determinants of Health. As presented by the framework, various social, economic, and political mechanisms give rise to individuals’ socioeconomic positions. In other words, populations of people are divided by income, education, gender, and ethnicity. These hierarchical socioeconomic positions in turn directly affect people’s specific determinants of health status (also known as the intermediary determinants of health). Social determinants of health can be defined as the structural social stratification mechanisms, institutions, and processes – which are in turn embedded in socioeconomic and political context.
An individual can be more exposed and vulnerable to health-compromising conditions as a direct result of his or her socioeconomic position. For example, a migrant farm worker from Mexico can potentially be more exposed to the harmful effects of pesticides. Or perhaps a Vietnamese American woman who provides manicures and pedicures is more exposed to the hazardous chemicals found in glues, nail polishes, and nail polish removers.
The guiding principle of the WHO Social Determinants of Health framework is health equity. The term health equity can be defined as the absence of unfair and avoidable differences in health among groups of people. The first element of the WHO Social Determinants of Health framework is the socioeconomic political context; this refers to a spectrum of societal factors that are immeasurable at the individual level. These are the broader structural, cultural, and functional aspects of a social system. They have powerful influences on one’s hierarchical position in society and, as a result of this position, one’s health.
The second element of the WHO Social Determinants of Health framework are the structural determinants and the resulting socioeconomic positions. Socioeconomic positions can be measured at three levels: the individual level, the household level, and the neighborhood level. Structural determinants generate or reinforce social hierarchies in the society. They can also define individual socio-economic position. These include elements such as income, education, occupation, social class, gender, and ethnicity.
Finally, the third element of the framework recognizes that these structural determinants operate through intermediary social factors – also known as the social determinants of health. The WHO purposefully chose the vocabulary of “structural determinants” and “intermediary determinants,” because they wish to underscore the causal effects of the structural factors. In other words, if the model only focused on the intermediary determinants, then it would fail to consider the root causes. These root causes are the structural determinants. According to WHO, intermediary determinants can be material, psychosocial, or behavioral and biological. Examples of these material determinants are housing, neighborhood, work environment, as well as money to purchase food and warm clothes. Examples of the psychosocial determinants can include stressful living circumstances or social isolation. Examples of behavioral and biological factors include nutrition, physical activity, alcohol, smoking, and genetics.
The WHO Social Determinants of Health framework makes it a point to explicitly state that the health care system itself can be considered a social determinant of health. Not everyone has equitable access to healthcare. Moreover, the WHO Social Determinants of Health framework also incorporates a feedback loop. The model recognizes that illness can feedback on, or directly affect, an individual’s social position. For example, if a person becomes very ill, he may lose his job, and as a result lose health insurance. Hence, this directly feedbacks and affects how this person can cope and treat his illness. Another type of feedback involves how pandemics can feedback and change the influence of social, economic, and political institutions.
According to the WHO Social Determinants of Health framework, there are three key strategic directions to ensure that policy to adequately addresses Social Determinants of Health. These helpful strategies suggests that we (1) address the context, (2) encourage intersectional action, and (3) enable social participation and empowerment. In conclusion, positive changes can be strategically be made to address social determinants of health – including the participation and empowerment of community members.
