Social determinants of health: a veil that hides socioeconomic position and its relation with health

The emergence of theoretical models of social determinants of health has added conceptual ambiguity to the understanding of social inequalities in health, as it is often not possible to clearly distinguish between socioeconomic position and these determinants. Whether the existence of social inequalities in health is based on differences in health or on differences in social determinants of health that are systematically associated with socioeconomic position, policymakers should be clearly informed of the importance of socioeconomic position for health. Thus, the following three basic requirements are proposed: to reach a consensus about the dimensions that reflect socioeconomic position; to agree about what are to be considered the social determinants of health and whether or not these determinants are a construct that can be distinguished from socioeconomic position; and finally, to establish which dimensions and measures of socioeconomic position are most appropriate for the evaluation of interventions that aim to reduce these inequalities.     

Gender differences in health: a Canadian study of the psychosocial, structural and behavioural determinants of health

Gender-based inequalities in health have been frequently documented. This paper examines the extent to which these inequalities reflect the different social experiences and conditions of men's and women's lives. We address four specific questions. Are there gender differences in mental and physical health? What is the relative importance of the structural, behavioural and psychosocial determinants of health? Are the gender differences in health attributable to the differing structural (socio-economic, age, social support, family arrangement) context in which women and men live, and to their differential exposure to lifestyle (smoking, drinking, exercise, diet) and psychosocial (critical life events, stress, psychological resources) factors? Are gender differences in health also attributable to gender differences in vulnerability to these structural, behavioural and psychosocial determinants of health? Multivariate analyses of Canadian National Population Health Survey data show gender differences in health (measured by self-rated health, functional health, chronic illness and distress). Social structural and psychosocial determinants of health are generally more important for women and behavioural determinants are generally more important for men. Gender differences in exposure to these forces contribute to inequalities in health between men and women, however, statistically significant inequalities remain after controlling for exposure. Gender-based health inequalities are further explained by differential vulnerabilities to social forces between men and women. Our findings suggest the value of models that include a wide range of health and health-determinant variables, and affirm the importance of looking more closely at gender differences in health.     

The importance of the gender perspective in health interview surveys

The identification and measurement of the population health needs should be the first step in health planning. In order to guarantee equity criteria, to know the situation of the whole population, and therefore also that of women, is a key issue. Health interview surveys are a good tool for pinpointing the needs of the population, but mainly they are usually focused on health risk factors that explain men's health status such as health behaviours and paid job. These factors often fail to capture aspects that are relevant for women's health, such as household work. The main objective of this paper is to emphasise the importance of a gender perspective in the design and analysis of health interview surveys, and to propose variables that should be included in health surveys in order to better know gender health inequalities. Likewise, this article deals with the gender concept and its importance as a health inequality factor. Gender is an analytical construct based on the social organisation of the sexes that can be used to better understand the conditions and factors influencing women's and men's health beginning by the social roles that each culture and society assigns to people based on their sex. Health is a complex process determined by a wide range of factors: biological, social, environmental and health services related factors. Gender, because of its close relation to all of them, plays a key role. The gender approach is characterised by the analysis of the social relation between men and women, taking into account that sex is a determinant of social inequalities. This paper presents the variables that health interview surveys should include from a gender approach point of view: reproductive work, productive work, social class, social support, self-perceived health status, quality of life, mental health and chronic conditions. In addition, issues related to the wording of questions, data collection and analysis are discussed.     

Gender and health promotion: a multisectoral policy approach

Women and men are different as regards their biology, the roles and responsibilities that society assigns to them and their position in the family and community. These factors have a great influence on causes, consequences and management of diseases and ill-health and on the efficacy of health promotion policies and programmes. This is confirmed by evidence on male-female differences in cause-specific mortality and morbidity and exposure to risk factors. Health promoting interventions aimed at ensuring safe and supportive environments, healthy living conditions and lifestyles, community involvement and participation, access to essential facilities and to social and health services need to address these differences between women and men, boys and girls in an equitable manner in order to be effective. The aim of this paper is to (i) demonstrate that health promotion policies that take women's and men's differential biological and social vulnerability to health risks and the unequal power relationships between the sexes into account are more likely to be successful and effective compared to policies that are not concerned with such differences, and (ii) discuss what is required to build a multisectoral policy response to gender inequities in health through health promotion and disease prevention. The requirements discussed in the paper include i) the establishment of joint commitment for policy within society through setting objectives related to gender equality and equity in health as well as health promotion, ii) an assessment and analysis of gender inequalities affecting health and determinants of health, iii) the actions needed to tackle the main determinants of those inequalities and iv) documentation and dissemination of effective and gender sensitive policy interventions to promote health. In the discussion of these key policy elements, we use illustrative examples of good practices from different countries around the world.     

Gender differences in structural and behavioral determinants of health: an analysis of the social production of health

This paper explores aspects of the social production of health by focussing on the ways in which levels of health are shaped by structures of social inequality and behaviors or 'lifestyles'. We address two questions: What is the relative importance of the social, structural and behavioral determinants of health? And, are there gender differences in the determinants of health? These questions are explored using multiple regression analyses of data from the 1994 Canadian National Population Health Survey. Two measures of health are used: subjective health status and the Health Utilities Index (a measure of functional health status). By structural determinants we refer to age, family structure, main activity, education, occupation, income and social support. Behavioral determinants include lifestyle factors related to smoking, drinking, weight and physical activity. Findings indicate that the structures of social inequality are the most important determinants of health acting both independently and through their influence on the behavioral determinants of health. There are very real differences in the factors that predict women's and men's health. For women, social structural factors appear to play a more important role in determining health. Being in the highest income category, working full-time and caring for a family and having social support are more important predictors of good health for women than men. Smoking and alcohol consumption are more important determinants of health status for men than women, while body weight and being physically inactive are more important for women than men. Our findings suggest the value of models which include a wide range of structural and behavioral variables and affirm the importance of looking more closely at gender differences in the determinants of health.     

Health policy and mental health.

Health policy can be described as policy directed at the determinants of health, i.e. biological and environmental factors, lifestyle and the health care system. This type of policy now has become a policy objective in an increasing number of countries. In this article mental health is placed in the broad context of this policy. The central question is: can the mental health field grasp the opportunity of a growing interest in prevention and health promotion in general, as major objectives of health policy? Or will it stay more or less isolated from the mainstream of current developments? Answering this question means looking at the conditions of health policy. For health policy it is required that a definition be given of health problems and "causing" conditions. There should further be available intervention possibilities of a preventive and intersectoral character and also preventive strategies. It is stated that there is enough standardized information on mental health problems and experience with community-based research to let mental health participate in drawing up a community diagnosis. It also appears possible to construct an ecological health status model for mental health. Research on the factors in this model shows a shift in focus from risk populations to risk situations, e.g. unemployment, industrial disability, divorce and isolation. Further it is recognized that the search for causal factors is substituted by that for precipitating factors. Social-demographic factors, taken alone, are not precipitating factors. What matters is the combination of an underdeveloped coping mechanism, little social support, and prolonged stressful conditions or sudden stressful events.(ABSTRACT TRUNCATED AT 250 WORDS)     

Engendering health disparities

How is gender implicated in our exploration of health disparities in Canada? Set against the backdrop of federal government policy, this review paper examines the ways in which gender intersects with other health determinants to produce disparate health outcomes. An overview of salient issues including the impact of gender roles, environmental exposures, gender violence, workplace hazards, economic disparities, the costs of poverty, social marginalization and racism, aging, health conditions, interactions with health services, and health behaviours are considered. This review suggests health is detrimentally affected by gender roles and statuses as they intersect with economic disparities, cultural, sexual, physical and historical marginalization as well as the strains of domestic and paid labour. These conditions result in an unfair health burden borne in particular by women whose access to health determinants is--in various degrees--limited. While progress has certainly been made on some fronts, the persistence of health disparities among diverse populations of women and men suggests a postponement of the vision of a just society with health for all that was articulated in the Federal Plan on Gender Equality. Commitment, creativity and collaboration from stakeholders ranging from various levels of government, communities, academics, non-governmental agencies and health professionals will be required to reduce and eliminate health disparities between and among all members of our society.     

Epidemiology and the macrosocial determinants of health

In the past two decades, public health researchers have taken renewed interest in investigating the role of social factors in health. This holds substantial promise in terms of identifying manipulable social factors that are amenable to policy intervention. Most existing empirical and conceptual epidemiologic work, however, has focused on the more proximal social determinants, such as interpersonal relations. These factors, although perhaps easier to study epidemiologically, are much less relevant to policy makers than more "macrosocial" factors such as taxation policies. Limited epidemiologic attention to macrosocial determinants of health is ironic given that macrosocial factors such as the rapid industrialization and urbanization in the 19th century contributed to the organization of public health practice and, tangentially, to academic public health research. We suggest here that greater investment in the study of macrosocial determinants has the potential to make a significant and unique contribution to the greater public health agenda and should be a prominent aspect of social epidemiologic inquiry in the coming decades.     

Social determinants and inequalities in urban health

Social and environmental factors are health determinants, in association with behavior, biological factors, and health services. Whereas socioeconomic characteristics (age, gender, ethnicity, social status) describe individuals, social determinants work through broader policies that are influenced by governments. The relation between health and four social areas is discussed. Social capital, measured as social networks and social support, appears to be protective in developing some heart disease and mental illnesses; job control at work is also found to protect against heart disease; early life experiences affect both biological and social development; and the degree of income inequality within societies correlates with health status. The Independent Report on Inequalities in Health, published in the United Kingdom in 1998, is also reviewed. The report (a) briefly describes inequalities in health by social class, sex, and ethnicity; (b) reviews the literature on policy areas that affect health; (c) includes a section indicating relatively little inequality of access or provision in the National Health Service; and (d) makes 132 recommendations. Social determinants is a new area of research having the potential to link epidemiology and environmental sciences at small area level.     

Gender Bias in den Gesundheitswissenschaften — ein Thema für die epidemiologische Allergieforschung?

There is growing interest in public health research on gender-associated inequalities in morbidity and mortality and their determinants. It has been demonstrated that gender bias exists in severalfields of medical research due to androcentricity, overgeneralization, gender insensitivity, and double standards. Therefore, the need of gendersensitive research concepts has been stated to analyse gender differences in biologic as well as social determinants of health, in disease-related risk factors and in medical care. Allergic diseases show significant gender differences in prevalence, which change markedly from childhood to adult age. The causes of these gender differences and their interaction with age are mostly unknown. Artefacts in data collection and gender-related differences in exposures, diagnoses or biologic factors have been proposed as hypotheses for explanation. This paper presents examples for the existence of gender bias in epidemiologic research on allergies. It is concluded that approaches in statistical analysis are needed that take both the biologic meaning and the social impacts of the variable ‘gender’ into account. Furthermore, gender-sensitive research should be performed in the field of asthma and allergies to clarify the underlying causes for the observed gender differences.     

Gender differences in the influence of economic,lifestyle, and psychosocial factors on later-life health

BACKGROUND: Gender differences in exposure to social resources play a significant role in influencing gender inequalities in health. A related question--and our focus--asks whether these inequalities are also influenced by gendered vulnerabilities to social forces. Specifically, this paper examines the differential impact of social forces on the health of elderly (65+) men and women. METHODS: Multiple linear regression analysis is used to estimate gender differences in the influence of socioeconomic, lifestyle, and psychosocial factors on both self-rated health and overall functional health using data from the 1994-1995 National Population Health Survey. RESULTS: Key findings include: 1) the relationship between income and health is significant for older women only, whereas the converse holds for education; 2) having an acceptable body weight is positively associated with health for elderly women only; and 3) stress-related factors are stronger determinants of health for older women. INTERPRETATION: Our findings shed light on the processes of healthy aging for men and women, and suggest that interventions to improve the health of elderly Canadians need to be gender-specific.     

Maintaining population health in a period of welfare state decline: political economy as the missing dimension in health promotion theory and practice

There is increasing recognition in the health promotion and population health fields that the primary determinants of health lay outside the health care and behavioural risk arenas. Many of these factors involve public policy decisions made by governments that influence the distribution of income, degree of social security, and quality and availability of education, food, and housing, among others. These non-medical and non-lifestyle factors have come to be known as the social determinants of health. In many nations--and this is especially the case in North America--recent policy decisions are undermining these social determinants of health. A political economy analysis of the forces supporting as well as threatening the welfare state is offered as a means of both understanding these policy decisions and advancing the health promotion and population health agendas. The building blocks of social democracies--the political systems that seem most amenable to securing the social determinants of health--are identified as key to promoting health. Health promoters and population health researchers need to "get political" and recognize the importance of political and social action in support of health.     

Gender differences in determinants and consequences of health and illness

This paper uses a framework developed for gender and tropical diseases for the analysis of non-communicable diseases and conditions in developing and industrialized countries. The framework illustrates that gender interacts with the social, economic and biological determinants and consequences of tropical diseases to create different health outcomes for males and females. Whereas the framework was previously limited to developing countries where tropical infectious diseases are more prevalent, the present paper demonstrates that gender has an important effect on the determinants and consequences of health and illness in industrialized countries as well. This paper reviews a large number of studies on the interaction between gender and the determinants and consequences of chronic diseases and shows how these interactions result in different approaches to prevention, treatment, and coping with illness. Specific examples of chronic diseases are discussed in each section with respect to both developing and industrialized countries.     

Gender-specific responses to social determinants associated with self-perceived health in Taiwan: a multilevel approach

There are well-documented gender differences in health. However, few studies have considered that the associations of personal and household characteristics with perceived health may vary between men and women because of their different socialized gender roles. This study investigates gender differences in health and addresses gender-specific responses to individual- and household-level determinants of health. We analyze the data of the 2001 Social Development Survey on Health and Safety, which consists of a representative sample of all registered households in Taiwan. Our findings give limited support to the hypothesis that women and men are differently associated with social determinants of health. We observe a significant gender gap in self-perceived health even after controlling for various health determinants. Notwithstanding, men and women are similar in many important aspects in relation to social determinants of health. Gender-specific responses are found only in the impacts of employment status, stressful life events, own disability, and number of family members with a disability. Men report having poorer health than women when being disabled and facing stressful events. Women's perceived health is at a higher risk when family members require short-term, intensive care. Further consideration of the observed, gender-specific responses to health determinants shed insight on the possible social and cultural relevance behind gender differences in self-perceived health.     

Testing relationships among determinants of health, health policy, and self-assessed health status in Quebec.

By removing financial barriers, the Canada Health Act (1984) equalized access to health care services in Canada. Yet class, educational, and geographical disparities in individual and population health status persist. Recent health reform policies in Quebec assert that health and well-being are a function of income, educational level, housing conditions, employment, and other socioeconomic factors. They suggest that health policy should encompass social policies that influence individual and community socioeconomic factors which in turn affect health. Against the backdrop of these reforms, this study tests the importance of socioeconomic factors as a determinant of health--while controlling for other known determinants through a logistic regression model--with data from the Santé Quebec health surveys 1987 and 1992-93. The results confirm the importance of economic security as a determinant of individual health. This effect appears to operate through an individual income variable and through the community-level variable of regional unemployment. The importance of the income effect declined between 1987 and 1992-93. This may indicate that an increased focus on the socioeconomic determinants of health has reduced inequalities in health. It may also mean that health inequalities appear inevitable until health care policy merges completely with broader health and social policies. But such integration may well conflict with economic (and political) imperatives of the post-Fordist capitalist system.     

Comparing social determinants of self-rated health across the United States and Canada

A large body of research shows that social determinants of health have significant impact on the health of Canadians and Americans. Yet, very few studies have directly compared the extent to which social factors are associated with health in the two countries, in large part due to the historical lack of comparable cross-national data. This study examines differences in the effect of a wide-range of social determinants on self-rated health across the two populations using data explicitly designed to facilitate comparative health research-Joint Canada/United States Survey of Health. The results show that: 1) sociodemographic and socioeconomic factors have substantial effects on health in each country, though the size of the effects tends to differ-gender, nativity, and race are stronger predictors of health among Americans while the effects of age and marital status on health are much larger in Canada; the income gradient in health is steeper in Canada whereas the education gradient is steeper in the U.S.; 2) Socioeconomic status (SES) mediates or links sociodemographic variables with health in both countries-the observed associations between gender, race, age, and marital status and health are considerably weakened after adjusting for SES; 3) psychosocial, behavioural risk and health care access factors are very strong determinants of health in each country, however being severely/morbidly obese, a smoker, or having low life satisfaction has a stronger negative effect on the health of Americans, while being physically inactive or having unmet health care needs has a stronger effect among Canadians; and 4) risk and health care access factors together play a relatively minor role in linking social structural factors to health. Overall, the findings demonstrate the importance of social determinants of health in both countries, and that some determinants matter more in one country relative to the other.     

Gender and health services use for a mental health problem

This study addresses whether the predictors of seeking help for a mental health problem differ by gender. An adaptation of Andersen's Socio-Behavioral Model is used to identify factors associated with seeking care for a mental health problem. Data are derived from two waves of a community survey undertaken in 1992-1993 and in 1993-1994 among a probability sample of adults (18-69 years), residing in poor areas of Puerto Rico. Paired data was used from those individuals who responded to both waves of the survey for a total of 3221 community respondents. Responses from wave 1 were used to predict mental health service use in wave 2. The dependent variable is any use of outpatient mental health services in the year preceding the second interview. Logistic regression was used to model the effects of the independent variables on use. Males and females were found to use mental health services in nearly equal proportions. Gender did not have a main effect on use when other covariates were controlled. Significant interactions with gender were found for several predictors of use. The largest intervention effects were encountered in our need for care indicators. Having a definite need for mental health care and poor self-rated mental health had a larger effect on predicting use of services for men than they do for women. It is concluded that strategies designed to improve access to mental health services for minority disadvantaged populations ought to take into account gender differences in the predictors of use. Studies addressing factors influencing health services utilization for a mental health problem should consider stratifying their sample by gender. Future research should establish whether or not these findings are sustained with other population groups.     

US opinions on health determinants and social policy as health policy

To examine what factors the public thinks are important determinants of health and whether social policy is viewed as health policy, we conducted a national telephone survey of 2791 US adults from November 2008 through February 2009. Respondents said that health behaviors and access to health care have very strong effects on health; they were less likely to report a very strong role for other social and economic factors. Respondents who recognized a stronger role for social determinants of health and who saw social policy as health policy were more likely to be older, women, non-White, and liberal, and to have less education, lower income, and fair/poor health. Increasing public knowledge about social determinants of health and mobilizing less advantaged groups may be useful in addressing broad determinants of health.     

Defining and measuring gender: A social determinant of health whose time has come

This paper contributes to a nascent scholarly discussion of sex and gender as determinants of health. Health is a composite of biological makeup and socioeconomic circumstances. Differences in health and illness patterns of men and women are attributable both to sex, or biology, and to gender, that is, social factors such as powerlessness, access to resources, and constrained roles. Using examples such as the greater life expectancy of women in most of the world, despite their relative social disadvantage, and the disproportionate risk of myocardial infarction amongst men, but death from MI amongst women, the independent and combined associations of sex and gender on health are explored. A model for incorporating gender into epidemiologic analyses is proposed.     

Joining up action to address social determinants of health and health inequities in Canada

Efforts are underway at the international, national, provincial/territorial, and local levels to address factors like income, education, and environment that influence the health of Canadians. Also known as the social determinants of health, these factors are closely linked to health equity. There are important Canadian innovations in research, practice, and policy that reflect our growing understanding of social determinants. However, concerted efforts are still required by health professionals to address social determinants of health through their work settings.