Social Determinants and Health Equity
Social determinants of health are the conditions in which people are born, grow, live, work and age, together with the structural forces that shape those conditions. This area examines how those determinants distribute health and illness across populations, why differences in health between social groups are often avoidable and unjust, and how health promotion can act on causes that lie outside the clinic.
Definition
Social determinants of health are the non-medical, socially patterned conditions and structural forces that shape health outcomes; health equity is the principle and goal that no one should be disadvantaged in achieving health because of socially defined position or circumstance, and that avoidable, unfair differences in health between groups should be reduced.
Scope
The area orients the reader to the social, economic, environmental and political drivers of population health and to the concept of health equity. It groups the conceptual frameworks (the social-ecological model and systems thinking), the normative ideas (equity and justice), the structural and policy influences that produce unequal conditions, and the action-oriented topics of upstream prevention and advocacy. It is a reference-educational overview within health promotion and education, not clinical guidance.
Sub-topics
Core questions
- Which social, economic and environmental conditions shape population health, and through what pathways?
- When is a difference in health between groups an inequity rather than simply a variation?
- How do structural factors and policy produce and sustain unequal health-shaping conditions?
- What kinds of upstream action and advocacy can change the distribution of health?
Key concepts
- Social determinants of health (SDOH)
- Social gradient in health
- Health equity and health inequity
- Health disparities and healthcare disparities
- Distal (upstream) versus proximal (downstream) causes
- Structural drivers and the causes of the causes
- Social-ecological levels of influence
Mechanisms
Determinants operate across levels: societal structures (economic systems, policy, discrimination) shape intermediary conditions (income, housing, education, working conditions, neighbourhood environment), which in turn pattern exposures, behaviours and access to care, and finally biological processes and health outcomes. Because these conditions are distributed by social position, health tends to follow a gradient rather than a simple threshold. The Commission on Social Determinants of Health framed action on these distal causes — the causes of the causes — as the route to greater equity.
Clinical relevance
Understanding social determinants helps health professionals interpret why patterns of disease differ across populations and why clinical care alone does not close health gaps. This area describes how social conditions generate health and inequity at the population level; it informs context and is not a basis for individual diagnostic or treatment decisions.
Epidemiology
Health outcomes consistently follow a social gradient: across many settings, each step down the socioeconomic ladder is associated with worse health, and differences in life expectancy between more and less advantaged groups can span years. These patterns appear for cardiovascular disease, mental health, child development and overall mortality, and are documented across high- and low-income countries.
History
Concern with the social roots of disease dates to nineteenth-century social medicine, but the modern field consolidated through the Black Report (1980), the Ottawa Charter for Health Promotion (1986), and the WHO Commission on Social Determinants of Health, whose 2008 report 'Closing the gap in a generation' placed health equity and action on social determinants at the centre of global public-health policy, reaffirmed by the 2011 Rio Political Declaration.
Debates
- How far should health systems act on social determinants?
- There is ongoing discussion about whether reducing health inequity is primarily a task for intersectoral and political action on upstream conditions or whether health-care and public-health programmes should themselves take on social-determinant interventions.
Key figures
- Michael Marmot
- Paula Braveman
- Nancy Krieger
- Ana Diez Roux
Related topics
Seminal works
- marmot-2008-csdh
- marmot-2014-ajph
- braveman-gottlieb-2014
Frequently asked questions
- What is the difference between social determinants of health and health equity?
- Social determinants are the conditions and structural forces that shape health; health equity is the normative goal that avoidable, unfair differences in health between social groups should be eliminated. Acting on social determinants is one of the main ways to advance health equity.
- Is every difference in health between groups an inequity?
- No. A health inequity is specifically a difference that is avoidable and unfair, arising from social disadvantage; differences driven by unmodifiable biological factors or freely chosen risk are not in themselves inequities.