Description
country chosen : Somalia
Overview
The goal of this assignment is to familiarize yourself with the most important determinants of health in your country in order to understand what drives health and to identify potential areas of intervention and disease reduction. The assignment is structured into four sections. In Section 1 to 3 you will be asked to collect information on determinants of health using the literature as well as the Global Burden of Disease study. In Section 4, you will be asked to elaborate in priority areas to focus mitigation efforts on.
Instructions
The Global Burden of Disease (GBD) study attributes mortality and morbidity to 87 risk factors, including behavioral, environmental, and metabolic risk factors. For part of this exercise, you will be using the GBD compare tool to analyze the relevant risk factors in your country of choice. As the GBD risk factor list is not exhaustive, and does not include all possible determinants of health, we also ask you to do additional research on determinates of health in your country. For example, risk factors currently not included in the GBD study include education, political stability, access to care, etc. You will also be asked to provide data on these additional risk factors and discuss their relevance.
Finally, we will ask you to discuss the role of determinants of health in your county and provide a short write-up. What are major focus areas for public health intervention? What are data gaps and limitations of data on determinants of health?
Please label all figures included in your responses, including a brief descriptive title. Please include references/citations for each response below; these do not count towards your word limit.
Guiding questions are:
Section 1: During this week’s lectures (videos) we learned about (social) determinants of health, sometimes also referred to as risk factors. Determinants that were specifically highlighted in the video were: income, education, nutrition, health care and access to water, sanitation and housing. What is the situation with regards to these risk factors in your country? How have they changed over time and compare to other countries in the region or globally? (5 points, 150-250 points, 1-2 figures)
Tip: Check out WorldBank (https://data.worldbank.org/indicator/Links to an external site.) and UNICEFdata warehouse (https://data.unicef.org/dv_index/Links to an external site.)
Section 2A: The GBD provides an overview over 87 individual risk factors, that are clustered into metabolic, behavioral and environmental risk factors. The GBD provides these risk factors on four different levels, with level 1 being the coarsest level (e.g., environmental risk factors). Higher levels of risk factors provide an increasing level of detail. For instance, level 2 of environmental risk factors provides information about air pollution, water and sanitation, occupational risk factors, temperature, and other environmental risk factors. When zooming into level 4 of “air pollution”, we see information on ambient and household particulate matter pollution as well as ozone. What information does GBD compare provide for your country? What risk factors contribute the highest burden of disease? Look at different levels and choose 1 to 2 figures that demonstrate the risk factor profile in your country. (Note: You are free to choose a risk factor level that you think provides most meaningful results.)(2 points, 50-150 words, 1-2 figures)
Tip: Go to the ‘Risk by cause’ tab in GBD compare and switch to ‘advanced settings’. Then choose your country from the drop-down menu. You can move the lever in order to choose a level or you can click on a risk to get to the next level.
Section 2B: How have risk factors and the risk attributable burden changed over the last three decades?Have they decreased or increased? Please consider all demographic and epidemiological drivers. This means evaluate whether population aging, or high fertility has intensified or offset the impact of risk factors. You can use the line or pattern display in GBD compare to answer this question and choose the appropriate metric you want to look at (tip: all age vs. age-standardized rates tell a different story). Include appropriate graphics in your answer and provide a brief narrative (2 points, 50-100 words, 1+ figures).
Tip: Go to the line setting and choose the ‘Risk’ tab (stay in advanced settings) and choose your country. Now you have the option to choose a cause, a risk, a measure, and age group including all ages and age-standardized, as well as a sex and a unit. For this section, I suggest looking at all causes, DALYs or deaths, both sexes and rates. Compare the risk-attributable burden for all ages versus age-standardized rates to better understand the role of demography.
Section 3: Are there additional risk factors that are relevant in your country but were not discussed during the lectures (and in Section 1) and are not part of GBD?If so, please list them and provide some additional information why you think these determinants of health are important! Possible determinants of health could be war and conflict, discrimination, domestic violence etc. If you can’t name any, please outline your approach to finding information (1 point, 50-100 words, 0+ figures)
Section 4: Based on what you have learned during this module and the information you have compiled for questions 1 to 3, what do you think are priority risk factors your country should focus on and aim to mitigate?Please provide a rationale for your suggestions! Factors to consider are, for instance, the burden of disease these determinants are causing, the cost and/or opportunity cost of mitigation, the ease of implementation etc. In addition to these hard considerations, ethical reasons and equity might also be driving forces behind your recommendation. Please provide a brief narrative (250 to 500 words). (5 points) – list all refrences and also use the files below to answer the questions needed
Unformatted Attachment Preview
SPECIAL COMMENTARY
The Social Determinants of Health?
Time to Focus on the Political
Determinants of Health!
Ranit Mishori, MD, MHS, FAAFP
T
he concept that health is significantly affected by social determinants is everywhere we
turn. This idea—that health and health inequities are driven by “the conditions in
which people are born, grow, live, work, and age [and are] shaped by the distribution of
money, power, and resources”1—is increasingly the focus of articles, research projects,
toolkits, courses, and conferences.
The medical and public health communities widely recognize that the social determinants of health (SDoH) deserve the attention of policymakers, public health professionals, medical schools, and researchers. There are calls for increased training in
SDoH2,3 and health care providers now have an array of tools to screen4,5 for such variables
as socioeconomic status, hunger, education, employment, physical environment, and social
support. Scholarship surrounding these factors is also on the rise. A quick search of the
academic literature, for example, shows that articles with “social determinants of health” as a
keyword jumped from 45 in 2007 to 1411 in 2018.6 This improved academic insight into the
role of SDoH leads to a natural question about root causes. Specifically, if these social
determinants shape health, then what shapes these social determinants?
As important as that question is, it is one the medical profession tends to duck. Perhaps
it is because of a sense of helplessness when asked to address factors outside the 4 walls of the
medical clinic, or fears of medicalizing issues like economic insecurity.7,8 Or perhaps it is
because the answer serves up a more uncomfortable truth: the root causes of health and, thus,
health disparities are driven as much by policy—and politics—as by any other cause.
These “political determinants of health”—the PDoH if you will—do not get nearly
the attention they deserve from the medical profession. Yet, there is nothing radical in
acknowledging the part played by political choices in affecting the nation’s health. Think
of areas as disparate as vaccines, air quality, seatbelt safety, and smoking cessation; all
cases where the public’s health was better off for the legislative choices made, by lawmakers, political appointees, and politicians, at the state and federal level.
There are many other areas that perhaps less obviously (but no less importantly)
impact health, where politics and health outcomes mix, including the oversight and regulation of corporations, immigration and refugee politics, responses to natural disasters,
legislation about reproductive health, etc. These political decisions upstream have large
health effects downstream. This is firmly captured in the movement known as Health in
All Policies.9,10
To go even bigger picture: 1 study found that people living in democracies enjoy
better health than those in repressive regimes11—which seems intuitive. But even among
democracies, there are variations based on political decisions. Universal healthcare is a
choice requiring an enormous political commitment that only some democratic states have
made—the ones that tend to have better population health outcomes.12,13
Right now politics is having an outsized influence on health. To be clear, I am not
referring to the many reports of higher levels of stress, anxiety, and depression14–16 the
From the Department of Family Medicine, Georgetown University School of Medicine, Washington, DC.
R.M. is paid consultant for Physicians for Human Rights, Program on Sexual Violence in Conflict Zones.
Reprints: Ranit Mishori, MD, MHS, FAAFP, Department of Family Medicine, Health & Media Fellowship, Robert L. Phillips, Jr Health Policy Fellowship,
Georgetown University School of Medicine, 3900 Reservoir Road NW, BG-01D, Washington, DC 20007. E-mail: [email protected].
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0025-7079/19/5707-0491
Medical Care Volume 57, Number 7, July 2019
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Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.
Medical Care Volume 57, Number 7, July 2019
Special Commentary
current political climate is afflicting on many Americans.
Rather, I am talking about the current ascendency and empowerment of political views that subordinate good health
outcomes to other cultural, philosophical and societal objectives, such as profit-making, prioritizing religious beliefs,
and satisfying populist impulses, among others.
Here are some other examples:
Access to care: political efforts are still ongoing to dismantle
the Affordable Care Act, which would strip many of their
ability to have affordable insurance, and would impact
millions who have preexisting conditions.17,18
Drug prices: high prices have hurt people with conditions
like diabetes and cancer. Many patients cannot afford lifesaving medications or have to skip doses. Even the ability
of the nation’s largest payer for prescription drugs—
Medicare—is prevented by law from negotiating down
such prices.19–23
Reproductive and women’s health: access to birth control
and abortion are affected by political decisions and funding
(such as through Title X) at the federal and state level.24
Gun violence: from government funding of research
activities to prevention efforts, decisions are frequently
linked to political processes and donations.25
The health of immigrants, especially those seeking asylum:
from the Muslim ban to refugee quotas26 to the situation on
the US-Mexico borders,27 those are all tightly linked to
political decisions and affect vulnerable populations,
children, and even the US workforce.28
RESEARCH
FIGURE 1. The key domains that make up the political determinants of health.
(such as education, advocacy and awareness raising) as part
of the political discourse in this country ultimately influencing
the domains that shape the PDoH.
EDUCATION
Although the PDoH is self-evident in an intuitive, “common
knowledge” sort of way, evidence to support their impact and
relevance is still in the early stages of being collected. This process
needs to continue as a deeper foray into “political epidemiology,”29
exploring and documenting the causal effects of political decisions
on the health of populations.30–32
“Health is a political choice,” writes Kickbusch33 in a
2015 editorial in the journal BMJ “and politics is a continuous
struggle for power among competing interests. Looking at
health through the lens of political determinants means analyzing how different power constellations, institutions, processes, interests, and ideological positions affect health…..”
Indeed, in the United States the different “power constellations”—the 4 general spheres of influence—are judicial
decisions, state laws, federal laws, and executive orders.
These domains may seem abstractions, yet they are comprised
of flesh-and-blood human beings—elected officials, judges,
their staff and their voters—all of whom embody their own
constellations of world views, aspirations, needs and impulses
(Fig. 1 describes the key domains that make up the political
determinants of health). In a perpetual bidirectional loop,
these key players are responsible for creating (or dismantling)
the rules, laws, and regulations that affect our health care
system and our population’s health. And all of these actors,
regardless of their political affiliation, have personal attributes
and attitudes that shape their politics, legislative agenda, and
actions. These “human factors” should also be studied, as
they may be the issues most amenable to outside influence
Finally, the political dimension of many health issues is
manifest, and yet, there is nearly a taboo about acknowledging
this in classroom discussions and on the wards. These needs to
change: we should be engaging in open and robust discussions
of how politicians and politics affect and shape our patients’
lives, our communities, and the SDoH themselves.
Importantly, we must help our future health professionals
understand these forces, and engage in discourse by creating educational content that includes governance, lobbying, and policymaking. We should teach students advocacy skills, institutionally
support student groups who engage in political discourse and activism and promote safe space for debate by emphasizing tolerance
and respectful dialogue.
I expect pushback and expect to hear excuses like “medical
school is about health and disease” or “we cannot be partisan” or
“there is no room in the curriculum.” I get it. Many health care
providers may feel it would not be pragmatic to mix medicine and
politics.34 This may stem from an effort to ensure objectivity and
protect the patient-provider relationship. There may also be concerns that their institutions will look askance at political activism
and perhaps even retaliate.
But there is pragmatism in the counter-argument as
well. Once we acknowledge the role of politics and politicians in shaping health, ignoring that becomes a cop-out and
shortchanges our students and patients. It is time we acknowledge politics head-on in our medical education system
and open the door for an exploration that goes beyond
the SDoH.
492 | www.lww-medicalcare.com
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Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.
Medical Care Volume 57, Number 7, July 2019
The 2020 presidential elections, already on the horizon,
provide a wonderful opportunity to bring up these issues with
our students. Health care has been one of the top-priority
issues for the recent midterm elections,35 and we must make
sure students but have opportunities to partake in the process
as important stakeholders in the field.
One of Rudolph Virchow’s frequently used quotations
goes like this: “Politics is nothing but medicine at a larger
scale.” I’d argue for a more direct rewording and acknowledge just how much health itself depends on politics. It is
time to bring the political determinants of health to the
forefront.
Special Commentary
1. WHO. About social determinants of health. Available at: http://who.int/
social_determinants/sdh_definition/en/. Accessed April 2, 2019.
2. Willems S, Roy KV, Maeseneer JD. Educating health professionals to
address the social determinants of health. National Academies Press
(US); 2016. Available at: https://www.ncbi.nlm.nih.gov/books/
NBK395989/. Accessed April 30, 2019.
3. Siegel J, Coleman DL, James T. Integrating social determinants of health into
graduate medical education: a call for action. Acad Med. 2018;93:159–162.
4. A practical approach to screening for social determinants of health. 2018.
Available at: https://aafp.org/journals/fpm/blogs/inpractice/entry/social_
determinants.html. Accessed April 2, 2019.
5. O’Gurek DT, Henke C. A practical approach to screening for social
determinants of health. Fam Pract Manag. 2018;25:7–12.
6. Social determinants of health. Results by year. Available at: https://lm-nihgov.proxy.library.georgetown.edu/pubmed. Accessed January 25, 2019.
7. Lantz PM. The medicalization of population health: who will stay
upstream? Milbank Q. 2019;97:36–39.
8. Adler KG. Screening for social determinants of health: an opportunity or
unreasonable burden? Fam Pract Manag. 2018;25:3.
9. Hall RL, Jacobson PD. Examining whether the health-in-all-policies
approach promotes health equity. Health Aff (Millwood). 2018;37:364–370.
10. Public Health Institute. Health in all policies: a guide for state and local
government. 2013. Available at: http://phi.org/resources/?resource=
hiapguide. Accessed April 2, 2019.
11. Franco A, Alvarez-Dardet C, Ruiz MT. Effect of democracy on health:
ecological study. BMJ. 2004;329:1421–1423.
12. Lena HF, London B. The political and economic determinants of health
outcomes: a cross-national analysis. Int J Health Serv. 1993;23:585–602.
13. Greer SL, Méndez CA. Universal health coverage: a political struggle and
governance challenge. Am J Public Health. 2015;105(suppl 5):S637–S639.
14. Zogbi E. Therapists coin new term: trump anxiety disorder. 2018
Available at: https://newsweek.com/therapists-report-rise-anxiety-trumpwas-elected-1046687. Accessed April 2, 2019.
15. Goldberg M. Trump-induced anxiety is a real thing. 2016 Available at:
https://slate.com/human-interest/2016/09/trump-induced-anxiety-is-a-realthing.html. Accessed April 2, 2019.
16. Psychology Today. What’s Trump doing in your therapy room? 2018.
Available at: https://psychologytoday.com/us/blog/living-single/201806/
what-s-trump-doing-in-your-therapy-room. Accessed April 2, 2019.
17. The Washington Post. Trump administration proposes further dismantling of
affordable care act through Medicare. 2018. Available at: https://
washingtonpost.com/national/health-science/trump-administration-proposesfurther-dismantling-of-affordable-care-act-through-medicare/2018/08/
09/cdf919f6-9c1a-11e8-843b-36e177f3081c_story.html?utm_term=.
9c21ce9040fb. Accessed April 2, 2019.
18. Sacks DW. The health insurance marketplaces. JAMA. 2016;320:
549–550.
19. Andrews M. Staggering prices slow insurers’ coverage of CAR-T cancer
therapy. Kaiser Health News. Available at: https://khn.org/news/
staggering-prices-slow-insurers-coverage-of-car-t-cancer-therapy/. Accessed
April 2, 2019.
20. Kesselheim AS, Avorn J, Sarpatwari A. The high cost of prescription
drugs in the United States: origins and prospects for reform. JAMA.
2016;316:858–871.
21. Prescription drug prices in the US. Med Lett Drugs Ther. 2017;59:81–82.
22. Spiking insulin costs put patients in brutal bind. Available at: https://
webmd.com/diabetes/news/20180725/spiking-insulin-costs-put-patientsin-brutal-bind. Accessed April 2, 2019.
23. Study examines reasons for high cost of prescriptions drugs in US,
approaches to reduce costs. Available at: https://medicalxpress.com/
news/2016-08-high-prescriptions-drugs-approaches.html. Accessed April
2, 2019.
24. Rosenzweig C. Proposed changes to title X: implications for women and
family planning providers. The Henry J. Kaiser Family Foundation.
Available at: https://kff.org/womens-health-policy/issue-brief/proposedchanges-to-title-x-implications-for-women-and-family-planning-providers/
. Accessed April 2, 2019.
25. Rostron A. The Dickey amendment on federal funding for research on
gun violence: a legal dissection. Am J Public Health. 2018;108:865–867.
26. Rubenstein L, Spiegel P. The revised US refugee ban, health, and
security. Lancet. 2017;389:1189–1190.
27. Almeida M, Rovner MR. Long-term medical consequences of the crisis
at the US-Mexico Border. J Public Health (Oxf). 2018. [Epub ahead of
print].
28. McCarthy M. Travel ban threatens medical research and access to care in
the US, medical groups warn. BMJ. 2017;356:j545.
29. Mackenbach JP. Political determinants of health. Eur J Public Health.
2014;24:2.
30. Martyn C. Politics as a determinant of health. BMJ. 2004;329:
1423–1424.
31. Policies for Equitable Access to Health (PEAH). The political
determinants of health. Available at: http://peah.it/2014/07/the-politicaldeterminants-of-health/. Accessed April 2, 2019.
32. Shibanuma A. Political determinants of health: concept and research
perspectives. Jpn J Health Educ Promot. 2015;23:50–55.
33. Kickbusch I. The political determinants of health—10 years on. BMJ.
2015;350:h81.
34. Bleakley A. The perils and rewards of critical consciousness raising in
medical education. Acad Med. 2017;92:289–291.
35. Wu B, Munana C. Kaiser health tracking poll: preview of the role of
health care in the 2018 Midterm Campaigns. The Henry J. Kaiser Family
Foundation. Available at: https://kff.org/health-costs/poll-finding/kaiserhealth-tracking-poll-preview-role-of-health-care-2018-midterm-campaigns/.
Accessed April 2, 2019.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
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ACKNOWLEDGMENTS
The author thanks Samantha Baste for her help
designing the PDoH visual framework.
REFERENCES
Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.
The Social Determinants of Health: It’s Time to Consider the Causes of the Causes
Author(s): Paula Braveman and Laura Gottlieb
Source: Public Health Reports (1974-) , JANUARY/FEBRUARY 2014, Vol. 129,
SUPPLEMENT 2: Nursing in 3D: Workforce Diversity, Health Disparities, and Social
Determinants of Health (JANUARY/FEBRUARY 2014), pp. 19-31
Published by: Sage Publications, Inc.
Stable URL: https://www.jstor.org/stable/23646782
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Nursing in 3D: Diversity, Disparities, and Social Determinants
The Social Determinants of Health: It’s
Time to Consider the Causes of the Causes
Paula Braveman, MD, MPHa
Laura Gottlieb, MD, MPHb
ABSTRACT
During the past two decades, the public health community’s attention h
drawn increasingly to the social determinants of health (SDH)—the factor
from medical care that can be influenced by social policies and shape he
in powerful ways. We use “medical care” rather than “health care” to ref
clinical services, to avoid potential confusion between “health” and “hea
care.” The World Health Organization’s Commission on the Social Determ
nants of Health has defined SDH as “the conditions in which people are
grow, live, work and age” and “the fundamental drivers of these conditi
The term “social determinants” often evokes factors such as health-related
features of neighborhoods (e.g., walkability, recreational areas, and accessibil
ity of healthful foods), which can influence health-related behaviors. Evidence
has accumulated, however, pointing to socioeconomic factors such as income,
wealth, and education as the fundamental causes of a wide range of health
outcomes. This article broadly reviews some of the knowledge accumulated to
date that highlights the importance of social—and particularly socioeconomic—
factors in shaping health, and plausible pathways and biological mechanisms
that may explain their effects. We also discuss challenges to advancing this
knowledge and how they might be overcome.
“University of California, San Francisco, School of Medicine, Department of Family and Community Medicine, Center on Social Disparities
in Health, San Francisco, CA
bUniversity of California, San Francisco, School of Medicine, Department of Family and Community Medicine, Center for Health and
Community, San Francisco, CA
Address correspondence to: Paula Braveman, MD, MPH, University of California, San Francisco, School of Medicine, Department
of Family and Community Medicine, Center on Social Disparities in Health, PO Box 0943, 3333 California St., Ste. 365, San Francisco, CA
94118-0943; tel. 415-476-6839; fax 415-476-5219; e-mail .
©2014 Association of Schools and Programs of Public Health
Public Health Reports / 2014 Supplement 2 / Volume 129 O 19
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20 O Nursing in 3D: Diversity, Disparities, and Social Determinants
A large and compelling body of evidence has accu- the country’s relative ranking has fallen over tim
mulated, particularly during the last two decades, that A recent report from the National Research
reveals a powerful role for social factors—apart from and Institute of Medicine has documente
medical care—in shaping health across a wide range U.S. health disadvantage in both morbidity
of health indicators, settings, and populations.1-16 This tality applies across most health indicat
evidence does not deny that medical care influences age groups except those older than 75 years
health; rather, it indicates that medical care is not the applies to affluent as well as poor Americans
only influence on health and suggests that the effects non-Latino white people when examined separ
of medical care may be more limited than commonly Other U.S. examples include the observat
thought, particularly in determining who becomes sick while expansions of Medicaid maternity care
or injured in the first place.4’6,7,1718 The relationships 1990 resulted in increased receipt of prenata
between social factors and health, however, are not African American women,36,37 racial disparities
simple, and there are active controversies regarding key birth outcomes of low birthweight and
the strength of the evidence supporting a causal role delivery were not reduced.38 Although import
of some social factors. Meanwhile, researchers increas- maternal health, traditional clinical pren
ingly are calling into question the appropriateness of generally has not been shown to improve
traditional criteria for assessing the evidence.17,19-22 in newborns.39″44
The limits of medical care are illustrated by the
work of the Scottish physician, Thomas McKeown,
THE IMPACTS OF SOCIOECONOMIC
who studied death records for England and Wales
AND OTHER SOCIAL FACTORS ON
from the mid-19th century through the early 1960s.
MOST HEALTH OUTCOMES
He found that mortality from multiple causes had
fallen precipitously and steadily decades before the A number of studies have attempted to
availability of modern medical-care modalities such impact of social factors on health. A review
as antibiotics and intensive care units. McKeown nis et al. estimated that medical care was re
attributed the dramatic increases in life expectancy for only 10%-15% of preventable mortalit
since the I9th century primarily to improved living U.S.;45 while Mackenbach’s studies suggest
conditions, including nutrition, sanitation, and clean percentage may be an underestimate, they affi
water.23 While advances in medical care also may have overwhelming importance of social factors.25,
contributed,23-26 most authors believe that nonmedical nis and Foege concluded that half of all
factors, including conditions within the purview of tra- the U.S. involve behavioral causes;18 other e
ditional public health, were probably more important;24 has shown that health-related behaviors are
public health nursing, including its role in advocacy, shaped by social factors, including income, edu
may have played an important role in improved living and employment.46,47 Jemal et al., studying
standards.27 Another example of the limits of medical death data, concluded that “potentially avoida
care is the widening of mortality disparities between tors associated with lower educational stat
social classes in the United Kingdom in the decades for almost half of all deaths among working-age
following the creation of the National Health Service in in the U.S.”48 Galea and colleagues conducted
1948, which made medical care universally accessible.28 analysis, concluding that the number of U.S.
Using more recent data, Martinson found that although in 2000 attributable to low education, racial
health overall was better in the United Kingdom than tion, and low social support was comparable wi
in the United States, which lacks universal coverage, number of deaths attributable to myocardial in
disparities in health by income were similar in the two cerebrovascular disease, and lung cancer, respec
countries.29 Large inequalities in health according to The health impact of social factors also is
social class have been documented repeatedly across by the strong and widely observed associations be
different European countries, again despite more a wide range of health indicators and meas
universal access to medical care.30-32 individuals’ socioeconomic resources or social
Another often-cited example of the limits of medi- typically income, educational attainment, or r
cal care is the fact that, although spending on medical an occupational hierarchy. In U.S. as well as Eu
care in the U.S. is far higher than in any other nation, data, this association often follows a stepwise
the U.S. has consistently ranked at or near the bottom pattern, with health improving incrementally
among affluent nations on key measures of health, such position rises. This stepwise gradient pattern
as life expectancy and infant mortality; furthermore, noted in the United Kingdom.28,50 Although
Public Health Reports / 2014 Supplement 2 / Volume 129
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SDH: Considering the Causes of the Causes O 21
on the socioeconomic gradient has been more limited enees in experience
in the U.S., the results of U.S. studies have mirrored are socioeconomic; f
the European findings. Figures 1-5 illustrate a few could harm the hea
examples using U.S. data, with social position reflected nomic levels by acting
by income or by educational attainment. Using national interactions, even in
data, the National Center for Health Statistics’ “Health, intent to discriminate.5
United States, 1998” documented socioeconomic gra- disparity in birth o
dients in the majority of numerous health indicators educated women.59
measured across different life stages.51 Braveman and legacy of racial dis
colleagues confirmed those findings using recent U.S. through psychobiologic
data.52 Both Pamuk et al.51 and Braveman et al.52 found discriminatory incide
that socioeconomic gradient patterns predominated How do widespread
when examining non-Latino black and white groups gradients in health
but were less consistent among Latino people. Minkler tors are important inf
and colleagues found dramatic socioeconomic gradi- between poverty and
ents in functional limitations among people aged 65-74 centuries.63″65 Ob
years. This finding is particularly remarkable because opposed to a simple th
income gradients generally tend to flatten in old age.53 erty line) of socioecon
As illustrated in Figure 5, and in both Pamuk et al.51 health indicators sugge
and Braveman et al.,52 these socioeconomic gradients tionship, adding to
in health have been observed not only in the U.S. factors—or factors clo
population overall, but within different racial/ethnic a causal role. Although
groups, demonstrating that the socioeconomic differ- health are rarely dispu
enees are not explained by underlying racial/ethnic the effects of incom
differences. Indeed, most studies that have examined the socioeconomic s
racial/ethnic differences in health after adjusting for income-health or educ
socioeconomic factors have found that the racial/ reverse causation (i.e.,
ethnic differences disappeared or were substantially and/or lower educationa
reduced.54″56 This does not imply that the only differ- health often results
Figure 1. Life expectancy in the U.S. at age 25, by education and gender, 2006a
Educational attainment
■ Less than high school
■ High school graduate
60.3
■ Some college
■ College graduate
Men
Women
“Source:
Department
of
Health
on
socioeconomic
status
and
he
www.cdc.gov/nchs/data/hus/2
the
Robert
Wood
Johnson
Fou
Public Health Reports / 2014 Supplement 2 / Volume 129
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22 O Nursing in 3D: Diversity, Disparities, and Social Determinants
Figure 2. Infant mortality rate in the U.S., by mother’s education, 2009a
Educational attainment
■ Less than high school
■ High school graduate
■ Some college
■College graduate
“Source: Mathews TJ, MacDorman MF. Infant mortality statistics from the 2009 period linked birth/infant death dataset. Natl V
2013;61:1-28. Also available from: URL: http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_08.pdf [cited 2013 Feb 14]. Reporte
P, Egerter S. Overcoming obstacles to health in 2013 and beyond: report for the Robert Wood Johnson Foundation Commissio
Flealthier America. Princeton (NJ): Robert Wood Johnson Foundation; 2013.
health could limit educational achievement, evidence the effects of socioeconomic factors that a
from longitudinal and cross-sectional studies indicate “upstream” (i.e., closer to underlying or f
that these do not account for the strong, pervasive causes)76 from their health effects
relationships observed.67 Links between education and stream” (i.e., near where health effects a
health, furthermore, cannot be explained by reverse
causation because once attained, educational attain- MULTIPLE MECHANISMS EXPLAIN
ment is never reduced.
The aforementioned evidence reflects associations
IMPACTS OF SOCIOECONOMIC AND
OTHER SOCIAL FACTORS ON HEALTH
that by themselves do not establish causation. However,
the observational examples cited as illustrations are Despite countless unanswered questions, kno
backed up by extensive literature employing a range the pathways and biological mechanisms co
of techniques (e.g., multiple regression, instrumental social factors with health has increased expone
variables, matched case-control designs, and propensity during the past 25 years. Mounting evidence
score matching) to reduce bias and confounding due causal relationships between many social—
to unmeasured variables.34’71719 This knowledge base socioeconomic—factors and many health o
is also enriched by natural experiments,3,36,68,69 quasi- not only through direct relationships but also
experiments,70 and some, albeit limited, randomized more complex pathways often involving b
controlled experiments.71″74 The overwhelming weight cial processes.77
of evidence demonstrates the powerful effects of socio- Some aspects of socioeconomic factors
economic and related social factors on health, even nected to health via responses to relatively
when definitive knowledge of specific mechanisms rapid-acting exposures. For instance, lead i
and effective interventions is limited. Accumulated in substandard housing contributes to low
knowledge also reveals, however, that the effects of any function and stunted physical development in
given social (including socioeconomic) factor are often children;78,79 pollution and allergens, also mo
contingent on a host of other factors.17,75 The third mon in disadvantaged neighborhoods, can exac
section of this article discusses challenges in studying asthma.80,81 Socioeconomic and other social fa
Public Health Reports / 2014 Supplement 2 / Volume 129
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SDH: Considering the Causes of the Causes O 23
may contribute to worse health through pathways that outlets and few recreati
play out over relatively short time frames (e.g., months to poorer nutrition and l
to a few years) but are somewhat more indirect. Fac- health consequences of the
tors affecting the social acceptability of risky health these conditions generally
behaviors are a case in point. For instance, exposure The strong and perva
to violence can increase the likelihood that young socioeconomic factors a
people will perpetrate gun violence;82 and the avail- can reflect even more
ability of alcohol in disadvantaged neighborhoods can ways, which may or may
influence its use among young people, affecting rates as key mediators or mode
of alcohol-related traumatic injury.83 Socioeconomic showed that the associat
factors can influence sleep, which can be affected by hood poverty and adu
work, home, and neighborhood environments, and to be explained not only
which can have short-term health effects.84’85 Working deficits, but also partly
conditions can shape health-related behaviors, which, Cutler et al. described wid
in turn, may impact others; for example, workers with- by educational achievem
out sick leave are more likely to go to work when ill, behavioral risk factors su
increasing the likelihood of disease spread to cowork- Children growing up
ers or customers.86 taged neighborhoods face greater direct physical chal
In addition to these relatively rapid health impacts, lenges to health status and health
the effects of socioeconomic and other social factors they also often experience emotion
on health-related behaviors can influence disease stressors, such as family conflict a
outcomes that only manifest much later in life. from chronically inadequate reso
Neighborhood socioeconomic disadvantage and depression, anxiety, and other negative emotional
higher co
