Understanding and tackling the wider social determinants of health
Our health is influenced by a wide range of social, economic and environmental factors. We as individuals cannot always control them and they influence and often constrain the ‘choices' we make and the lifestyle we lead.
The social determinants of health have been described as 'the causes of the causes'. They are the social, economic and environmental conditions that influence the health of individuals and populations. They include the conditions of daily life and the structural influences upon them, themselves shaped by the distribution of money, power and resources at global, national and local levels. They determine the extent to which a person has the right physical, social and personal resources to achieve their goals, meet needs and deal with changes to their circumstances. There is a clear link between the social determinants of health and health inequalities, defined by the World Health Organisation as “the unfair and avoidable differences in health status seen within and between countries”.
The social determinants of health
The socio-economic conditions that influence the health of individuals, communities and jurisdictions as a whole. These determinants also establish the extent to which a person possesses the physical, social and personal resources to identify and achieve personal aspirations, satisfy needs and cope with the environment."
Raphael, 2004 ‘Social Determinants of Health: Canadian perspectives', Toronto, CSPI.
Lack of income, inappropriate housing, unsafe workplaces and poor access to healthcare are some of the factors that affect the health of individuals and communities. Similarly, good education, inspired public planning and support for healthy living can all contribute to healthier communities.
Barton and Grant and the UKPHA strategic interest group (2006) developed the health map based on Dalgren and Whitehead's earlier model (Dahlgren and Whitehead 1991) which shows how individual determinants including a persons age, sex and hereditary factors are nested within the wider determinants of health which include lifestyle factors, social and community influences, living and working conditions and general socio-economic cultural and environmental conditions. The health map (below) continues to place people at the centre, but sets them within the global ecosystem which includes:
- natural environment
- built environment
- activities - such as working, shopping, playing and learning
- local economy - includes wealth creation and markets
- community - social capital and networks
These are the social, economic and environmental determinants of health.
The publication in 2008 of the report of the WHO Global Commission on the social determinants of health raised the profile of the social determinants of health and highlighted the importance of addressing the conditions of everyday life that lead to health inequities, defined as the “unfair and avoidable differences in health status”.
Professor Sir Michael Marmot in his Strategic Review of Health Inequalities in England, Post 2010 - Fair Society Healthy Lives presented an evidence-based strategy for the reduction of health inequalities with a focus on policies and interventions that address the social determinants of health. Further information on the Marmot review can be found here.
Looking at the social determinants of health challenges the notion that health is the domain of the NHS and brings it squarely into the arena of local government. The Foresight Report into obesity made abundantly clear, many of the health issues facing society today cannot be addressed by the health sector alone. Many would argue that the health sector has a relatively minor role in addressing inequalities and the social determinants of health.
The health map above illustrates why the social determinants are of such relevance to local government. The majority of local government services impact upon or can influence the conditions in which people live and work and, to a certain extent, the life chances of individuals. This has been illustrated by Campbell (2010) in the IDeA's publication ‘the social determinants of health and the role of local government'
Opportunities for local action
- Community engagement - enhancing mechanisms for getting people engaged and involved in things that matter to them
- Better quality homes - addressing the quality of housing and fuel poverty
- Education - investing in early child years and in the quality of schooling
- Community safety - reducing crime and violence
- Spatial planning - designing in physical activity
- Food and nutrition - planning for food resilience and ensuring availability and access to food.
Much of it is common sense. For example, local government as a deliverer and commissioner of children's services makes a huge contribution to the social, mental and physical wellbeing of young people. It provides them with vital skills and social capital which lead to better life chances as they grow up. As a planning authority, local government can do a great deal to plan for healthy environments. Not just those which promote physical activity but also promote mental wellbeing by including green space and opportunities to interact with others.
As a provided and commissioner of leisure and cultural services local authorities have further potential to influence health not simply through offering activity and promoting healthy lifestyle but also in the way culture shapes an area and communities within. Local authorities' power of wellbeing enables them to do anything to enhance the well being of an area for example through work with partners who may provide housing or care services to ensure clients needs are being thought of in the round. The wellbeing power has been little used and it remains to be seen if the proposed power of general competence will be better employed to improve health and address inequalities.
The Healthy Communities Programme work stream on the Social Determinants of Health sets out to ensure the vital role that local authorities can play is fully understood and that local government is not only involved but has the capacity, capability and confidence to deliver improvement against the Marmot strategic objectives. Bringing recognition to the health improving outcomes of many of the core functions of local government is a key aspect of this work recognising that the way in which services are delivered is often as important as what is delivered.
As we move forward towards the transfer of responsibility for public health and health improvement from the NHS to local government it is vital that a whole council approach to addressing the social determinants of health is delivered.
3 November 2010