The Havana confab brought together public health and social scientists from sixteen different Latin American countries, and focused on three interrelated themes: the social determinants of health; food security and nutrition, and the prevention and control of disease.
During the November 15-18 meeting, the most compelling discussion centered on the difference between the social determinants of health and the social determination of health and the implications of this debate for policy and intervention strategies. The WHO Commission on Social Determinants of Health expanded the “social determinants” of health framework to include the “social determination of health” perspective, but they continued to use the term “social determinants” in this expanded conceptual model. At the Havana meeting, however, the term social determination of health was used to contrast this larger scheme of conceptualization with the traditional framework. The core issue in this discussion was to identify the framework best suited to guide research that enhances understanding of the determinants and mechanisms which shape health outcomes and guide policy-making that illuminates entry points for health intervention. Neighborhood effects on health outcomes was a sidebar to the larger discussion, but deliberations on this question added to understanding the difference between the two concepts.
The discourse caused me to reflect on the subtle, but hugely important, distinctions among social determinants, social determination, and neighborhood effects on health and the implications of this discourse for policy-making and the shaping of health intervention strategies. In this blog, I will outline my views on the topic.
The social determinants and social determination of health frameworks view health and disease as social products, which are unevenly distributed throughout society. Health, then, is a social phenomenon that intersects with health equity and social justice. It is influenced by multifarious social, economic and physical conditions, including economic stability, education, social and community context, health and health care, and neighborhood and built environment, and, as such, it requires an intersectoral approach to research, policy-making, and intervention.
Although similar, important distinctions exist between these two frameworks. The social determinants of health framework is concerned with the influence of social, economic and physical conditions on health outcomes, including quality of life and premature death; and it calls for a policy-action agenda that focuses on the mitigation of these intermediary social determinants of health. The social determination of health framework expands this foci to include the structural determinants of health. So, while the social determinants model is concerned with symptoms, the social determination model emphasizes symptoms and theirroot causes. This framework views social factors, such as poverty, food insecurity, limited education, behavioral, and neighborhood and built environment issues as the outcomes (symptoms) of structural failures (root causes). The socioeconomic and political context (structure), then, decides one’s socioeconomic positionality in society (social class), which, in turn, determines the social factors that influences their health outcomes. Thus, to realize health equity in practice, a policy-action agenda is required that attacks both the structural and socialdeterminants of health.
This is where neighborhood effects comes into play. Both determination frameworks minimize the importance of adverse neighborhood conditions on health outcomes in underdeveloped communities. While both frameworks acknowledge the importance of underdeveloped neighborhoods as a site where social determinants influence health outcomes, they nevertheless minimize the neighborhood setting by juxtaposing it with economic stability, education, social and community context, and health and health care. All five sites are considered equally important as entry points for intervention.
The underdeveloped neighborhood, however, is not just a site; it is the primary site, where the interaction of social factors with the built environment produces a powerful negative synergism that spawn undesirable health outcomes. This expanded neighborhood effects model also includes a structural dimension, where root causes are found. The neighborhood, then, should be the crucial entry point for policy-making and health intervention. Concurrently, to bring about sustainable change, action must also be taken on the structural determinants of these neighborhood-based social determinants of health.