What are the social determinants of health?

The social determinants of health (SDH) are the social and economic factors that influence people's health. These are apparent in the living and working conditions that people experience every day. The SDH influence health in many positive and negative ways. Extreme differences in income and wealth, for example, have negative health consequences for those who are living in poverty and these effects are magnified when these people are congregated in poor regions. In contrast, those who are well-off and living in well-off regions have better overall health.

SDH influence health positively and negatively

This variation among individuals and groups due to income is referred to as the "social gradient."^1,2 The social gradient illustrates that higher income levels result in better health outcomes, where lower income levels result in poorer health outcomes. Even in affluent countries such as Canada the social gradient exists but is often masked by the high levels of overall population health status (Mikkonen & Raphael, 2010). The social gradient not only represents the effects of income on health but also the importance of income as a means of gaining access to other social determinants of health such as education, food, housing, recreational activities, and other societal resources.

The following is a list of fourteen social determinants of health:²

• Income and Income Distribution
• Education
• Unemployment and Job Security
• Employment and Working Conditions
• Early Childhood Development
• Food Insecurity
• Housing
• Social Exclusion
• Social Safety Network
• Health Services
• Indigenous Status
• Gender
• Race
• Disability

Making the connections

The potential impact of some SDH are not always clear or obvious. Social exclusion, or its opposite, social inclusion, for example, do not generally ignite thoughts of health and wellness for the general population. Commonly when referring to social inclusion it is generally associated with how many friends someone has, how often they go to the movies, or where they tend to spend their time. But from the perspective of a single mother a social exclusion can mean lack of access to emergency child care when she has to stay late at her job. For a teenage boy with depression it can mean the one or two people he reaches out to when he feels he has nowhere else to turn. A neighbour checking in on an elderly woman who cannot leave her house may be the only means of social inclusion she has. Without that neighbour the elderly woman may go days without any other human interaction and, in some cases, personal support care. The social inclusion processes that make up our lives can have a huge impact on our health outcomes.

Education plays an important role in determining health status of an individual, but is more likely to be linked to income, employment, and career success than it is to an individual having a greater store of personal knowledge. With higher levels of educational attainment, individuals have access to less hazardous jobs, and reduce their risks associated with workplace injuries. In addition, their education attainment proves more access to employment with job security, retirement plans, and health insurance that is not covered by government health programs.

In addition, education is also associated with health literacy. Health literacy is the understandings individuals have about their health and how to access health services and health information. Individuals need to understand the health information they are provided to take control of their health. For one person this may mean being able to follow the directions for taking a prescribed medication, knowing where to go when they have questions about their health, or being able to articulate their health concerns to a health care provider. Without adequate health literacy a person is dependent on those around them knowing and providing what they need for their best health.

Determining the outcomes

Governmental social policies have a direct impact on the social determinants of health. How a government - either municipal, provincial, or federal - decides to focus its regulatory legislation and funding can influence health across the country. For example, implementing employment laws that provide employment security, benefits during and if these jobs end, deciding whether to fund early child development programs or supports to seniors, foster care programs, or continuing education can have very different health impacts upon different segments of the population. Those whose SDH needs are left to the whims of the employment market may suffer negative health consequences as a result.

Mikkonen and Raphael (2010) call attention to an issue that many people never consider: When is something a privilege or right of citizen right as opposed to something that has to be purchased as a commodity? Take the example of health care. Some countries offer full coverage for all required health care including prescribed medications, dental care, and home care. Access to health care, in this example, is determined by the decisions of those in political power. But this concept also applies when we consider the important social determinants of freedom from poverty, housing, food, employment, and the ability to participate in society. In many developed nations, governments take on the responsibility of assuring access to these social determinants of health.³ This is clearly not the case in Canada where access to food and housing is clearly not available to many Canadians, family poverty rates are amongst the highest of developed nations, and the evidence indicates that these circumstances leads to adverse health outcomes. Governments - and the citizens that elect them - have the power to determine when access to health care and these other social determinants of are citizen rights or something that should be seen as the condoned results of the operation of Canadian society, and in some cases, a personal liability.

"Poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements, and bad politics".¹

Governments make choices when making SDH-related public policies. Choosing to overlook the impact on the social determinants of health is not a prescription for a healthy Canada. Although the social determinants of health are complex and intertwined, good public policy created by informed governments can strengthen these social determinants and provide means of both promoting health in general and reducing health inequalities to a minimum.

1. Commission on Social Determinants of Health (2008). Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.
2. Mikkonen, J., & Raphael, D. (2010). Social Determinants of Health: The Canadian Facts. Toronto, Canada: York University School of Health Policy and Management.
3. Raphael, D. (2012). Tackling Health Inequalities: Lessons from International Experiences. Toronto: Canadian Scholars' Press.