Definition • Branch of epidemiology that studies the social distribution and social determinants of health (Berkman and Kawachi 2000). • All epidemiology is social epidemiology (Kaufman and Cooper 1999) with the analysis of the social determinants of Health . • Builds and expands by posing new research questions, utilising new research methods and influencing government policy agenda.
History: • I1674 john Graunut: who was dying during outbreaks . • 1763 Loiusrenevillerme: social class & work condition as the crucial determinants of health & diseases. • 1800 physician & other argued that bad air & emanation from decaying matter cause outbreak of illness , observing that death were commonly clustered among poor . • 1830 john snow who methodically covered the street of London collecting statistics documenting the location of outbreak. Snow identified that contaminated water from communal pumps is the source of cholera
History cond…. • 1844 Freidrich Engels : the horrible working condition & identified the relationship between these condition & disease. • 1860 Germ theory identifies single causal agent such as Salmonella Typhias the cause of disease. • By the 1950 -60 : clinician & epidemiologist monitoring these condition to understand the chronic disease caused by combination of biological social behaviour patterns.
1960-the health impact of social condition & social class as the key determinants of morbidity & mortality . • By the end of 20th century the concept of social causation of disease gained traction
DIFFERENCE BETWEEN MODERN & SOCIAL EPIDEMIOLOGY • MODERN EPIDEMIOLOGY • Biological paradigm • All diseases are biological phenomena can be described in fully biological paradigm. • Disease is reflection of individual risk factor • SOCIAL EPIDEMIOLOGY • Bio psychosocial paradigm • Biology of organism is determined in multilevel interactive environment • Disease are assumed to be product of mutual interaction among social factor,individualfactor & biological factor
Goals of Social epidemiology is to conceptualize,operationalize and test the associations between aspects of the social environment (families, workplaces, residential neighbourhoods, the political economy) and population health • The range of problems studied by social epidemiologist : whether neighbourhood contexts , or workplace organization, or income inequality and social cohesion affect the health
What are the social determinants of health? • "The poor health of the poor, the social gradient in health within countries, and the health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives –their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, –and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a natural phenomenon….Together, the structural determinants and conditions of daily life constitute the social determinants of health." (WHO Commission on Social Determinants of Health, 2008)
Why emphasize social determinants? • Have a direct impact on health. • Predict the greatest proportion of health status inequity. • Social determinants of health structure health behaviours. • Interact with each other to produce health.
Mortality over 25 years according to level in the occupational hierarchy: Whitehall (Marmot & shipley , BMJ 1996)
Theories of Social Epidemiology in the 21st century Ecosocialprospective • In social epidemiology the three main theoretical framework for explaining disease distribution are • Psychosocial (2) Social production of disesase /political economy of health (3) Ecosocial & other emerging multi level frameworks
Commission on social determinant of health: closing the gap in generation • The commissioner overreaching recommendation: • 1. Improve daily living condition • 2. Tackle the inequitable distribution of power money & resources 3. Measure & understand , assesses the impact of action
Improve daily living condition 1.1 Equity from start What must be done • Commit & implement a comprehensive approach to early life building on existing child survival programms & extending intervention in early life to include social emotional & language /cognitive development • Expand the provision & scope of education to include the principal of early child development (physical social emotional & language).
1.2 Healthy places healthy people What must be done • Place health & health equity at the heart of urban governance & planning • Promote health equity between rural & urban areas through sustained investment in rural development • Ensure that economic & social policy responses to climate change & other environmental degradation take into account health equity.
1.3 Fair employment decent work What must be done • Make full & fair employment & decent work a central goal of national & international social & economic policy. • Achieving health equity requires safe ,secure & fairly paid work year round work opportunities & healthy work balance for all • Improve the working condition for all worker to reduce their exposure to material hazard , work related stress & health damaging behaviour
1.4 Social protection across life course What must be done • Establish & strengthen universal comprehensive social protection policies that supports a level of Income sufficient for healthy living. • Ensure social protection to those normally excluded .
1.5 Universal health care What must be done • Build health care system based on principles of equity , disease prevention & health promotion • Ensure that health care system financing is equitable . • Build & strengthen the health workforce & expand capabilities to act on the social determinant of health
2. Tackle the inequitable distribution of power money & resources the structural drivers of the conditions of daily life globally, nationally, and locally • 2.1 Health equity in all policy system programmes what must be done • Place responsibility for action on health & health equity at the highest level of goverance & ensure its coherent consideration across all policies. • Adopt a social determinant framework across the policy & programmatic function of the ministry of health & strengthen in supporting a social determinants approach across government.
2.2 Fair financing What must be done • Strengthen public finance for action on the social determinants of health. • Increase international finance for heath equity & coordinate increased finance through social determinants of health action framework. • Fairly allocate government resources for action on the social determinant of health
2.3 Gender equity What must be done • Address gender biases in the structures of society –in laws & their inforcement in the way organisation are run & intervention designed. • Develop finance policies & programme that closes gaps in education & skills & that support female economic participation. • Increase investment in sexual & reproductive health services & programme building to universal coverage & right.
2.4 Political empowerment- inclusion of voiceWhat must be done • Empower all group of society through fair representation in decision making & how society operates particularly in relation to its effect on health equity . • Enable civil society to organise & act in a manner that promotes & realize the political & social right affecting health equity
2.5 Good global governanceWhat must be done • Make health equity global development goal & adopt a social determinant of health framework to strengthen multilateral action for development . • Strengthen WHO leadership in global action on the social determinant of health institutionalizing social determinants of health as a guideline principle across WHO department
3. Measure and Understand the Problem and Assess the Impact of Action 3.1 The Social Determinants of Health: Monitoring, Research, and Training • Ensure that routine monitoring systems for health equity and the social determinants of health are in place, locally, nationally, and internationally. • Invest in generating and sharing new evidence on the ways in which social determinants influence population health and health equity and on the effectiveness of measures to reduce health inequities through action on social determinants. • Provide training on the social determinants of health to policy actors, stakeholders, and practitioners and invest in raising public awareness
Examples of action • Sweden • –National health policy with a focus on decreasing health inequity based on population interventions defined with a social determinants approach . • Cuba • –Intersectoral approach to child health between health and education sectors resulting in strong interaction between health staff in polyclinics and other sectors, along with emphasis on early child development with almost all children (99.8%) attending early child services. • Cuba has very low child mortality across all groups and high educational attainment despite significant economic difficulties
Examples action New Zealand • –Whole-of-government national policy to reduce inequities led by health sector with primary health care reform, now showing reduction in major health inequity (between health status of indigenous and non-indigenous New Zealanders) Thailand • –Implementation of universal health care coverage without fee-for-service, using a capitation based system with a primary health care approach Brazil • –Implementation of Family Health Programme to improve coverage of health care using a health team approach, building in intersectoral action, which is already showing impressive improvements in infant mortality
Government of India • Indira Aawasyojna • MNREGA • Public distribution system • Rajiv gandhiswasthya guarantee yojna • ICDS • VHNSC • Vridha Pension Yojna
Social Determinants of Health and Primary Health Care • Advance holistic view of health, with primary value of health equity • The Declaration of Alma implicitly referred to the social determinants • Primary health care starts with the health sector and reaches out to other sectors • Social determinants discourse sees health sector as one of the social determinants • –Report of the Commission and the upcoming World Health Report thus complement each other, and the Commission's findings will inform WHO's revitalisation of primary health care
How society affect health: area of research • The social determinants of health: • Health behaviours • Material, economic and political determinants of health: • Life course • Social biology • Ecological prospective • General susceptibility of disease • Social support • Social disorganisation • Work stress • Depression & affective disorder
References: • ChanolaTarani, Marmot Micheal :social epidemiology , Dept of Epidemiology & public health , University college London • Kriger Nancy International journal of epidemiology 2001:30: 668-667 • Commission on social determinant of health 2008: final Report World Health Organisation • Candace Miller , Chapter 2 , social epidemiology Jones & Bartlett Publisher • Equity, Social Determinant & Public Health Programme: World Health Organisation 2010 • Eric Blas , Social Determinants Approach to Public Health , from concept to practice