• By Dartington SRU
  • Posted on Monday 25th July, 2011

Health policy: why social context matters

“There is no simple biological reason why the risk of pregnancy-related death in Sweden is one in 17,400 while it is one in eight in Afghanistan; why the life expectancy at birth of men in the Calton region of Glasgow is 54 years, 28 years lower than that of men in Lenzie, just a few kilometres away.” These striking disparities “reflect avoidable and unnecessary suffering,” a California-based team of healthcare researchers say. Social environments clearly matter for health. Yet these critical factors – the social determinants of health – have been “conspicuously absent” from the recent US healthcare debates.However, the policy situation may now be changing, say researchers from the University of California, Los Angeles (UCLA). The obesity epidemic, for example, is forcing policy makers to recognize the effect of changing social contexts. But the question remains: if health is individual and biological, how do social determinants get “into the body”? How, exactly, does my social context affect my health?The UCLA team, led by Professor of Pediatrics and Public Policy Neal Halfon, sets out to answer this question – and to provide the building blocks on which to base a radical policy shift. What are social determinants, and why do they matter?Most broadly, social determinants can include anything in an individual’s environment. In the past, researchers usually limited themselves to considering family income and social class. In recent years, however, interest has turned toward education, housing, social capital, neighborhood safety, the quality of parenting in early life and even aspects of the natural and human-made environment. Social determinants appear to be important for almost any disease imaginable. A classic study of civil servants, for example, showed that mortality rates were much higher among those in lower employment grades. This “inverse gradient” holds across a range of health conditions, including angina, hypertension and lung cancer, and is observed in all developed countries studied.Children’s health outcomes show similar gradients across a range of conditions. This includes specific diseases and disorders – but, just as seriously, also includes social-emotional and cognitive functioning and general indicators of health such as obesity that set the stage for later health and well-being.And of course, negative social influences early in life – such as exposure to abuse – continue to exert effects on health into mid-life and beyond. “Failure to address these social determinants affects adult health as much as, if not more than, health in childhood,” the authors say. Conversely, social determinants can also have positive effects, as when parents read to children or show interest in their academic progress.How do social determinants get “into the body”?If social context matters for individual health, how do social determinants get “into the body”? The authors outline a few different mechanisms. In one, a process known as “biological embedding,” the biological systems relevant to disease risk get re-programmed. So, malnutrition in the womb can alter a child’s glucose metabolism in a way that predisposes them to obesity and diabetes, particularly if they are later exposed to lots of junk food.In another mechanism, repeated exposure to harmful social determinants builds up over time. Cardiovascular disease, for instance, has a long incubation period. It can build up from before birth, starting with the mother’s poor diet, through stress in childhood, to smoking, inactivity and unemployment in adulthood. A more negative social environment?Traditional support networks have helped to protect children from environmental change, the researchers claim, but they cannot keep up with rapid changes in the social environment. Child poverty rates are increasing; more births are to single mothers; more parents work outside the home and children are spending longer in daycare; children are spending more hours using electronic gadgets. What can be done to make the social determinants of health an advantage, not a disadvantage? A second article sets out some policy proposals from the UCLA team.ReferenceHalfon, Neal, Kandyce Larson, and Shirley Russ. 2010. “Why social determinants?” Healthcare Quarterly 14 (Special issue, October): 9-20.

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