 Reviewing approaches and building a comprehensive reference framework for an improved analysis and action on the Social Determinants of Health
When different analyses on SDH are reviewed, three main approaches may be identified, including complementary contributions (Solar & Irwin, 2007)*:
 The psychosocial approach;
The social production of health /disease approach;
The multilevel ecosocial approach.
These three approaches attempt at accounting for health inequities. Even though all of them are based on the analysis of the social distribution of disease, their interpretations are not restricted to the biological aspects, but integrate them with social explanations, with varying emphasis on the population health perspective
The psychosocial approach focuses on the weight assigned to the individual’s perception of his/her own status within unequal societies, which leads to stress and worse health conditions. According to these theorists, the experience of living in social settings of inequality forces people constantly to compare their status, possessions and other life circumstances with those of others, engendering feelings of shame and worthlessness in the disadvantaged, along with chronic stress that undermines health. At the level of society as a whole, steep hierarchies in income and social status weaken social cohesion. This research has inspired a substantial literature on the relationship between perceptions of social inequality, psychobiological mechanisms, and health status. |
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The social production of health /disease approach explicitly addresses economic and political determinants of health. Its advocates do not deny negative psychosocial consequences of income inequality, but stress the need to begin with the structural causes of inequalities. Under this interpretation, the effect of income inequality on health reflects both lack of resources held by individuals and groups, and systematic under-investments in infrastructure (education, health services, environmental controls, availability of food, quality of housing, occupational health regulations, transportation, etc.). Political decisions and economic processes shape a cluster of material conditions that have an impact on the health of the population. |
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More recently, the multilevel ecosocial approach has sought to interpret inequities in health as the cause and the result of a dynamic, historical and ecological relationship. This approach seeks to develop analysis of the population patterns of health, disease and well-being as biological expressions of social relations, and grasp how social relations influence our most basic understandings of biology and our societal constructions of disease. More than simply adding biology to social analysis, this approach seeks to envision a more integrated and complex view of the changing population patterns of health. |
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But, what is the contribution of these approaches?
These approaches provide a deeper insight into the mechanisms through which social determinants influence health, by recognizing a series of complementary, non-mutually-excluding explanations: :
Social selection: This perspective implies that health determines a person’s socioeconomic position and not the other way around. Health exerts a strong effect on the attainment of social position, through social mobility, through which the healthier are in better conditions to move up the social ladder than the ill or disabled.
Social position: By complementing the mechanism above, in this perspective social position determines health through intermediary factors. Health problems are more likely to develop in the lower socioeconomic groups, in an indirect manner. Socioeconomic health differences occur when the quality of these intermediary factors in unevenly distributed between the different socioeconomic classes.
Life course perspective: Within an individual life course, across generations and at the population level, this perspective helps identify critical periods in the life of an individual, paying attention to the timing of exposure to risk as well as to the accumulation of risks over time. It particularly facilitates the understanding of the concept of “timely” intervention in the lifelong process (early childhood, childhood, adolescence, adulthood).
Food-for-Thought Activity
*Solar, Orielle & Irwin, Alec. Discussion paper for de Commission of Social Determinants of Health, Ginebra, Abril de 2007.
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