Social Determinants of Health - Theoretical Approaches

Theoretical Approaches

The UK Black and The Health Divide reports considered two primary mechanisms for understanding the process by which the social determinants influence health: cultural/ behavioural and materialist/structuralist. The cultural/behavioural explanation was that individuals' behavioural choices (e.g., tobacco and alcohol use, diet, physical activity, etc.) were responsible for their developing and dying from a variety of diseases. However, both the Black and Health divide reports found that behavioural choices are heavily structured by one’s material conditions of life, and these behavioural risk factors account for a relatively small proportion of variation in the incidence and death from various diseases.

The materialist/structuralist explanation emphasizes the material conditions under which people live. These conditions include availability of resources to access the amenities of life, working conditions, and quality of available food and housing among others. Within this view, three frameworks have been developed to explain how social determinants influence health. These frameworks are: (a) materialist; (b) neo-materialist; and (c) psychosocial comparison. The materialist explanation is about how living conditions – and the social determinants of health that constitute these living conditions—shape health. The neo-materialist explanation extends the materialist analysis by asking how these living conditions come about. The psychosocial comparison explanation considers whether people compare themselves to others and how these comparisons affect health and wellbeing.

The Wealth of Nations is a strong indicator of population health. But within nations, socio-economic position is a powerful predictor of health as it is an indicator of material advantage or disadvantage over the lifespan. Material conditions of life determine health by influencing the quality of individual development, family life and interaction, and community environments. Material conditions of life lead to differing likelihood of physical (infections, malnutrition, chronic disease, and injuries), developmental (delayed or impaired cognitive, personality, and social development), educational (learning disabilities, poor learning, early school leaving), and social (socialization, preparation for work, and family life) problems. Overall wealth of nations is a strong indicator of population health. But within nations, socio-economic position is a powerful predictor of health as it is an indicator of material advantage or disadvantage over the lifespan. Material conditions of life also lead to differences in psychosocial stress The fight-or-flight reaction—chronically elicited in response to threats such as income, housing, and food insecurity, among others—weakens the immune system, leads to increased insulin resistance, greater incidence of lipid and clotting disorders, and other biomedical insults that are precursors to adult disease.

Adoption of health-threatening behaviours is also influenced by material deprivation and stress. Environments influence whether individuals take up tobacco, use alcohol, experience poor diets, and have low levels of physical activity. Tobacco and excessive alcohol use, and carbohydrate-dense diets are also means of coping with difficult circumstances. The materialist approach offers insight into the sources of health inequalities among individuals and nations and the role played by the social determinants of health.

The neo-materialist approach is concerned with how nations, regions, and cities differ on how economic and other resources are distributed among the population. This distribution of resources can vary widely from country to country. The neo-materialist view therefore, directs attention to both the effects of living conditions – the social determinants of health—on individuals' health and the societal factors that determine the quality of the distribution of these social determinants of health. How a society decides to distribute resources among citizens is especially important.

The social comparison approach holds that the social determinants of health play their role through citizens’ interpretations of their standings in the social hierarchy. There are two mechanisms by which this occurs. At the individual level, the perception and experience of one’s status in unequal societies lead to stress and poor health. Feelings of shame, worthlessness, and envy can lead to harmful effects upon neuro-endocrine, autonomic and metabolic, and immune systems. Comparisons to those of a higher social class can also lead to attempts to alleviate such feelings by overspending, taking on additional employment that threaten health, and adopting health-threatening coping behaviours such as overeating and using alcohol and tobacco. At the communal level, widening and strengthening of hierarchy weakens social cohesion, which is a determinant of health. The social comparison approach directs attention to the psychosocial effects of public policies that weaken the social determinants of health. However, these effects may be secondary to how societies distribute material resources and provide security to its citizens, which are described in the materialist and neo-materialist approaches.