Social, Behavioral, and Cultural Health Determinants
DQ1
What are social, behavioral, and cultural determinants? How do social, behavioral, and cultural determinants impact public health? Present specific examples within your answer as well as justifying your rationale with evidence. Respond to three other class members’ posts specifically peer-reviewing their answers.Social, Behavioral, and Cultural Health Determinants
DQ2
Very wealthy or influential public figures (such as Bill Clinton and Bill Gates) have become major funders in the global health arena, providing millions to developing countries and/or international organizations. How do you think this will influence the future of public health? What benefits and challenges may develop?
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.Social, Behavioral, and Cultural Health Determinants
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.Social, Behavioral, and Cultural Health Determinants
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
Although varying models exist, consideration of social determinants of health generally includes: individual and community behaviors, economic circumstances, and environmental factors. Our analysis does not intend to be a comprehensive look at all factors that could be considered social determinants – nor does it aim to isolate a set of health determinants outside the realm of the health system. It aims instead to gather data we do have about some of the better-understood factors that may influence health. These data are limited, and won’t allow us to pinpoint, for instance, the effect of income on diabetes outcomes. Rather, these data can give us a sense of whether the U.S. has higher rates of external factors that might negatively influence health outcomes or lead to higher spending relative to similarly sizable and wealthy OECD countries.
The complex nature of social determinants makes it difficult for researchers to estimate the relative contribution to health. Racial health inequalities, for example, can coincide with other socioeconomic factors that affect health, such as income and education. Additionally, the relationship between social circumstances and health is not always unidirectional. For example, having a lower income can lead to healthcare access barriers and difficulty living a healthy lifestyle, while in turn, poor health can lead to an inability to work, and thus lower income. And while cross-national assessments of social determinants of health are a useful compass, comparisons are complicated by differences in measurement, as well as national demographics (including race and age).
In a 2005 article, Philip Alston offered the analogy of two ships passing in the night, each with little awareness of the other, to characterize the relationship between the human rights and development communities. Employing the Millennium Development Goals (MDGs) as a lens, he showed that, although the agenda and interests of the two communities overlap considerably, neither embraces cooperation with any enthusiasm or conviction.1 Much the same could be said about the character of the interaction between the health and human rights community and the social epidemiology and the social medicine communities. On the one side, work on the social determinants of health has rarely acknowledged the potential contributions of a human rights approach. On the other side, rights-based approaches to health, with some notable exceptions, have not engaged in a meaningful way with the growing body of research that demonstrates the significant impact of the social determinants of health and health inequalities on health status and population health.Social, Behavioral, and Cultural Health Determinants
The 2008 report of the World Health Organization Commission on Social Determinants of Health (CSDH) is an important example of the first tendency. While the report, Closing the gap in a generation: Health equity through action on the social determinants of health (hereafter Closing the gap), addresses many of the same issues as does the health and human rights community, its authors seems reluctant to acknowledge this common ground.2 Even when the report uses rights-based terminology, it rarely cites relevant international human rights instruments or notes the potential contribution of United Nations human rights institutions. To offer examples, the report’s first mention of the right to the highest attainable standard of health attributes the right to the Constitution of the World Health Organization and “numerous international treaties.”3 Despite the Commission’s commitment to achieving universal health care, Closing the gap does not refer to Article 12 of the International Covenant on Economic, Social and Cultural Rights until page 158 of the 208-page report, and then only very briefly; nor does the CSDH acknowledge the role of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health (hereafter the Special Rapporteur on the right to health) until page 173. The Committee on Economic, Social and Cultural Rights’s seminal general comment on the right to “the highest attainable standard of health” warrants only a brief citation that is buried in the chapter on political empowerment and a listing as one of the proponents of health for all.4
This reticence to recognize the shared agenda and potential contribution of the human rights paradigm is particularly surprising in view of the Commission secretariat’s recommendation that the CSDH adopt a rights-based approach as an appropriate conceptual framework to advance towards health equity through action on the social determinants of health.5 The secretariat’s framework document explains:
Human rights offer more than a conceptual armature connecting health, social conditions and broad governance principles…. Rights concepts and standards provide an instrument for turning diffuse social demand into focused legal and political claims, as well as a set of criteria by which to evaluate the performance of political authorities in promoting people’s wellbeing and creating conditions for equitable enjoyment of the fruits of development.6
Others have also noted the conspicuous absence of human rights in the CSDH report. Paul Hunt, the former Special Rapporteur on the right to health, expressed disappointment that, despite “the multiple, dense connections between social determinants and human rights,” the report’s human rights comment, while not absent, is “underdeveloped and understated” and “disappointingly muted.”7 Although he recognized the contributions of the report, he characterized the work of the CSDH as “a series of missed opportunities.”8Social, Behavioral, and Cultural Health Determinants
Like Paul Hunt, I suggest that proponents of the social determinants of health and rights-based approaches to health have much to contribute to one another. In contrast with Hunt, whose viewpoint identified the contributions that human rights could bring to the work of CSDH, this article argues that the right to health requires greater attention to the social determinants of health, health inequalities, and power dynamics than these have received to date. A forthcoming companion article will build on Hunt’s concerns to identify how the integration of a human rights paradigm could have strengthened the CSDH report and prospects for implementation of its recommendations.9 In the present article, after presenting a brief overview of the CSDH report, I compare the perspectives of the Commission and those working on health and human rights issues on 1) the social determinants of health and the underlying determinants of health; 2) health inequalities and inequities; and 3) power, money, and resources. Before proceeding, however, it is important to acknowledge that there is considerable diversity in all three communities — social medicine, social epidemiology, and human rights — to which this article will not be able to do justice. In addition, there is already a small group of researchers who bridge the divide between human rights and health equity work.10Social, Behavioral, and Cultural Health Determinants
Eating a low-fat diet, getting regular exercise and watching your weight can help lower risk for heart disease and stroke. But environmental and cultural factors also make a difference. So can how much you make for a living, especially if it barely brings in enough to pay for housing, groceries or the electricity bill.
Social determinants of health are factors that influence where and how people live, learn, work and play. They provide context to a person’s life and can play just as big of a role in affecting health as medications and physical lifestyle changes.
The new prevention guidelines developed by the American Heart Association and American College of Cardiology recognizes that “socioeconomic inequalities are strong determinants” of cardiovascular risk.
Healthcare providers need to address social determinants when working with patients just as much as they might address a smoking habit or strategies to lower blood pressure or cholesterol, said Dr. Michelle Albert, a member of the guideline writing committee.Social, Behavioral, and Cultural Health Determinants
“Social determinants must be part of the cardiovascular prevention conversation with patients. Doctors know these things are important but typically, they’ve just focused on traditional risk factors,” she said.
In a pie chart of cardiovascular disease, “only about 20 percent of cardiovascular risk is genetics. The other 80 percent is either behavioral or environmental,” said Albert, a professor of medicine at the University of California at San Francisco and director of the Center for the Study of Adversity and Cardiovascular Disease.
“What we’ve done with our previous guidelines is focused on behaviors that are traditional risk factors when, in fact, social determinants are driving the show, especially for those communities where socioeconomic adversity and thus gaps in cardiovascular mortality persist,” she said.
Social determinants of health influence a person’s cardiovascular health factors and behaviors. For example, a person’s neighborhood and how safe it feels can have an impact on the ability to both exercise and eat healthy, said Dr. Tiffany Powell-Wiley, chief of the Social Determinants of Obesity and Cardiovascular Risk laboratory at National Heart, Lung, and Blood Institute.
People who feel unsafe where they live may be more likely to stay home, resulting in less physical activity, she said.
“The feeling of being unsafe may cause you more stress and increase stress-related hormones,” she said. “Those stress hormones may then promote weight gain. There’s definite data to support a relationship between that feeling of safety and health markers like weight … and even blood pressure.”
Allowing patients to put context to their lives can be the key to having them follow a healthcare provider’s advice, Powell-Wiley said.
“If you live in a community where there are no sidewalks and there are no opportunities to be physically active, a physician telling you to exercise more may go in one ear and out the other,” she said. “Or if you are told you need to eat a better diet, but you don’t have any access to healthy foods in your community because the closest store is a convenience store or a gas station, the concept of eating healthy may not exist for you.”Social, Behavioral, and Cultural Health Determinants
The new guidelines suggest ways for healthcare providers to embed social determinants into conversations about various risk factors. For example, when talking about diet modifications, “body size perception, as well as social and cultural influences, should be assessed,” the guidelines say.
That’s because some patients considered overweight on paper may think “their body looks perfectly fine” because of cultural beliefs and ideals, Albert said.
Taking a patient’s lifestyle and background into consideration can be critical when trying to counsel people about lowering risks of cardiovascular disease, she said. “Addressing social determinants can give you a bigger bang for your buck, likely, than using a pill.”Social, Behavioral, and Cultural Health Determinants