Social determinants of health

Social determinants encompass things that societies can change, and all of them affect what people do and the circumstances in which they do them. Most research on the social determinants of health has focused on problems. These are briefly summarised before examining implications for the social determinants of good health.

Many well-known risk factors contribute to the prevalence of disease, including smoking, alcohol, poor diet and inactivity. But are these behaviours solely the responsibility of individuals or are there social conditions that predispose people to unhealthy behaviours? International studies show there is a social gradient in health. Most diseases become more common and life expectancy is shorter the lower the social standing. This may be linked to people further down the social ladder having more stressful lives and worse environmental quality, both of which can directly damage health and cognitive functioning. Unhealthy behaviours may be the consequence of disadvantage, rather than, as some believe, ignorance or irresponsibility. According to Richard Wilkinson and Michael Marmot:

"Disadvantage has many forms and may be absolute or relative. It can include having few family assets, having a poorer education during adolescence, having insecure employment, becoming stuck in a hazardous or dead-end job, living in poor housing, trying to bring up a family in difficult circumstances and living on an inadequate retirement pension. These disadvantages tend to concentrate among the same people, and their effects on health accumulate during life. The longer people live in stressful economic and social circumstances, the greater the physiological wear and tear they suffer and the less likely they are to enjoy a healthy old age".¹⁶

They argue that societies will be healthier if people are free from insecurity, exclusion and deprivation, and can play a full and useful role in their society's economic, social and cultural life.

Among the social determinants of health are the 'commercial determinants' of health, defined as "strategies and approaches used by the private sector to promote products and choices that are detrimental to health".¹⁷ The retailing of tobacco products, alcohol, and foods high in sugar, salt and fat is big business and embedded in an economic system that prioritises wealth creation over health improvement. There have been successful efforts to counter the health-damaging effects of commercial interests. Banning smoking in public places, and litigation against tobacco companies, combined with substantial price increases on cigarettes, as well as advertising bans, and reducing visibility and attractiveness of cigarette packets, has led to a substantial decline in smoking related diseases and deaths in almost all countries.¹⁸

Do we drink less if alcohol costs more?

The Scottish government recently tackled the alarming rise in alcohol-related health and social harm resulting from cheaper alcohol leading to higher consumption. In a world first, they set a high minimum unit price that resulted in a 25-year low in alcohol consumption - their lowest level of drinking since records began in 1994. Households that usually bought the most alcohol showed the greatest reduction in alcohol purchases. Minimum unit pricing not only reduces total alcohol consumption but shifts consumption towards drinks with lower alcohol content.

Michael Marmot and colleagues' review Fair Society, Healthy Lives'⁹ makes six policy recommendations that are beginning to be implemented by many regional health organisations.

• 1. Give every child the best start in life.
• 2. Enable all children, young people and adults to maximise their capabilities and have control over their lives.
• 3. Create fair employment and good work for all.
• 4. Ensure a healthy standard of living for all.
• 5. Create and develop healthy and sustainable places and communities.
• 6. Strengthen the role and impact of ill-health prevention.