Social Determinants of Health

The social determinants model ‘offers a window into the microlevel processes by which social structures lead to individual health or illness, and offers the opportunity to consider the macrolevel processes by which power, relationships and political ideology shape the quality of these social structures’ (Raphael, 2006, p. 668). However, the very fact that social processes may impact on biological systems in the human body, and that this differs depending on social class, education, and a whole range of factors throughout the life course, must also be explained (Kelly, Bonnefoy, Morgan, & Florenzano, 2006). For example the psychobiological stress response explains how different health outcomes may arise when stressors (e.g. daily hassles, life events) and resistance and vulnerability factors (e.g. social support, coping response) differ between individuals (Brunner & Marmot, 2006). Regardless ot mediating and biological causal factors such as genetic structure, nutritional status or resilience, ultimately ‘there is a plausible causal pathway from a number of social factors or social determinants to biological structures in the individual human body’ (Kelly, Bonnefoy, Morgan, & Florenzano, 2006, p. 12).

A Social Determinants of Health Framework

In the USA, the social determinants of health have been described as ‘conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks’ (Office of Disease Prevention and Health Promotion, 2014). This ‘place based’ framework developed by the Federal Healthy People 2020 includes five key areas circling around a social determinants core: economic stability; education; social and community context; health and health care; and neighbourhood and built environment.1

Other frameworks have attempted to explain different levels of social determinants and the dynamic within an overall construct. For example the Dahlgren and Whitehead (1991) framework2 portrays main determinants operating at different levels, emanating out from:

  • 1. The ‘fixed’ individual characteristics including age, sex, and genetics at the centre
  • 2. Individual lifestyle factors and behaviours surrounding that
  • 3. Social and community supports as a layer between the two prior elements
  • 4. Living and working conditions, which include work, education, agriculture, and food production as well as unemployment, water and sanitation, health care services, and housing
  • 5. At the macrolevel, the overarching societal-level factors including socio-economic, cultural, and environmental conditions

The World Health Organisation (WHO) framework by Solar and Irwin (2010) distinguished further between ‘structural’ and ‘intermediary’ social determinants.’ It illustrates the relationships between different types of determinants, including the health system itself as a determinant, and the overall dynamic that shapes health outcomes for individuals. In the WHO framework, social, economic, and political mechanisms give rise socio-economic positions in which people are grouped according to certain factors including education, occupation, and income with people’s socio-economic positions shaping specific determinants of health status or ‘intermediary determinants’. Driven by their respective social status, individuals experience different exposure and vulnerability to health conditions.

Poor health outcomes can then ‘feed back’ on socio-economic position, for example impacting on employment and income, with inequalities and health outcomes reinforcing each other, as noted above (Dannefer, 2003). The WHO framework defines ‘context’ as ‘all social and political mechanisms that generate, configure and maintain social hierarchies’ (Solar & Irwin, 2010, p. 5), and includes the educational system, labour market, political institutions as well cultural and societal values. Structural mechanisms ‘generate stratification and social class divisions in the society and define individual socioeconomic position within hierarchies of power, prestige and access to resources’ (Solar & Irwin, 2010, p. 5). These mechanisms are rooted in the social, economic, and political processes and institutions. Taken together, the context, structural mechanisms and socio-economic outcome for individuals constitute structural determinants, referred to as the ‘social determinants of health inequities’. These function through a set of intermediary determinants to shape particular health outcomes tor individuals, including material circumstances, behaviours, and biological factors; and psychosocial factors which includes living circumstances, relationships, and social support (Solar & Irwin, 2010).

In all of these frameworks, social determinants influence health across the lifespan at both the individual and the societal level. Despite many of the same social factors impacting greatly on the health of people with disabilities, as a group they are far less visible than other groups within the social determinants discourse (Wolbring, 2011). This chapter attempts to address this by situating our analysis of health and wellbeing for older people with intellectual disabilities within a social determinants framework. Given restrictions ot space, we will tocus primarily on intermediary determinants within a social and community context.

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