Definition

 Branch of epidemiology that studies the social distribution and
social determinants of health (Berkman and Kawachi 2000).
 All epidemiology is social epidemiology (Kaufman and Cooper
1999) with the analysis of the social determinants of Health .
 Builds and expands by posing new research questions, utilising
new research methods and influencing government policy
agenda.
History:

 I1674 john Graunut : who was dying during outbreaks .
 1763 Loius rene villerme : social class & work condition as the crucial
determinants of health & diseases.
 1800 physician & other argued that bad air & emanation from
decaying matter cause outbreak of illness , observing that death were
commonly clustered among poor .
 1830 john snow who methodically covered the street of London
collecting statistics documenting the location of outbreak. Snow
identified that contaminated water from communal pumps is the
source of cholera
History cond….

 1844 Freidrich Engels : the horrible working condition &
identified the relationship between these condition & disease.
 1860 Germ theory identifies single causal agent such as
Salmonella Typhi as the cause of disease.
 By the 1950 -60 : clinician & epidemiologist monitoring these
condition to understand the chronic disease caused by
combination of biological social behaviour patterns.

 1960- the health impact of social condition & social class as the key
determinants of morbidity & mortality .
 By the end of 20th century the concept of social causation of disease
gained traction
DIFFERENCE BETWEEN MODERN &
SOCIAL EPIDEMIOLOGY

 MODERN EPIDEMIOLOGY
 SOCIAL EPIDEMIOLOGY
 Bio psychosocial paradigm
 Biological paradigm
 All diseases are biological
phenomena can be described
in fully biological paradigm.
 Disease is reflection of
individual risk factor
 Biology of organism is
determined in multilevel
interactive environment
 Disease are assumed to be
product of mutual interaction
among social factor,individual
factor & biological factor
Goals of Social epidemiology

is to conceptualize, operationalize and test the associations between
aspects of the social environment (families, workplaces, residential
neighbourhoods, the political economy) and population health
 The range of problems studied by social epidemiologist : whether
neighbourhood contexts , or workplace organization, or income
inequality and social cohesion affect the health
What are the social determinants of health?

 "The poor health of the poor, the social gradient in health within
countries, and the health inequities between countries are caused by
the unequal distribution of power, income, goods, and services,
globally and nationally, the consequent unfairness in the immediate,
visible circumstances of peoples lives –their access to health care,
schools, and education, their conditions of work and leisure, their
homes, communities, towns, –and their chances of leading a
flourishing life. This unequal distribution of health-damaging
experiences is not in any sense a natural phenomenon….Together, the
structural determinants and conditions of daily life constitute the
social determinants of health."
(WHO Commission on Social Determinants of Health, 2008)
What are the social determinants of health?

Pathway underlying Social determinant
Marmot & Wilkinson


Why emphasize social determinants?

 Have a direct impact on health.
 Predict the greatest proportion of health status inequity.
 Social determinants of health structure health behaviours.
 Interact with each other to produce health.
Under 5 mortality (per 1000 live births) by
wealth group

Mortality over 25 years according to level in
the occupational hierarchy: Whitehall
(Marmot & shipley , BMJ 1996)

80
70
60
50
Admin
40
Prof/Exec
clercial
30
others
20
10
0
40-64
65-69
70-89
Infant mortality in Brazil by race and
mother's education, 1990

Theories of Social Epidemiology in the 21st
century Ecosocial prospective

 In social epidemiology the three main theoretical framework for
explaining disease distribution are
(1) Psychosocial
(2) Social production of disesase /political economy of health
(3) Ecosocial & other emerging multi level frameworks
Commission on social determinant of health:
closing the gap in generation

 The commissioner overreaching recommendation:
1. 1. Improve daily living condition
2. 2. Tackle the inequitable distribution of power money &
resources
3. Measure & understand , assesses the impact of
action
Improve daily living condition
1.1 Equity from start

What must be done
 Commit & implement a comprehensive approach to early life building
on existing child survival programms & extending intervention in
early life to include social emotional & language /cognitive
development
 Expand the provision & scope of education to include the principal of
early child development (physical social emotional & language).

1.2 Healthy places healthy people

What must be done
 Place health & health equity at the heart of urban governance &
planning
 Promote health equity between rural & urban areas through
sustained investment in rural development
 Ensure that economic & social policy responses to climate change &
other environmental degradation take into account health equity.
1.3 Fair employment decent work

What must be done
 Make full & fair employment & decent work a central goal of national
& international social & economic policy.
 Achieving health equity requires safe ,secure & fairly paid work year
round work opportunities & healthy work balance for all
 Improve the working condition for all worker to reduce their
exposure to material hazard , work related stress & health damaging
behaviour
1.4 Social protection across life course

What must be done
 Establish & strengthen universal comprehensive social protection
policies that supports a level of Income sufficient for healthy living.
 Ensure social protection to those normally excluded .
1.5 Universal health care

What must be done
 Build health care system based on principles of equity , disease
prevention & health promotion
 Ensure that health care system financing is equitable .
 Build & strengthen the health workforce & expand capabilities to act
on the social determinant of health
2. Tackle the inequitable distribution of power money &
resources the structural drivers of the conditions of daily life
globally, nationally, and locally

 2.1 Health equity in all policy system programmes
what must be done
 Place responsibility for action on health & health equity at the
highest level of goverance & ensure its coherent consideration across
all policies.
 Adopt a social determinant framework across the policy &
programmatic function of the ministry of health & strengthen in
supporting a social determinants approach across government.
2.2 Fair financing

What must be done
 Strengthen public finance for action on the social determinants of
health.
 Increase international finance for heath equity & coordinate
increased finance through social determinants of health action
framework.
 Fairly allocate government resources for action on the social
determinant of health
2.3 Gender equity
What must be done

 Address gender biases in the structures of society –in laws & their
inforcement in the way organisation are run & intervention designed.
 Develop finance policies & programme that closes gaps in education
& skills & that support female economic participation.
 Increase investment in sexual & reproductive health services &
programme building to universal coverage & right.
2.4 Political empowerment- inclusion of voice
What must be done

 Empower all group of society through fair representation in decision
making & how society operates particularly in relation to its effect on
health equity .
 Enable civil society to organise & act in a manner that promotes &
realize the political & social right affecting health equity
2.5 Good global governance
What must be done

 Make health equity global development goal & adopt a social
determinant of health framework to strengthen multilateral action
for development .
 Strengthen WHO leadership in global action on the social
determinant of health institutionalizing social determinants of health
as a guideline principle across WHO department
3. Measure and Understand the Problem
and Assess the Impact of Action

3.1 The Social Determinants of Health: Monitoring, Research,
and Training
 Ensure that routine monitoring systems for health equity and the
social determinants of health are in place, locally, nationally, and
internationally.
 Invest in generating and sharing new evidence on the ways in which
social determinants influence population health and health equity
and on the effectiveness of measures to reduce health inequities
through action on social determinants.
 Provide training on the social determinants of health to policy actors,
stakeholders, and practitioners and invest in raising public awareness
Examples of action
 Sweden

 –National health policy with a focus on decreasing health inequity
based on population interventions defined with a social determinants
approach .
 Cuba
 –Intersectoral approach to child health between health and
education sectors resulting in strong interaction between health staff
in polyclinics and other sectors, along with emphasis on early child
development with almost all children (99.8%) attending early child
services.
 Cuba has very low child mortality across all groups and high
educational attainment despite significant economic difficulties
Examples action
New Zealand

 –Whole-of-government national policy to reduce inequities led by health
sector with primary health care reform, now showing reduction in major
health inequity (between health status of indigenous and non-indigenous
New Zealanders)
Thailand
 –Implementation of universal health care coverage without fee-for-service,
using a capitation based system with a primary health care approach
Brazil
 –Implementation of Family Health Programme to improve coverage of
health care using a health team approach, building in intersectoral action,
which is already showing impressive improvements in infant mortality
Government of India

 Indira Aawas yojna
 MNREGA
 Public distribution system
 Rajiv gandhi swasthya guarantee yojna
 ICDS
 VHNSC
 Vridha Pension Yojna
Social Determinants of Health and Primary
Health Care

 Advance holistic view of health, with primary value of health equity
 The Declaration of Alma implicitly referred to the social determinants
 Primary health care starts with the health sector and reaches out to
other sectors
 Social determinants discourse sees health sector as one of the social
determinants
 –Report of the Commission and the upcoming World Health Report
thus complement each other, and the Commission's findings will
inform WHO's revitalisation of primary health care
Progress can be achieved in short time
periods

How society affect health: area of
research

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







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The social determinants of health:
Health behaviours
Material, economic and political determinants of health:
Life course
Social biology
Ecological prospective
General susceptibility of disease
Social support
Social disorganisation
Work stress
Depression & affective disorder
References:

 Chanola Tarani, Marmot Micheal :social epidemiology , Dept of
Epidemiology & public health , University college London
 Kriger Nancy International journal of epidemiology 2001:30: 668-667
 Commission on social determinant of health 2008: final Report World
Health Organisation
 Candace Miller , Chapter 2 , social epidemiology Jones & Bartlett
Publisher
 Equity, Social Determinant & Public Health Programme: World Health
Organisation 2010
 Eric Blas , Social Determinants Approach to Public Health , from
concept to practice