Social Determinants of Health
March 2015
Course lecturers:
Anca Simionca, PhD Lecturer, Faculty of Sociology and Social Work, Babeș-Bolyai University
Contact information: ancasimionca@gmail.com
Alexandra Brinzaniuc, PhD(c) Research assistant, Department of Community and Behavioral Health, Cluj School
of Public Health, Babes-Bolyai University Cluj-Napoca.
PhD candidate, Department of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, UK
Contact information: alexandra.brinzaniuc@publichealth.ro
Room 909 Cluj School of Public Health, 7 Pandurilor street, Cluj-Napoca; Tel. 0264 402 215
Course objectives: The purpose of this course is to offer students an introduction to the structural
determinants of population health as well as to issues around health inequalities. A set of theoretical
and methodological approaches to the study of social determinants of health are discussed, using a
social-ecological framework. Students will gain a better understanding of social stratification, social
mobility, education, poverty and deprivation, employment and working conditions, discrimination,
housing and living conditions, social cohesion, social support and their impact on health outcomes. By
the end of the module, students should be able to critically discuss these determinants as well as
associated intervention strategies, to improve population health and mitigate health inequities.
Course material: For the courses in the module, you will have to prepare reading from several sources,
all made available by the course lecturers. The distribution of these materials is described in the Course
Schedule.
The seminar and course readings: A set of scientific manuscripts, lay articles and book chapters are
set as readings for each course and seminar. Seminars are structured as a critical readings seminar, so
make sure you undertake all of the required reading as most of the activities will rely on them. Also
within courses, a set of unannounced pop-quizez are embeded in the course activity, with questions
from the respective day’s reading material (more information on the quizzes can be found in the
evaluation section of the syllabus). Thus, you are strongly advised to allow yourself adequate time to
undertake this reading. The assigned readings for each day can be found in the Course Schedule table.
If you have difficulties retrieving or accessing any of these resources please contact course lecturers, in
a timely manner (at least 48 hours in advance), for assistance.
Course evaluation:
Students must achieve at least a total grade of 5 for passing the course. The evaluation throughout the
course will be a mix of:
1) Un-announced (pop-) quizzes (20% of the grade): Eight quizzes will be delivered within eight
different courses (not seminars), and consist of two brief questions each (one multiple choice
question and one short-answer, open-ended question). The questions for each quiz rely on the
readings assigned for the respective day. Each quiz will take 5 minutes to complete , with 2 minutes/
multiple-choice question and 3 minutes/ open-ended question. The questions are projected on the
screen (ppt slide) at any time within the course (beginning, middle or end of class). Students can
obtain a total maximum of 2 points for this component, based on the following grading system for
each quiz:
 2 good answers – 0.4 points
 1 good answer, 1 wrong answer – 0,3 points
 2 wrong answers – 0,2 points
The rationale for grading wrong answers relies in the fact that the questions are discussed and
clarified in class immediately after the quiz, so the mere presence in class is hypothesized to improve
student knowledge. The proposed grading system also allows students to miss one-two quizzes
and/or give wrong answers to some quiz questions, and still receive a the 2 points allocated for this
component of the evaluation.
2) Individual written examination (30%): A final written examination is organized to assess the
understanding of key constructs and theoretical underpinings. The examination is scheduled on 31st
of March. This exam will consist of multiple-choice questions, short open-ended questions and an
essay. Items will be based on the entire curricula of the module, course and seminar topics and
associated readings.
3) Case study presentations (15%): Working in 5 groups of 2 or 3 members, you will have to give a
presentation on a topic regarding a theme of interest in the field of Social Determinants of Health,
using the conceptual framework of the WHO Commission on Social Determinants of Health (CSDH).
Each student will be randomized to a group, in the third seminar (March 16th) when they will also be
introduced to CSDH model. Each team will be assigned to a topic and will have to deliver a
presentation, based on one book chapter from Equity, social determinants of health and public health
programmes (WHO, 2010). The book is available online, in PDF format, here. Teams with 3 members
will be required to add to their presentation 2 additional bibliographical references to support their
case study, in addition to the book chapter. Teams will be randomly assigned to selected case studies,
which need to be presented on the following dates:
Team
1
2
3
4
5
Topic & reading
Alcohol: equity and social determinants (Chapter 2)
Tobacco use: equity and social determinants (Chapter 11)
Cardiovascular disease: equity and social determinants (Chapter 3)
Oral health: equity and social determinants (Chapter 9)
Diabetes: equity and social determinants (Chapter 5)
Date & time of
presentation
March 23rd 12:00
March 23rd 12:15
March 24th 12:00
March 25th 11:00
March 27th 12:00
4) Final project (35%): The final project for this module will represent conducting and reporting on a
Scoping Study to answer a research question of choice, concerning effective strategies in addressing
the wider, structural determinants of health in Romania. Students will work in teams of 3- or 42
stundets. Students can form their teams freely but need to inform Alexandra Brinzaniuc, via email, of
their team structure by Sunday, 15th of March, 23:59. All remaining students will be placed randomly
in teams on Monday, March 16th.
Potential approaches that students can undertake are (but not limited to):
a.
b.
c.
Identifying and documenting a real health problem (such as malnourishment amongst children from a
particular rural area, obesity amongst adolescents in Cluj, diabetes among certain population groups,
violence and injuries among young adults in a certain area, HIV prevalence among drug users, etc) and
identify in the literature structural strategies to address the health problem (effective strategies/ good
practices addressing the wider social determinants of health associated with the health problem such as
improving housing conditions to reduce injuries, micro-financing schemes to alleviate poverty in rural
areas, etc); strategies have to be critically discussed and compared, and a set of culturally-adequate
strategies need to be proposed to be implemented at a local level; local stakeholder consultations should be
incorporated as a sixth stage of the scoping study (see Levac 2010 and Colquhoun 2014) to ensure
theoretical transferability of the findings for the local context as well as to describe future areas of research.
Alternatively, students can start from a structural determinant (such as unemployment, poverty,
discrimination, segregation, educational attainment, housing, etc) and discuss the benefits of implementing
strategies to improve the determinant for a defined population (alleviate poverty or improve housing
standards among certain deprived populations, reduce discrimination and empower selected minorities,
increase employability among chronically ill patients or persons with disabilities, etc). Evidence from the
literature of best practices to improve selected social determinants need to be critically discussed. Again,
stakeholder consultation is critical in both identifying problems as well as discussing realistic intervention
strategies that should be further investigated.
Other approaches can involve focusing on a specific entry-point in the CSDH model and discuss
intervention strategies, based on evidence in the literature and stakeholder consultation. For example, bring
evidence to address differential exposure to stress among low-socioeconomic populations diagnosed with
cardiovascular diseases; or address differential vulnerability in childhood diseases related to poverty and
access to adequate nutrition; or address differential outcomes of tobacco use in relation to its impact on
household expenditures in low-income families, etc. Again, defining the health problem and target
populations, critically discussing intervention options as well as conducting stakeholder consultations are
essential.
Regardless of the strategy of developing the Scoping studies, within their projects, students should
(1) demonstrate a good understanding of the theories around the social determinants of health, (2)
demonstrate strong abilities of critically and comparatively discussing different intervention
strategies as well as (3) show responsiveness to local context and effectively include/ integrate
stakeholder-provided information in research reports. Support for identifying relevant stakeholders
can be provided by course tutors, if this is requested in advance.
Project reports are due on March 31st at 23:59, sent by email to Alexandra Brinzaniuc. The document
must contain 10-15 pages and touch on the following chapters: An executive summary (400 words),
background and significance (study rationale, as well as a description of the community profile/
target population), research questions (exploratory nature), methodology (with literature search
strategy – process and keywords - and stakeholder consultation strategy – selection of stakeholders,
interview guide and process description), results (3-5 significant points and best practices presented
and discussed) and conclusions (with future research directions). Project presentations will take
place on March 31st and should describe the background of your research and associated research
questions, the research strategy/methods following (as much as possible) a scoping study
methodology, the stakeholder consultation process, main results and suggestions for future research.
3
Students are encouraged (but no limited) to use the following resources to guide their scoping
project:
Levac et al (2010). Scoping Studies: advancing the methodology, Implementation Science, 5:69 . The paper is
open access and can be retrieved online here. It offers a good introduction to Scoping Studies and offers a stepwise approach to implementing them, which can support students in developing their own group project.
Colquhoun et al (2014). Scoping reviews: time for clarity in definition, methods and reporting, Journal of
Clinical Epidemiology 67:1291-1294. A brief commentary, building on the Levac (2010) paper, which provides a
clear description of all 6 stages of a scoping review. The document is available on the drive (Colquhoun et al
2014).
5) Bonus points (up to one point per student): Each student can also receive up to one bonus point.
Bonus points can be gained by conducting a book review/book presentation OR writing a brief
reflection essay on a documentary. Book reviews have to be presented within a commonly-agreed
seminar and students wishing to subscribe to conducting one, need to inform the course lecturers
by Friday, March 13th (within Seminar 2). Book reviews/presentations are to be conducted on
one of the two books written by Barbara Ehrenreich’s 1) Nickel and Dimed: On (Not) Getting By in
America or 2) Bait and Switch: The (Futile) Pursuit of the American Dream. Reflection essays need
to be submitted by Thursday, March 19th 2015 at 23:59, and need to derive from watching “Our
School”, a documentary following three Roma children in a process of desegregating schools in a
Transylvanian county. The documentary will be presented on March 18th at 18:00 in the first floor
lecture room, for SPH students. Students do not need to subscribe to undertake a reflection essay,
but rather need to send the essay by email to Alexandra Brinzaniuc by the deadline to be
considered for the bonus point. Students can accumulate fractions of points from multiple sources
(reflection essay on documentary and book review) but cannot be awarded more than one bonus
point in total.
Class attendance:
Class attendance is mandatory for seminars. Students with less than 75% seminar attendance (more
than 3 absences) will not be able to take the final examination (presentation and submission of final
project & sit the final written exam).
Academic honor and integrity:
When conducting your assignments, you are expected to demonstrate the highest level of ethical and
academic conduct. Any attempt of academic fraud (plagiarism or any type of cheating) is a serious
offence which could result in failing the class as well as expulsion from the program. It is your
responsibility, as a student, to ensure that your work is not the subject of plagiarism, and to seek
clarification wherever you are uncertain. More information on the types of plagiarism and strategies
for avoiding them can be found on the College of Political, Administrative and Communication Sciences
website (http://polito.ubbcluj.ro/resurse/formulare-regulamente/reguli-etice-si-deontologice/).
4
Module schedule
Date and
Time
Topic
Thursday
Course 1: What is “the social”
March 12th
09:00-11:00
11:00-13:30
(Anca Simionca)
Readings & activities
(Review of) Johnson, A. (2008). The forest and the trees: Sociology as life, practice, and promise. Temple
University Press. Chapter 1, pages 7- 36 (Full book available on drive Johnson 2008)
Seminar 1
(Anca Simionca)
Friday
13th
March
10:00-12:00
12:00-14:00
Course 2: Theoretical perspectives
on social stratification
Giddens, A (2009). Stratification and social class in Sociology, 6th edition, Polity Press, pp. 432 – 462. (Full book
available on drive Giddens 2009)
(Anca Simionca)
Seminar 2
(Anca Simionca)
Monday
Course 3: Social determinants of
March 16th
health and health inequalities: The
10:00-12:00 Basics
(Alexandra Brinzaniuc)
12:00-14:00
Seminar 3*
(Alexandra Brinzaniuc)
Tuesday
March 17th
10:00-12:00
Course 4: Theoretical models
explaining causal links between
social structure and health
(Alexandra Brinzaniuc)
12:00-14:00
Seminar 4
McCartney et al (2013). What (or who) causes health inequalities: Theories, evidence and implications?,
Health Policy, 113:221-227. (Article available on drive McCartney 2013)
Adler & Stewart (2010). Health disparities across the lifespan: Meaning, methods and mechanisms, Annals of
the New York Academy of Sciences, 1186: 5-23. (available online here)
Optional further reading:
WHO (2010). A conceptual framework for action on the social determinants of health, Social Determinants of
Health Discussion Paper 2, pages 20-49. (available online here).
* In-class discussions on case-study presentations & final projects
Mackenbach, JP (2012). The persistence of health inequalities in modern welfare states: the explanation of a
paradox, Social Science and Medicine, 75(4):761-9. (Article available on drive Mackenbach 2012)
Law, C (2009). Life-course influences on children’s futures in Graham H (ed) Understanding Health Inequalities,
second edition, Open University Press: Berkshire. (Book chapter available on drive Law 2009)
(Alexandra Brinzaniuc)
Wednesday
18th
March
09:00-11:00
11:00-13:00
Course 5: Education and Inequality
Giddens, A (2009). Education in Sociology, 6th edition, Polity Press, pp. 833 – 880. (Full book available on drive
Giddens 2009)
Seminar 5
Student presentation for bonus point:
Ehrenreich, B. (2006). Bait and switch: The (futile) pursuit of the American dream. Macmillan.
(Anca Simionca)
(Anca Simionca)
Afternoon: viewing of the documentary “Our School” and submission of reflection papers (18:00, 1 st floor lecture
room)
5
Thursday
March 19th
15:00 – 17:00
17:00-19:00
Course 6: Employment, working
conditions and health
(Alexandra Brinzaniuc)
Seminar 6
(Alexandra Brinzaniuc)
Friday
March 20th
10:00 – 12:00
12:00-14:00
Monday
March 23rd
15:00-17:00
Course 7: Poverty, relative wealth
and precariousness
(Anca Simionca)
Seminar 7
March 24th
10:00-12:00
12:00-14:00
March 25th
09:00-11:00
11:00-13:00
Standing, G (2011). The precariat: the New Dangerous Class (essay available here)
Course 8: Measuring
socioeconomic status in public
health
Galobardes et al (2004). Indicators of socioeconomic position (part 1), Journal of Epidemiology and
Community Health, 60(1): 7-12. (available online here)
Seminar 8
Galobardes et al (2004). Indicators of socioeconomic position (part 2), Journal of Epidemiology and
Community Health, 60(2): 95-101. (available online here)
Optional further reading:
Geyer et al (2006). Education, income, and occupational class cannot be used interchangeably in social
epidemiology. Empirical evidence against a common practice, J Epidemiol Community Health, 60:804-810.
(available online here)
Course 9: Social ties and health:
social cohesion and social support
Student presentations of case-studies: Teams 1 & 2
Stansfeld, S (2006). Social support and social cohesion in Marmot & Wilkinson (eds) Social Determinants of
Health, second edition, Oxford University Press: New York. (Full book available on drive Marmot 2006)
Seminar 9
Harpham et al (2002). Measuring social capital within health surveys: Key issues, Health Policy and Planning,
17(1):106-11. (available online here)
(Alexandra Brinzaniuc)
(Alexandra Brinzaniuc)
Wednesday
In-class viewing of Unnatural Causes Documentary – Part 7: Not Just a Paycheck (30 mins)
Butler, T and P. Watt (2007). New work and new workers in Understanding Social Inequalities, SAGE, pages
135- 156 (Available on drive Butler 2007)
Student presentation for bonus point:
Ehrenreich, B. (2010). Nickel and dimed: On (not) getting by in America. Macmillan.
(Alexandra Brinzaniuc)
Tuesday
Benach et al (2014). Precarious employment: understanding an emerging social determinant of health, Annual
Review of Public Health, 35:229-53. (available online here).
(Anca Simionca)
(Alexandra Brinzaniuc)
17:00-19:00
Bartley M et al (2006). Health and labor market disadvantage: unemployment, non-employment and job
insecurity in Marmot & Wilkinson (eds) Social Determinants of Health, second edition, Oxford University Press:
New York. (Full book available on drive Marmot 2006)
Course 10: Social mobility
(Anca Simionca)
Seminar 10
(Anca Simionca)
Student presentations of case-studies: Team 3
In-class viewing of Unnatural Causes Documentary – Part 3: Becoming American (30 mins)
Giddens, A (2009). Social mobility in Sociology, 6th edition, Polity Press, pp. 463 – 470. (Full book available on
drive Giddens 2009)
Nunn, A. (2011). European Committee of Social Cohesion. Draft report on fostering social mobility as a
contribution to social cohesion. (Available on drive Nunn 2011)
6
Thursday
March 26th
09:00-11:00
11:00-13:00
Course 11: Race, racism and
marginalization
Student presentations of case-studies: Team 4
In-class viewing of Unnatural Causes Documentary – Part 2: When the Bough Breaks (30 mins)
Invited lecturer TBA, readings accordingly
(Anca Simionca)
Seminar 11
(Anca Simionca)
Friday
March 27th
10:00-12:00
12:00-14:00
Course 12: Place & health
(Alexandra Brinzaniuc)
Seminar 12
(Alexandra Brinzaniuc)
ManChui & Takeuchi (2011). Chapter 5 Race, place and Health in Burton et al Communities, Neighborhoods,
and Health - expanding the boundaries of place, Springer: New York. (Chapter available on drive ManChui 2011)
Komro et al (2011). Creating nurturing environments: a science-based framework for promoting child health
and development within high-poverty neighborhoods, Clin Child Fam Psychol Rev, 14: 111-134. (available online
here)
Optional further reading:
Williams & Collins (2001). Racial residential segregation – a fundamental cause of racial disparities in health,
Public Health Reports, Volume 116, pp 404-416. (available online here)
Monday
March 30th
10:00-12:00
Course 13: Globalization and global
influences of inequality +
Conclusions
Student presentations of case-studies: Team 5
In-class viewing of Unnatural Causes Documentary – Part 5: Place matters (30 mins)
Giddens, A (2009). Sociology, 6th edition, Polity Press, pp. 42 – 66. (Full book available on drive Giddens 2009)
(Anca Simionca)
12:00-14:00
Seminar 13: Policy and
intervention impacts on health
inequalities
(Alexandra Brinzaniuc)
Tuesday
March 31st
09:00-11:00
11:00-13:00
Marmot et al (2012). WHO European review of social determinants of health and the health divide, The Lancet,
380: 1011-29 (available online here)
Williams et al (2008). Moving upstream: How interventions that address the social determinants of health can
improve health and reduce disparities, J Public Health Manag Pract, 14(Suppl): S8-17. (available online here)
Presentation of final projects and
final discussions
Final written exam
7