Social determinants of child health and well.docx
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Social determinants of child health and well.docx
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Socialdeterminantsofchildhealthandwell
Socialdeterminantsofchildhealthandwell-being
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JianghongLi
CentreforInternationalHealth,SchoolofPublicHealth,CurtinUniversityofTechnology,PerthWA
EugenMattes
TelethonInstituteforChildHealthResearch,CentreforChildHealthResearch,UniversityofWesternAustralia,PerthWA
FionaStanley
TelethonInstituteforChildHealthResearch,CentreforChildHealthResearch,UniversityofWesternAustralia,PerthWA
AnneMcMurray
SchoolofNursingandMidwifery,MurdochUniversity,MurdochWA
ClydeHertzman
HumanEarlyLearningPartnership,UniversityofBritishColumbia,Canada
PP:
3-11
Abstract
ThisEditorialprovidesacriticalreviewoftheprogressinsocialdeterminantsofhealthresearchoverthelasttwodecades,suggestingnewperspectiveswhichmayfurtherourunderstandingofpersistentsocialinequalitiesinhealth.IthighlightstheglobalsignificanceoftheSpecialIssuesettingitinthecontextoftherecentlyreleasedWHOCommissiononSocialDeterminantsofHealthFinalReport(CSDH2008).
TheEditorialintroducesindividualpapersintheSpecialIssueanddiscusseshowtheyareinlinewith,complementorprovidefeedbackto,theWHOCSDHFinalReportanditscallforactionstoclosethehealthgapinageneration.Finally,basedonthearticlesinthisSpecialIssueandemergingthemesoftheglobalresearchandpolicyliterature,itoutlinesanumberofsignificantdirectionsforfutureresearchandactions,frombothmethodologicalandtheoreticalpointsofview.
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Keywords
childhealthanddevelopment,healthinequity,socialdeterminants,socialgradient,intervention,Indigenoushealth,sociology
ArticleText
Strongassociationsbetweensocioeconomicstatus,measuredbysuchfactorsaslevelofeducation,income,andoccupationalstatus,greateraccesstoresourcesandpoliticalpower,andanindividual'shealthandwell-beingarewellestablishedandevidentthroughoutthewholelifecourse.Clearly,socialfactorsarefundamentalelementsofthecausalpathwaystoillhealthanddisease(Link&Phelan1995;Marmot&Wilkinson1999;CSDH2008)andindirectlythroughtheirimpactonearlychilddevelopment.Hencetheyalsoinfluenceourcurrentandfuturewealth(Keating&Hertzman1999).Withthegrowingevidenceoftheimpactofsocialinequalitiesonhealth,policymakersinallcountriesareshowinganincreasedinterestinunderstandingthemandinseekingwaystocreatemoreequitablesocieties.TheimportanceofthistrendischartedintwoeditionsofSocialDeterminantsofHealthbyMichaelMarmotandRichardWilkinson(1999,2006),theestablishmentoftheCommissionontheSocialDeterminantsofHealth(CSDH)bytheWorldHealthOrganisation(WHO),theCSDHFinalReport(CSDH2008),governmentalinitiativestotacklehealthinequalities(theUKDepartmentofHealth2005;EUROTHINE2007;theMinistryofSocialAffairsandHealth-HelsinkiFinland2008;TheUNSpecialRapporteur2008)andtheproliferationofscholarlypublicationsonsocialinequityinhealthinleadingjournals,suchasTheLancet,BritishMedicalJournal,SocialScienceandMedicine,TheNewEnglandJournalofMedicine,theInternationalJournalofEpidemiology,AmericanJournalofPublicHealthandJournalofEpidemiologyandCommunityHealth.
Researchonthesocialdeterminantsofhealthhasmovedbeyondtheinitialstageofsimplisticdescriptionsofdiseasesandillnesspatternsbysocio-economicstatus(Townsend&Davidson1982;Achesonetal1998;Marmotetal1991;Marmot&Wilkinson1999,tocitejustafew),toaquestfordeeperknowledgeofwhatmightbethecomplexmechanismsthatunderpinthecommonlyobservedsocialdisparitiesandgradientsinhealthfromboththeoreticalandempiricalapproaches(Berkman&Kawachi2000;Kellyetal2006;Eckersleyetal2001;Spencer2006;Thrane2006).Whileitisacceptedthatsocialgradientsanddisparityinhealthareuniversalandstrong,thereislessagreementastowhatmightexplainthem.Threedominantperspectivesofferingdifferentexplanationsexist(Thrane2006;Turrell2001;Taylor2001;Raphael2002):
materialisticexplanations,psychosocialperspectives(Marmot&Wilkinson1999;Marmot2004;Kawachietal1997,1999)andlifestyleexplanations.Accordingtothematerialisticexplanations,socialdisparitiesandgradientsinhealthstemfromdifferentialaccesstoeconomicandsocialresourcesthatenablehealthyliving,andtopreventiveandcurativehealthcare,anddifferentialexposurestooccupationalhazardsandunhealthylivingenvironments.Thepsychosocialexplanationemphasisessocialsupport,socialcapitalandperceivedandrelativeincomeinequalityasthemaincausesofhealthinequality.Thelifestyleperspectiveseesdifferentlifestylechoicesindividualsmake,suchassmoking,drinking,dietandexercise,astheprimarycausesofhealthinequality(seeRaphael2002;Thrane2006forareview).Bythemselves,noneoftheseexplanationscanadequatelyexplainthepervasivehealthinequalitysoconsistentlyevidentcrosstimeandspace.Thesocial,economicandbehaviouralfactorshighlightedineachoftheseperspectivesmayjointlyinfluence,mediateormoderateeachothertoproducehealthinequalityandthereisemergingresearchthatattemptstocombinethem(Thrane2006).
However,muchoftheliteratureonthesocialdeterminantsofhealthstilllacksacommonstructuralapproachtoexplainuniversallyobservedhealthinequity.Whilstthereissomeresearchonthelinkbetweenchildhoodsocialandeconomiccircumstancesandadultmorbidityandmortality(DaveySmithetal2001;Osleretal2003;Pultonetal2002;Hayward&Gorman2004),mostfocusprimarilyonadulthealth.Theneedtofocusoninfancyandchildhoodisparamount,giventhatincreasingevidencefromdevelopmentalhealthresearchsuggeststhattheearlyyearsofdevelopmentplayavitalroleincreatingandmaintainingsocioeconomichealthinequalitiesthroughtoadulthood(Keating&Hertzman1999).Fromapathwayapproach,earlydevelopmentfromconceptiontofiveyearsofageiswidelyacceptedasestablishingthefoundationforlearning,behaviourandhealththroughoutthelifecycle(Keating&Hertzman1999;McCain&Mustard1999).Itmayalsohaveanintergenerationalinfluenceonhealthandwell-being.The'biologicalembedding'processoccurringinearlylife(Keating&Hertzman1999:
1),andearlysocialisation(Singh-Manoux&Marmot2005;Kendal&Li2005)thattransmitshealthenhancingvaluesandbehavioursfromparentstooffspring,offersinsightsintohowhealthinequalitybeginsinearlychildhood,persistsintoadulthoodandactsacrossgenerations.Interactionsamonggenetic,psychologicalandsocialinfluencesmayalsobeimportant.Theseperspectivesdeservegreaterattentioninfutureinquiryaboutcausesofpersistentsocialinequalityinhealth.
Formanyyears,theglobalcommunityhasbeenawareoftheimportanceofresearchandpolicydevelopmentrelatedtothesocialcontextsofchildhealth,particularlyinimpoverishednations.Todaytheconcernswithsocialenvironmentsforchildren'shealthhavealsobeenbroughtintoclearfocusincountriesoftheWest,particularlygiventheevidenceofpooroutcomesfortoday'schildrenandyouth(Keating&Hertzman1999;McCain&Mustard1999;TheWorldBank2006;Stanleyetal2005;TheUNICEFInnocentiResearchCentre2007;Lietal2008;CSDH2008;ARACYReportCardOctober2008).Theseissuesarealsorapidlybecomingofgreaterrelevancetomediumandlowincomecountriesastheireconomieschange.ThisisreflectedintheengagementandsupportoftheWorldBank,WHO,UNICEFandOECDencouraginggovernmentsofdevelopingcountriestopromoteearlychilddevelopmentasaninternationalgoaltoenhancehumancapital.However,thecurrentglobaleconomicrecessioncouldposeamajorthreattotheseconcertedeffortstopromotechilddevelopmentworldwide.
Recently,thereleaseoftheWHOCommissiononSocialDeterminantsofHealthFinalReportcallsforclosingthehealthgapinageneration.TheReportoutlinesthreeprinciplesofactiontoreducehealthinequity:
'Improvedailylivingconditions;Tackletheinequitabledistributionofpower,money,andresources;Measureandunderstandtheproblemandassesstheimpactofaction'(CSDH2008:
2).TheReportemphasisesinvestmentsinearlychilddevelopmentandeducationas'powerfulequalizers'andcallsforamorecomprehensiveapproachtounderstandingearlychilddevelopment,andtoearlychildhoodinterventions(CSDH2008:
50-59).Wewelcomethiswell-deservedrecognitionofthecriticalroleearlychildhealthanddevelopmentplaysperpetuatinghealthinequityinadultpopulations.
Itisalsopleasingtoseethatinmorerecentyears,thereisanincreasingrecognitionoftheneedforastructuralapproachtoprovideadeeperunderstandingofthe'fundamentalcauses'ofhealthinequityandtoactionsaimedatreducingit.Insteadofsolelyfocusingonindividualsocioeconomicstatus(egeducation,occupationandincome),individualpsychosocialattributes(egsocialcapital,socialconnectedness,perceivedinequality)andneighbourhoodcharacteristics,thisnewperspectivelooksintothemacroforcesthatultimatelydrivethesocialdeterminantsofhealthandprofoundsocialinjusticeandhealthinequity.Theseincludethenatureofthedominantpoliticaleconomyandneo-liberalisms(Coburn2004;Lietal2008),thewelfarestate(Chung&Muntaner2006;Bambra&Eikemo2009)andglobalisationanditsconsequencesforhealthinequity(Labonteetal2005;Waitzkinetal2005;CSDH2008:
110-144).
Thisspecialissue
Inlinewith,andtocomplementtheWHOCSDHFinalReport,thisSpeci
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