Social determinants of child health and well.docx

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