SPECIAL ARTICLEThe Social Determinants of Chronic Disease
Introduction
This review article addresses the concept of the social determinants of health (SDH), its theoretic basis, and its application in selected studies demonstrating a causal link with chronic diseases. According to WHO, the social determinants of health are “the conditions in which people are born, grow, work, live, and age, and the set of forces and systems shaping the conditions of daily life.”1 WHO finds that SDH encompass a wide array of subjects that include not only social behavior but topics as far ranging as health equity, global ecology, the global economy, and similar broadly defined areas.2
For the purposes of this discussion, however, SDH refers to SDH variables directly relevant to chronic diseases and, in some circumstances, obesity, in the research agenda of the Mid-South Transdisciplinary Collaborative Center for Health Disparities Research. The Mid-South region of the U.S. has the highest incidence of obesity, diabetes, heart disease, and cancer in the country.3 SDH in this context include social practices and conditions (such as lifestyles, living and work situations, neighborhood characteristics, poverty, environmental pollution, etc.); SES (income, education, and occupation); stressful circumstances; and racial discrimination, along with economic (e.g., unemployment, business recessions), political (e.g., government policies, programs, and public insurance benefits), and religious (e.g., piety, proscriptions against smoking and drinking) factors that affect the health of individuals, groups, and communities—either positively or negatively.4 Social determinants can have a causal role in fostering illness and disability but conversely can promote prospects for preventing disease and maintaining health.
Once ignored or regarded only as distant or secondary influences on health and disease, social determinants have been increasingly acknowledged as fundamental causes of health afflictions.5, 6, 7 There is evidence that assigning causation solely to biological anomalies has not been wholly successful in accounting for all of the relevant factors in a disease’s pathogenesis and progression, especially in relation to the social behaviors and conditions that caused the person to acquire the disease in the first place.2, 3, 4, 5, 6, 7, 8 Social factors have thus been found to initiate the onset of health problems and in this way serve as a direct cause for a number of diseases. With respect to infectious diseases, there are numerous examples of social determinants having a key role in the onset and course of both local epidemics and larger pandemics, such as the black plague in the 14th century and Ebola in the 21st century.3
Importantly, the effect of social determinants is not limited to infectious diseases; it extends to chronic diseases as well, including cardiovascular disease, Type 2 diabetes, stroke, cancers, pulmonary diseases, kidney disease, and many other ailments.2, 4, 8, 9 Several studies have found that the social context of a person’s life determines the risk of exposure, degree of susceptibility, and the course and outcome of a disease—regardless of whether it is infectious, genetic, metabolic, malignant, or degenerative.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17
Social factors can initiate the onset of the pathology and in this way serve as a direct cause for a number of chronic diseases. Smoking, for example, is associated with more diseases than any other health-related behavior, as seen in its association with more than 21 chronic diseases, including at least 12 types of cancer, six types of cardiovascular disease, diabetes, chronic obstructive pulmonary disease, pneumonia including influenza, and others.8, 18 It might seem that the causal factors are all biological in that it is the tar in smoke from tobacco that causes cancer, impairs blood circulation, and instigates other health problems. Yet, smoking cigarettes and inhaling tar is a learned experience that typically begins socially in the company of someone else instructing the novice.19 Though perhaps not all smokers begin smoking under another person’s tutelage, it appears that almost all do. Growing up in a household where one or both parents smoke, having a spouse who smokes, and regularly socializing with smokers are all social situations producing an environment promoting smoking on the part of an individual. Thus, it is through social interaction that smoking-prone social environments are created that begin the path to lung cancer and various other tobacco-related diseases.
Smokers also show a characteristic social pattern that indicates tobacco use is not a random, individual decision completely independent of social influences. Rather, some people, especially those from socially disadvantaged circumstances, collectively express poor health habits like smoking and have greater exposure to the types of social situations that promote this behavior.8, 19, 20 Smoking patterns, however, are not just about social situations that lead to smoking; they are also about socioeconomic factors that work against cessation (e.g., debt, stress, unemployment).
The result is that smoking today is unusual among people at the higher and middle levels of society and is concentrated among those toward the bottom of the social ladder. Individuals in higher socioeconomic groups were the first to adopt smoking in the early 20th century and other social classes followed, but growing publicity about the harmful effects of cigarettes in the 1960s led to a shift in smoking patterns over time as better educated and more-affluent groups began avoiding the practice.19, 20
According to the National Research Council and the Institute of Medicine, the most important social factors determining health are income, accumulated wealth, education, occupational characteristics, and social inequality based on race and ethnic group membership.10 These variables have direct effects on both unhealthy and healthy lifestyles, high- or low-risk health behavior, and on living conditions, food security, levels of stresses and strains, social disadvantages over the life course, environmental factors that influence biological outcomes through gene expression, and other connections to chronic diseases.
One of the strongest examples of the effect of social determinants of health is found in the Whitehall studies of Marmot et al.21, 22 This research, involving several thousand British male civil government employees, uncovered a distinct social gradient in longevity in which—regardless of the cause of death—those with the highest occupational rank had the lowest percentage of deaths, which increased in a step-wise fashion the lower an individual’s position in the rank structure of the organization. Those at the bottom were three times more likely to die than those at the top, especially from cardiovascular disease. Of interest was the fact that all the jobs were stable, white collar, provided security, were hazard free, and in a socialized system of free health care. There was a suggestion that if a virus was killing as many civil servants as the professional hierarchy seemed to be, the Whitehall buildings should be evacuated and closed.23
Marmot and colleagues22 conducted a second study to confirm their results that included women and found the same pattern. As in the first study, each occupational category had higher mortality than the one above it in the social hierarchy until the top was reached. An interesting aspect of this research was verification of a social gradient linked to differences in hierarchy rather than hardship. When the social gradient in mortality is extended from the Whitehall studies to society generally, the pattern is the same: The upper class has the lowest mortality, the upper middle class the next lowest, and so on down the social scale until the lower class is reached who have the highest mortality. It is not just that people at the top of society live longer on average than those at the bottom, but also that the different classes have shorter lives than those above them and longer lives than those below them. Group differences are depicted as outweighing individual differences in producing health outcomes, but such differences are not caused just by a person’s material circumstances. Rather, a host of other factors were identified as contributing to the gradient, namely, self-esteem, status differences, self-direction in work, control over one’s environment, social capital, and sense of social support—all variables that decline in strength as one descends the social ladder.
There are numerous other examples of social factors acting as a powerful determinant of health outcomes, as seen in studies of end-stage renal disease,24 breast cancer,25 childhood obesity,26 coronary heart disease,27 and cardiometabolic health.28 Research on the social determinants of health has evolved into an increasingly larger field of investigation, as seen in Table 1 listing the number of papers indexed in PubMed (MEDLINE) using the term social determinants. In 2006, only 88 such papers were published, compared with 1,024 in 2015 and 688 in just the first 7 months of 2016.
Section snippets
Selected Social Determinants of Health Theories
In addition to an expansion of social determinants research, there has been a corresponding effort to formulate theoretic perspectives explaining the dynamics of the relationship of such determinants with health and disease. Although there are several theoretic approaches that guide SDH research, four of the most commonly used psychosocial models in medical sociology were selected to briefly discuss in this section. These theories—life course, fundamental cause, social capital, and health
Other Social Determinants of Health Applications
Although it is beyond the scope of this paper to explore the entire literature of SDH research, the authors additionally review three major areas of current SDH research to illustrate their relevance as social determinants: neighborhood disadvantage, social networks, and perceived discrimination.
Conclusions
It is already clear from research on SDH that the debate over whether or not social factors are fundamental causes of health and disease is essentially over. A large body of research currently shows that society can make you sick or promote your health; the next step is to refine the causes and consequences of this phenomenon. To that end, the methodologic approaches and research findings of the Mid-South Transdisciplinary Collaborative Center for Health Disparities Research will be discussed
Acknowledgments
Publication of this article was supported by the National Institutes of Health. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the National Institutes of Health.
This paper was supported by a grant from the National Institute on Minority Health and Health Disparities (U54MD008176).
No financial disclosures were reported by the authors of this paper.
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This article is part of a supplement issue titled Social Determinants of Health: An Approach to Health Disparities Research.