the social determinants of health

PU32CH21-BravemanARI7February201117:34TheSocialDeterminantsofHealth:ComingofAgePaulaBraveman,1SusanEgerter,1andDavidR.Williams21CenteronSocialDisparitiesinHealth,DepartmentofFamilyandCommunityMedicine,UniversityofCalifornia,SanFrancisco,California94118;email:[e-mail],[e-mail]2SchoolofPublicHealth,HarvardUniversity,Boston,Massachusetts02115;email:[e-mail]2011.32:381–98FirstpublishedonlineasaReviewinAdvanceonNovember22,2010TheAnnualReviewofPublicHealthisonlineatpublhealth.annualreviews.orgThisarticle’sdoi:10.1146/annurev-publhealth-031210-101218Copyrightc2011byAnnualReviews.Allrightsreserved0163-7525/11/0421-0381$20.00Keywordssocialfactors,socioeconomic,socialposition,socialpatterningofhealthAbstractIntheUnitedStates,awarenessisincreasingthatmedicalcarealonecan-notadequatelyimprovehealthoverallorreducehealthdisparitieswith-outalsoaddressingwhereandhowpeoplelive.Acriticalmassofrelevantknowledgehasaccumulated,documentingassociations,exploringpath-waysandbiologicalmechanisms,andprovidingapreviouslyunavailablescientificfoundationforappreciatingtheroleofsocialfactorsinhealth.Wereviewcurrentknowledgeabouthealtheffectsofsocial(includingeconomic)factors,knowledgegaps,andresearchpriorities,focusingonupstreamsocialdeterminants—includingeconomicresources,edu-cation,andracialdiscrimination—thatfundamentallyshapethedown-streamdeterminants,suchasbehaviors,targetedbymostinterventions.Researchprioritiesincludemeasuringsocialfactorsbetter,monitoringsocialfactorsandhealthrelativetopolicies,examininghealtheffectsofsocialfactorsacrosslifetimesandgenerations,incrementallyeluci-datingpathwaysthroughknowledgelinkage,testingmultidimensionalinterventions,andaddressingpoliticalwillasakeybarriertotranslatingknowledgeintoaction.381Annu.Rev.Public.Health.2011.32:381-98.Downloadedfrom:34Socialdeterminantsofhealth(SDOH):social(includingeconomic)factorswithimportantdirectorindirecteffectsonhealthWorldHealthOrganization(WHO)Commission:CommissionontheSocialDeterminantsofHealthRobertWoodJohnsonFoundation(RWJF)Commission:CommissiontoBuildaHealthierAmericaSocialadvantageordisadvantage:referstotherelativelyfavorableorunfavorablesocial,economic,orpoliticalconditionsthatsomegroupssystematicallyexperiencebasedontheirrelativepositioninsocialhierarchiesINTRODUCTIONGrowingAttentionintheUnitedStatestotheSocialDeterminantsofHealthTheimpactofabsolutematerialdeprivation—grosslyinadequatefood,clothing,shelter,water,andsanitation—onhealthhasbeenrec-ognizedforcenturies(93);untilrelativelyre-cently,discussionsofsocioeconomicinfluencesonhealthintheUnitedStatesfocusedprimar-ilyonlinksbetweenpovertyandhealth.Overthepast15–20years,however,anewdiscourseonsocialfactorsandhealth—withwiderrele-vancetothegeneralpopulation—hasemergedintheUnitedStates,buildingonearlierworkinEuropeandCanada.Figure1illustratestherapidlygrowingliteratureonthesocial(includingeconomic)determinantsofhealth(SDOH)intheUnitedStatesandelsewhere.TheconceptisbecomingfarlessmarginalintheU.S.publichealthrealmingeneral,notonlyinacademia;theSDOHhavereceivedincreasingattentionfrompublichealthandnonprofitagencies(21,29,88,90,113).Thisgrowingmomentumreflectsacon-fluenceofseveralphenomena:First,anaccumulatingcriticalmassofknowledgeinsocialandbiomedicalsciencesfromtheUnited025507510012519891991199319951997199920012003200520072009NumberofarclesU.S.-publishedor-fundedNon-U.S.YearFigure1IncreasingnumberofstudiesofsocialdeterminantsofhealthintheUnitedStatesandEurope.Source:ResultsofaPubMedsearchfor“socialdeterminants.”Literaturerelatedtohealthoutcomes,indicators,orpromotionwasincluded;health-careliteraturewasnotincluded.Statesandothercountries(1,10,123)hasledtoincreasedunderstandingofhowsocialfactorsinfluencehealthandhasenhancedthescientificcredibilityofrelevantefforts.NotablerecentinitiativesincludetheWorldHealthOrganization(WHO)CommissionontheSocialDeterminantsofHealth(122),theMacArthurFoundationNetworkonSo-cioeconomicStatusandHealth(111),andtheRobertWoodJohnsonFoundation(RWJF)CommissiontoBuildaHealthierAmerica(91).IncrementalimprovementsinhealthwithincreasingsocialadvantagehavenowbeenobservedintheUnitedStates(14)aswellasinEurope(69,92),indicatingtherelevanceofSDOHformiddle-classaswellasthemostdisadvantagedAmericans.SystematiceffortshavedisseminatedthisknowledgeandmadeitcompellingforbroaderU.S.audiences(17,91).AnincreasingfocusamongU.S.researchers,healthagencies,andadvocatesonthecon-ceptofhealthequityhasalsocontributed,encompassingthespectrumofcauses—includingsocialdeterminants—ofracial/ethnicandothersocialdisparitiesinhealththatraiseconcernsaboutjustice(8,15,79,88,113).Finally,U.S.publichealthleadersandresearchershaveincreasinglyrecognizedthatthedramatichealthproblemsweface382Braveman·Egerter·WilliamsAnnu.Rev.Public.Health.2011.32:381-98.Downloadedfrom