The social determinants of health (SDH) are the socioeconomic factors operating in the background that ultimately lead to poor health outcomes. These can include education level, community violence, pollution levels and more. Here are places to learn more: 

• A good video introduction to SDH...by the AAMC!   

• A special volume of the Annals of the New York Academy of Sciences from 2010 was devoted to exploring the biology of social economic status (SES).  Scientists from a wide range of disciplines jointly addressed the question: How does SES get under the skin to affect health?

• Non-medical determinants and health outcomes: What is the evidence?
•                    - Galea (2012) - 50% of deaths in the US attributable to social factors.  
                     - McGinnis (2002) many people quote this one: 40% behavioral, 15% social, 5% environmental,
                       10% clinical care
                     - Franks (1993) The effect of insurance on mortality was comparable to that of education,                                income, and self-rated health.
                     - References from the County Rankings (see data sources tab) and America's Health                                          Rankings, which has State by State rankings.  The Public Health Agency of Canada also                                  references SDH as a significant factor in health.

• The Robert Wood Johnson Foundation website features several documents on SDH including A New Way To Talk About the SDH that resonates across the political spectrum.

• The British Medical Association has written a report published in 2011 titled "Social Determinants of Health: What Can Doctor Do." (Download PDF) 

• The WHO Commission on SDH focused on 9 broad areas that contain within them major determinants of health.  They are known as theme or knowledge networks--early child development, employment conditions, globalization, social exclusion, health systems, priority public health conditions, measurement and evidence, women and gender equity, urbanization.  Under priority public health conditions, the Commission outlined an SES/health equity analysis framework around: alcohol, CVD, children’s health/nutrition, diabetes, food safety, mental health, NTDs, oral health, unintended pregnancy and outcome, tobacco use, TB, violence and injury.  

• Proximal and distal determinants - proximal factors refer to physical, behavioral, psychosocial and biological exposures that trigger pathogenic process including gene expression thereby causing disease; distal factors denote environmental, institutional and societal influences.  Nancy Krieger urged us to abandon the confused language of proximal  (downstream) and distal  (upstream, moi guilty) from the public health lexicon and replace them with terms like levels and pathways to more accurately represent the relationships of social determinants of health.

• Income inequality measures: Did you know that there may be 6 (or more) different measures of income inequality? the Gini coefficient, the decile ratio, the proportion of income earned by the poorest 50%, 60% and 70% of households, the Robin Hood index, the Atkinson index and Theil's entropy measure (see the review article by De Maio)

• Government agenies, academic institutions and community organizations are interested in the role of social determinants of health at the local level to implement interventions aimed at improving socioenvironmental conditions.  A group of researchers based at the University of Michigan School of Public Health funded by the CDC compiled a Data Set Directory of Social Determinants of Health at the Local Level (published 2003) organized according to 12 dimentions of social environment--economy, employment, education, political, environmental, housing, medical, governmental, public health, psychosocial, behavioral and transport.  Each dimension is subdivided into various components with suggestions for possible data sources and specific variables that might be used to measure the components of each dimension.

• The Adverse Childhood Experiences (ACE) Study: early exposure to family violence, abusive treatment, neglect, substance use, or separated/divorced parents can lead to health or social problems, risk-taking behaviors, and early mortality. The initial ACE Study was a collaboration between the CDC and Kaiser Permanente analyzing the relationship between childhood trauma and health and behavioral outcomes later in life.  Several countries and with the assistance of the WHO are replicating the ACE Study.

OUR FAVORITE BLOGS:
Physicians and Health Care Reform by Dr. Richard Cooper

Epianalysis
Ted Schrecker

Caring for the underserved

Caring with Compassion - an online curriculum with 7 modules