--- module: 103-01 language: en chapter: 103 title: "Social Determinants, Health Systems, Economics, and Global Burden" module_title: "Social determinants, inequality, inequity, and population health" source_sha256: 28f386fd0bb1b840d256847c38c6a9ba441475603bb55f90d6df84ca58e545a3 --- # Social determinants and population health ## Determinants and definitions ### Biology interacts with living conditions ### Income, education, housing, work, food, transport ### Environment, connection, law, discrimination, power ### Shape exposure, stress, detection, treatment, recovery ### Clinic sees bodies, population health sees distribution ### Inequality: any measurable difference ### Inequity: avoidable and unjust difference #### Adds a normative claim to make explicit ### Equality: same resources ### Equity: allocate by need and barriers ## Social gradient ### Health improves at each socioeconomic step ### Material resources: nutrition, shelter, access ### Relative position: autonomy, status, chronic stress ### Lifestyle framing mistakes mechanism #### Demands behaviour the environment makes costly ## Education and employment ### Education shapes literacy, income, navigation ### Health affects education: bidirectionality ### Schooling years vary in quality ### Attainment may reflect several pathways ### Work gives income, identity, structure ### Precarious, hazardous, low-control work harms ### Leaving dangerous work may improve health ### Task, schedule, control matter, not job title ## Housing, neighbourhood, food, transport ### Housing: damp, mould, crowding, sleep ### Instability disrupts medicines and follow-up ### Homelessness is not one uniform state ### Ask where people live before advising #### Otherwise a correct plan may be impossible ### Neighbourhoods distribute exposures and services ### Segregation concentrates advantage and disadvantage ### Individual adjustment can remove the pathway ### Food insecurity: restriction alternating with availability ### Advice assuming money and facilities adds shame ### Structural food interventions beyond education ### Transport barriers cause missed care ### Improvements can displace low-income residents #### Evaluate distribution with average benefit ## Connection and discrimination ### Isolation: objective lack of contact ### Loneliness: perceived mismatch in connection ### Illness causes and results from isolation ### Match intervention to the barrier ### Discrimination: interpersonal, institutional, structural ### Alters access and stress physiology ### Racism not a biological property of groups #### Biological effects via unequal treatment, exposure ### Race categories cannot replace genotype or experience ### Intersectionality: systems combine, not add ### Group averages are not individual destiny ## Life course and commercial determinants ### Exposures accumulate, cluster, act in sensitive periods ### Cumulative disadvantage reduces reserve ### Chains of risk, interrupted by protection ### History changes probability, not inevitability ### Corporate products, practices, political activity ### Choice occurs in engineered environments ### Regulation changes defaults at scale #### Anticipate substitution, illicit markets, adaptation ## Access and inverse care ### Availability, geography, cost, acceptability, quality ### Entitlement does not guarantee timely care ### Language, hours, digital exclusion, fear ### Volume without continuity does not improve outcomes ### Unmet need includes the uncounted ### Inverse care: least care where need greatest ### Equal appointment length can be inequitable ### Proportionate universalism scales to disadvantage ## Population strategies and data ### High-risk strategy: large benefit, few people #### Depends on detection and engagement ### Population strategy shifts whole distribution #### Widens inequality if advantaged adopt first ### Combine universal change with targeted support ### Absolute and relative gaps can diverge ### Missing equity data rarely random ### Averages can hide minority decline ## Acting on determinants ### Causal candidates, not therapeutic pessimism ### Clinicians: barriers, adaptation, connection, advocacy ### Policy acts upstream ### Neither level substitutes for the other