Social determinants of Health’s universe. Third part. Marcio Ulises Estrada Paneque. MD. PhD.* Genco Estrada Vinajera. MD.** Caridad Vinajera Torres. PhD.***

Some questions. Why the equity and social justice in health constitute ethical guides to build bases and suggest public policies? Why the frame of the HHRR offers structure for the approach of the social determinants in health? In what extent globalisation has contributed to tie its results of health equity and social justice in populations?

SDH frame of reference. Different analyses around SDH identifies three main boardings, with complementary contributions (Solar & Irwin, 2007): Psycho-social approach Social production of the disease-health Eco-social approach with multiple reference levels. All of them look explain health inequities. Although don’t leave from disease social distribution analysis, its interpretation is not reduced to biological aspects that are integrated to social explanations with different emphases in the prospect of population health

SDH. Psychosocial approach. It emphasizes the weight that has personal status perception in unequal societies, which leads to tension and worse conditions of health. In this construction, individual life in inequity situation forces to compare status, possessions and another condition of life with others, generating feelings of devaluation and disadvantage, conflicts and deterioration in the health. At social level, income hierarchies and status debilitate social cohesion. Thus are related social perception of inequity, psycho- biological mechanisms and situation of health

Social production of health/disease. It emphasizes economic and political determinants. It does not deny psycho-social consequences of inequity in the income, but argue the necessity of begin from the inequity structural causes. It explains that the inequity reflects lack of resources (groups and individuals) and lack of investment in the infrastructure (environmental education, services of health, controls, food availability, quality of house, environmental regulations of occupational health, medical controls, transport, etc)

Ecosocial approach. Its multiple reference levels look for interpret health inequity like cause and result of a dynamic, historical and ecological relation. It proposes to study the rule and behaviors of population health, disease and well-being together like biological expressions of social relations. More than to add biological and the social elements, looks for integrate a complex vision of the population health changes.

Different approaches contributions. Allow understand the mechanisms by which the determinants influence the health, with explanations that are not mutually excluding: - Social selection, where health determines socioeconomic position and not the inverse process. Health exerts an important influence in the profit of social positions as a result of the social mobility, through which the healthy ones are in better conditions for ascending than those that suffer diseases or incapacities.

Different approaches contributions. -Social Position, complements previous mechanism and determines health through intermediary factors. Health problems have majors possibilities of being developed in lower socioeconomic groups, mainly in indirect form. -Perspective of the life course (individual, through generations or concerning populations). It allows to detect critic periods in the life, exposure time to the risk importance and risks accumulation throughout the time. Facilitates intervention “in time” in temporal process (early childhood, childhood, adolescence and adults.

Reflection on factors and mechanisms. Which characteristics have, in form and magnitude, health inequalities and ? What contribute to the different perspective or approaches for SDH interpretation? Which are the differentials or vulnerability (that led to health), and its consequences? How can extent policies and inter-sectoral strategies to drive on the SDH deep causes?

SDH perspective. A strategic frame to act on the SHD adopts a concept of social position like central concept to interpret health inequities mechanisms, that generate power distribution, wealth and risks. From this perspective there are: - Structural determinants, defined by the social stratification and its mechanisms of maintenance. - Intermediaries determinants, regarding factors and specific social circumstances.

Structural SDH approach. Consider social stratification like central factor in SDH understanding, productor of inequality in the power, prestige, income and wealth in different socio-economic positions. Consider mechanisms that influence in health results from social stratification operate through social context (assigns to individuals and groups different social positions, create hierarchies, establish market of work, educative system, political institutions and sociocultural values)

Structural SDH approach. Consider the differential exposure to health and health damages; the differential vulnerability in health conditions and material resources availability according to population groups. Consider differentials consequences in health and disease conditions for groups with more disadvantages.

Intermediaries SDH approach. Structural determinants promote that intermediary determinants operate: Material circumstances: quality of house, food access and physical environment conditions Psycho-social circumstances: social tensions (stress, violence, coercion, etc, gender and ethnic group tensions, and change of the life styles. Biological and behavioral factors: like nutrition, physical activity, alcohol and tobacco consumption, and genetic factors.

How it interact? Social stratification generates unequal exposure to conditions of risk disease and differential vulnerability, in conditions of health and resources available materials. It determines differentials consequences of the results of health Degree of social cohesion affects the structural and intermediaries factors. Magnitude of the problem, hits morbidity & mortality and affects the economic and social growth.

Change’s requirements. To reduce the inequities in health entails: - To change power distribution within the society. - To benefit disadvantaged groups, in several levels. - Action on the SDH is a political process, that involves social agencies, community and State in a collective action.

Change’s requirements. -Empowerment of vulnerable groups. - Surpass depoliticized approaches in State for the equity promotion. -Generate inter-sectoral policies to attack the deep causes of the differential vulnerability and the risks exposure differential.

Health systems like SHD. Policies that approach health problems with preventive and curative actions trough improvement of health services effectiveness. In order to prevent diseases between people and groups with high risk, with individual actions on life styles. Health systems that tries to improve the equity in health.

Health systems like SDH. Health systems is a result of social and political processes. It are socially determined and a SDH. Its organization and values affect people to exposure and vulnerability. Well designed can solve exposure inequality and vulnerability between population groups (equity in access, inter-sectoral promotion, communitarian participation in the decisions and with innovating policies).

Primary attention (PHC) and SDH. Both concepts prioritize equity in health and social justice. PHC is an approach for Health Systems and society with the intention of reaching health equity (“Health for All”). SDH offer an analysis of how existence of inequities in health include society as a whole.

PHC and SDH. Both insist on health promotion and prevention and increasing accessibility to the resources for the health and protection of diseases. PHC and SDH center in the paper of communities to guarantee their health

PHC and SDH. SDH analysis in PHC considers the impact on the health of the communitarian factors, like social inclusion and exclusion, relative social status and communitarian aid and flexibility. Actions on the SDH in PHC demand of marginalized communities empowerment.

Inequity facts. Even in the developed world the more socioeconomic affected groups live less and have always a bigger morbidity than the rich one. Globally exists differences in the way that persons can develop healthy life. Health levels are keys to measure that differences

Requirements for SDH approach application. Design a capacity map to clarify necessary knowledge, skills and attitudes and to stimulate a new thought in the health phenomena explanation, disease and the death. Three key functions have been identifies for which twelve capacities are identified.

Key purpose. To reduce inequities and to advance to inclusive, democratic, sustainable and healthful societies through a participating work of decision makers, civil society and academy. Profit of reflection, consensus, learning and design, implementation and evaluation of public policies directed to the construction of a society of men and women more free and healthy.

Key strategies. Articulate different actors involved in decision making to construct a common vision, produce models and methodologies for the design and implementation of public politics with SDH approach. Objective: Diminish inequities and its impact in society welfare. Design learning and communication strategies that may useful to communities and institutional capacities in SDH application. Produce useful models and methodologies for the design and implementation of the public policies with SDH focus.

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