The social determinants of health have been described as “the causes of the causes” of illness. They affect people’s health and well-being in the environment into which “they are born, grow up, live, work and age.”
Key behavioural pathways leading to NCDs and jeopardizing the achievement of SDG3.4 (by 2030, reduce by one third premature mortality and promote mental health and well-being) have long been identified, and frequently the focus in NCD prevention has been on improving diet, reducing smoking prevalence and harmful use of alcohol, and increasing physical activity, as well as managing conditions following diagnosis. Much of this work is within the remit of public health and health professionals. As low- and middle-income countries strive to address NCDs as a major threat to sustainable development, a social determinants approach is increasingly highlighted as one of the important focus areas due to its relevance to all sectors.
Social determinants of NCDs include: socio-economic context; inequality; level of education; gender; ethnicity; social norms; cultural beliefs and practices; social exclusion; income; employment; access to health services; and transportation; social and community support networks, including social cohesion. In addition, public policies (policy coherence) and the economic and political structures and accompanying ideologies shape the adverse circumstances negatively influencing health.
By definition, the social determinants of health are the result of human action and therefore their transformation requires human efforts involving intersectoral and coherent public policies that can be implemented through the whole-of-society and whole-of-government approach for health equity.
The social determinants approach is central to achieving not only SDG targets, including SDG 3.4 on the one third reduction of premature mortality from NCDs, but other related targets as well, such as SDG 3.8 on enhancing universal health coverage. However, aligning policies, regulations and actions across various sectors and stakeholders has proved to be a challenge, as countries strive to implement their NCD commitments and achieve universal health coverage.
Interventions on the social determinants of NCDs can be defined through using analysis of the determinants in shaping interventions across the life-course in order to enable children, young adults and elderly to live up to their full potential and have control over their lives. Taking action to improve the conditions of daily life well before birth, during early childhood, at school age, during reproductive and working ages, are particularly important to improve populations’ mental health and to reduce the risk of those mental health disorders that are associated with health inequalities.
These interventions may include poverty-reduction strategies, social protection measures, community engagement, including addressing social norms and cultural beliefs, enhanced health literacy and tailored health promotion approaches. Furthermore, social determinants of health underpin the implementation of all SDGs due to their interlinked nature and the need for policy coherence and intersectoral interventions, most of which fall outside the health sector.
The health sector, an important social determinant itself, also has an important role within the Health-in-all Policies, whole-of-government and whole-of-society frameworks to act as a facilitator of policy development and coordination across sectors and stakeholders. As a backbone of health systems, medical professionals have a critical role in the prevention and control of NCDs. Therefore, it is important to ensure that healthcare workers are trained to have clinical competency in global health and primary care and understand the preventive strategies for NCDs and their social determinants.
Current medical and nursing curricula, particularly in low- and middle-income countries, have not kept pace with the changing dynamics of public health, health policy and health demographics. As a result, medical education in these countries does not adequately cover the prevention and control of NCDs. Medical education and training should be reoriented by introducing competency-based, health system-connected curricula that reflect national needs and priorities. In addition, continuous education should incorporate knowledge of social determinants for NCD prevention to respond to the demands of evolving health systems, changing disease patterns and growing patient expectations.
• Take stock of available evidence on interventions and public policies to address the social determinants and promote social equity in different contexts for the prevention and control of NCDs
• Highlight the importance of early childhood interventions to prevent NCDs throughout the life-course
• Explore the role of the social determinants of health as modifiable risk factors that, if addressed, could lead to major health improvements in socially disadvantaged and marginalized groups, such as people living with mental health and substance abuse disorders
• Highlight the role of medical education in preparing healthcare workers with clinical competencies to address NCDs and their social determinants
• Highlight examples (delivery platforms, NCD-specific actions) of the successful implementation of the social determinants of health approach through policy coherence and action across sectors, departments, health agencies and community groups for NCD prevention
• Understand the role of enhanced health literacy for action on the social determinants of NCDs
Director, Institute of Health Equity
Department of Epidemiology and Public Health, University College London
South African Medical Research Council
Public Health Agency of Sweden