Social determinants

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Social determinants

• Prof Mike Kelly
• Centre for Public Health Excellence
• NICE

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Key problems
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Core conundrum

• Health improvement
• The unintended consequences of health policy and
  health delivery
• Regressive population health worsening
  inequalities

4
Current gaps

• What is effective?
• What is ineffective?
• What is harmful or dangerous?

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Gaps in the evidence

• Gaps in the initial formulation of primary
  research studies.
• Gap between evidence and practice
• Failure to distinguish between determinants of
  health and determinants of inequalities in health

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• Morbidity data much less secure than mortality
  data
• Extremely limited evidence about major policy
  initiatives

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Social variation and social difference

• Different dimensions of social difference
  class, occupation, gender, ethnicity, geography,
  residence
• The highly variegated nature of British society
• Biological and social variation in the population
• Differential responses to interventions in
  different parts of the population

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• Theoretical and empirical dimensions of the
  contours and dimensions of inequality not well
  described.
• The conceptual and operational apparatus for
  describing the mechanism of social determinants
  underdeveloped.

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• The precise nature of the causal pathways to the
  different dimensions of inequality is
  under-investigated
• The health interaction between different aspects
  of inequalities not highly developed.

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What works

• Lack of evidence of what works (less than 0.4 of
  studies)
• Lack of cost effectiveness data
• Preponderance of downstream rather than upstream
  evidence

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Social structure within behavioural change models

• Social factors treated as characteristics of
  individuals.
• Social factors not treated as sui generis
• Universal precepts of human behaviour ignoring
  social variegation

12
What should be done

• Life course
• The division of labour