The Future of Social Determinants of Health: Looking Upstream to Structural Drivers

The past three decades of research on social determinants of health have produced a wealth of evidence demonstrating how the conditions of daily life shape population health. Social factors, including access to healthy food, education, income, working conditions, health behaviors, interpersonal discrimination, neighborhood conditions, social relationships, and stress have all been shown to play an important role in health and well-being^.1–8 The majority of research on social determinants of health has focused on proximate or intermediate determinants of health that are conceptualized and measured as individual-level resources and exposures; however, scholars have increasingly called for research that looks farther upstream to assess how structural factors operate as fundamental drivers of population health.^4,9–12

The World Health Organization (WHO) provides a useful conceptual framework on social determinants of health for understanding how large-scale institutions that structure a society shape the distribution of downstream social determinants, as well as their necessity and utility for achieving good health.¹³ Notably, the distribution and value of the social determinants of health are not neutral or uniform across population groups owing to structural oppression. Structural oppression involves interconnected systems of discrimination across societal domains (e.g., educational, economic, social, political, criminal–legal, and health care systems) that create and perpetuate the relational subordination of socially disadvantaged groups (and superordination of advantaged groups). These conditions are reflected in inequalities within institutions, and both reinforce—and are reinforced by—discriminatory beliefs, values, and the distribution of resources.^14–21 For example, in the United States, there are drastic inequities imbedded in our institutional arrangements that constitute structural oppression for Black people¹⁴ and women.^22,23 Structural racism and structural sexism refer to the systematic race and gender based exclusion from resources, power, and opportunity across an array of societal domains.^15,24,22 New lines of research have emerged that are beginning to measure structural racism, structural sexism, structural lesbian, gay, bisexual, transgender plus (LGBT+) stigma, structural xenophobia, and other forms of structural oppression, and examine their links to health^{3,19,20,22,25–30} but this research is still in its infancy. Many additional forms of structural oppression such as cissexism, structural ageism, structural classism, and structural ableism have yet to be conceptualized, measured, or thoroughly examined as structural drivers of health.

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