The Milbank Quarterly | A Multidisciplinary Journal of Population Health and Health Policy

The Future of Population Health  (Volume 101)

Quarterly Article

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

Tags:
Centennial Issue
Topics:
Population Health Social drivers of health

Authors:

Tyson H. Brown

Patricia Homan

Citation:
Brown TH, Homan P. The Future of Social Determinants of Health: Looking Upstream to Structural Drivers. Milbank Q. 2023;101(S1): 36-60.

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Policy Points:

  • Policies that redress oppressive social, economic, and political conditions are essential for improving population health and achieving health equity. Efforts to remedy structural oppression and its deleterious effects should account for its multilevel, multifaceted, interconnected, systemic, and intersectional nature.
  • The U.S. Department of Health and Human Services should facilitate the creation and maintenance of a national publicly available, user friendly data infrastructure on contextual measures of structural oppression.
  • Publicly funded research on social determinants of health should be mandated to (a) analyze health inequities in relation to relevant data on structural conditions and (b) deposit the data in the publicly available data repository.

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 health3,19,20,22,25–30 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.

References

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  2.  Pearlin LI. The sociological study of stress. J Health Soc Behav.1989;30(3):241-256. https://doi.org/10.2307/2136956
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  4. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annu Rev Public Health. 2011;32(1):381-398. https://doi.org/10.1146/annurev-publhealth-031210-101218
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  11. Reynolds MM. Health Power Resources Theory: A Relational Approach to the Study of Health Inequalities. J Health Soc Behav. 2021;62(4):493-511. https://doi.org/10.1177/00221465211025963
  12. Michener JD. Politics, Pandemic, and Racial Justice Through the Lens of Medicaid. Am J Public Health. 2021;111(4):643-646. https://doi.org/10.2105/AJPH.2020.306126
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  25. Nagle A, Samari G. State-level structural sexism and cesarean sections in the United States. Soc Sci Med. 2021;289:114406. https://doi.org/10.1016/j.socscimed.2021.114406
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  27. Hatzenbuehler ML. Structural stigma and the health of lesbian, gay, and bisexual populations. Curr Dir PsycholSci. 2014;23(2):127-132. https://doi.org/10.1177/0963721414523775
  28. Samari G, Nagle A, Coleman-Minahan K. Measuring structural xenophobia: US state immigration policy climates over ten years. SSM Popul Health. 2021;16:100938. https://doi.org/10.1016/j.ssmph.2021.100938
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  30. Brown TH, Kamis C, Homan P. Empirical evidence on structural racism as a driver of racial inequalities in COVID-19 mortality. Front Public Health.2022;10:1007053. https://doi.org/10.3389/fpubh.2022.1007053
Citation:
Brown TH, Homan P. The Future of Social Determinants of Health: Looking Upstream to Structural Drivers. Milbank Q. 2023;101(S1): 36-60.

 Back to The Milbank Quarterly

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