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"las circunstancias en que las personas nacen crecen, trabajan, viven y envejecen, incluido el conjunto más amplio de fuerzas y sistemas que influyen sobre... 

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OMS-Concepto de Determinantes Sociales de la Salud

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OMS-Concepto de Determinantes Sociales de la Salud

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La Organización Mundial de la Salud define los determinantes sociales de la salud (DSS) como "las circunstancias en que las personas nacen crecen, trabajan, viven y envejecen, incluido el conjunto más amplio de fuerzas y sistemas que influyen sobre las condiciones de la vida cotidiana". Estas fuerzas y sistemas incluyen políticas y sistemas económicos, programas de desarrollo, normas y políticas sociales y sistemas políticos. Las condiciones anteriores pueden ser altamente diferentes para varios subgrupos de una población y pueden dar lugar a diferencias en los resultados en materia de salud. Es posible que sea inevitable que algunas de estas condiciones sean diferentes, en cual caso se consideran desigualdades, tal como es posible que estas diferencias puedan ser innecesarias y evitables, en cual caso se consideran inequidades y, por consiguiente, metas apropiadas para políticas diseñadas para aumentar la equidad.

A pesar de alcanzar la meta de los ODM de reducir a la mitad la tasa de extrema pobreza, la reducción de esta tasa en la Región casi se ha detenido en los últimos años. Esto tiene implicaciones graves para la Región pues la pobreza repercute directamente sobre el acceso a la vivienda digna, los servicios, la educación, el transporte y otros factores vitales para la salud y el bienestar generales. De hecho, la pobreza es posiblemente el determinante individual más importante de la salud.

Para superar los obstáculos y lograr progresos, es indispensable que las políticas sociales reconozcan la función de género como un fuerte determinante estructural de la salud. Por ejemplo, las mujeres tienen costos de salud mayores que los hombres debido a su mayor utilización de los servicios de atención de salud. Al mismo tiempo, las mujeres corren un mayor riesgo que los hombres de ser pobres, desempleadas o estar contratadas en trabajos que no ofrecen prestaciones de atención de salud.

Al abordar los determinantes sociales de salud se ha hecho claramente hincapié en la importancia de la acción multisectorial la inaceptabilidad de las marcadas inequidades en materia de salud y la salud como derecho humano. Para actuar con respecto a los determinantes sociales de la salud en la Región de las Américas sobre la base de la equidad, es necesario reconocer las causas complejas y a menudo duraderas de la mala salud y la inequidad en materia de salud mediante la investigación desde las ciencias sociales y la epidemiología. Un cúmulo cada vez mayor de pruebas ha dado lugar a la acción intensificada en todo el espectro mundial de salud con una participación notable a nivel nacional en la Región de las Américas. Al abordar las "causas de las causas" que son fundamentales para la buena y la mala salud, el enfoque de los determinantes sociales de la salud puede eliminar algunos de los principales obstáculos que repercuten en la salud y resolver algunos de los problemas de salud de más difícil solución en la Región que están estrechamente vinculados con las dimensiones de la inequidad, y apoyar así la transición progresiva hacia la salud universal.

El marco conceptual de los determinantes sociales de la salud

En la Estrategia para el acceso universal a la salud y la cobertura universal de salud de la Organización Panamericana de la Salud se señala que las recientes mejoras logradas en el ámbito de la salud en toda la Región se debieron en parte a los avances del desarrollo económico y social de los países, la consolidación de los procesos democráticos, el fortalecimiento de los sistemas de salud y el compromiso político de los países para atender las necesidades de salud de sus poblaciones. En esa estrategia se reconoce que las políticas e intervenciones en las que se abordan los determinantes sociales de la salud y se fomenta el compromiso de la sociedad en su totalidad de promover la salud y el bienestar, haciendo hincapié en grupos en situaciones de pobreza y vulnerabilidad, son requisitos esenciales para avanzar hacia el acceso universal a la salud y la cobertura universal de salud. Hay una clara necesidad de seguir realizando esfuerzos para superar la exclusión, la inequidad y los obstáculos para el acceso y la utilización oportuna de los servicios de salud integrales. Es necesario adoptar mejores medidas intersectoriales para influir en las políticas, los planes, la legislación y los reglamentos que abordan los determinantes sociales de la salud, así como en la acción conjunta en este sentido más allá del sector de la salud.
Mandatos y estrategias

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La Organización Mundial de la Salud define los determinantes sociales de la salud (DSS) como "las circunstancias en que las personas nacen crecen, trabajan, viven y envejecen, incluido el conjunto más amplio de fuerzas y sistemas que influyen sobre las condiciones de la vida cotidiana".

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This chapter describes the frameworks the committee reviewed in developing a single unified framework for educating health professionals in the social determinants of health. All of these ten frameworks have unique perspectives that can be grouped into several categories. The first two discussed in this chapter put the community in charge of taking actions to assess and improve population health and the wellbeing of the community. The next three provide a broad public health and systems context for impacting the social determinants of health. The three that follow focus on education and collaboration; one of these addresses health professional education in particular. The discussion then turns to two frameworks that expand upon educational concepts to include collaborations focused on interprofessional education and linkages among different sectors, respectively. Finally, two frameworks involve measuring aspects of health workforce development (health workers in underserved areas and social accountability of health professional schools) that are often overlooked in evaluations. All of these overarching categories are reflected in the committee's framework, which is presented in the next chapter.
PUTTING THE COMMUNITY IN CHARGE

The framework published by Audrey Danaher at the Wellesley Institute (see Figure 3-1) is part of a larger effort to reduce health disparities and improve population health through contributions from the community sector ( Danaher, 2011). Within the context of the framework, the community sector is defined as "the wide range of not-for-profit organizations whose mandate is to work with and provide services to communities to meet local needs." As described in the box to the far right of the figure, a responsive and effective community sector can contribute to reducing health disparities. This is accomplished through direct community engagement that builds trust, provides services that ameliorate the impact of disparities, and mobilizes communities to influence policy on the social determinants of health as noted in the three center circles adjacent to the box. The far left circles describe the conditions in which the community sector functions: the top circle depicts the policies, economics, and social systems that give rise to the social determinants of health, and the bottom circle is the community characteristics that influence the social determinants of health.

As part of their guide to action on rural community health and wellbeing, researchers at Brandon University, the University of Manitoba, and Concordia University in Canada partnered with various stakeholder groups to build the framework seen in Figure 3-2 ( Annis et al., 2004; Ryan-Nicholls, 2004). Stakeholders included

rural community development corporations,

regional health authorities,

Community Futures Partners of Manitoba,

Wheat Belt Community Futures Development Corporation,

Brandon University researchers.

The purpose of the framework was to assist residents of rural communities in self-assessing quality-of-life measures that are listed under the framework as "Being," "Belonging," and "Becoming." Being involves understanding the current state of the community; belonging denotes how the community fits within the broader context; and becoming encompasses all the purposeful activities that are carried out to achieve the community's goals ( Annis et al., 2004; Raphael et al., 1999).

In the center of the framework are the social, economic, and environmental factors that often predetermine a community's health and wellbeing. Stemming from these three circles are ten items that rural residents identified (and tested) as important considerations and additions to the framework. Each item is linked to an easily understood and interpreted indicator that has accessible and available data sources; measures what is important, credible, and acceptable to the residents of the rural community; and has a scientific, traditional, or community basis for inclusion that is considered reliable, trustworthy, and relevant. Through such an analysis of what is valued by rural communities, the residents themselves can begin to understand the current state of their community's health, well-being, and quality of life ( Annis et al., 2004).

PUBLIC HEALTH AND SYSTEMS CONTEXT FOR IMPACTING THE SOCIAL DETERMINANTS OF HEALTH

In 2010, the World Health Organization (WHO) Commission on Social Determinants of Health published a conceptual framework for action on the social determinants of health ( Solar and Irwin, 2010) that it used to orient its work, discussed in Chapter 1 ( WHO, 2008). This framework is displayed in Figure 3-3 and is divided into structural and intermediary determinants. The structural determinants comprise the societal, economic, and political context in which a person is born and lives, which dictates one's socioeconomic position. One's socioeconomic position then sets the stage for the intermediary determinants (material circumstances, psychosocial circumstances, behavioral and/or biological factors, and the health system itself) and the likelihood of exposure to health-compromising conditions. Illnesses caused by poor living conditions can then circle back to the structural determinants if, for example, a person experiences a loss of employment or income, thereby lowering his or her socioeconomic status.

Bridging the structural and intermediary determinants are concepts of social cohesion and social capital. The commissioners who developed the framework acknowledged that the inclusion of these concepts risked depoliticizing approaches to public health and the social determinants of health. However, they opted to include this bridge because they also believed that states could be in a position to promote equity through cooperative relationships between citizens and institutions by developing systems that would facilitate such connections. The final box to the far right of the figure shows the impacts of structural and intermediary determinants on equity in health and well-being and how those impacts can feed back to the structural determinants, having a positive, negative, or neutral influence on future generations.

Frieden (2010) developed a five-tier pyramid as a framework for improving public health (see Figure 3-4). Anchoring the base of the pyramid are interventions that Frieden states have the greatest potential impact on social determinants of health (e.g., poverty reduction, improved education). Next are interventions that benefit the vast majority of populations and are not labor-intensive, such as fluoridated water, followed by interventions that benefit large segments of the population and are more labor-intensive, such as immunizations. The tier above is direct clinical interventions for prevention of certain conditions, such as cardiovascular disease, that have the greatest health impact on individuals. Finally, at the top of the pyramid is education about health, which is believed to be the most labor-intensive intervention with the lowest public health impact.

According to Frieden (2010), since 1994, researchers have put forth public health frameworks that are similar but place greater emphasis on impacting health through clinical health services and the delivery of health care. Unlike these frameworks, Frieden used the social determinants of health to underpin his model.

Bay Area Regional Health Inequities Initiative is a group of local health departments in the San Francisco Bay Area dedicated to addressing health inequities. The initiative developed a health equity framework that depicts the link between health and social inequalities (see Figure 3-5). This framework shows upstream and downstream influences on health, as well as entry points for public health intervention. It broadens the scope of public health to include upstream drivers of health such as social inequities, institutional power, and living conditions (including physical, social, economic and work, and service environments). This framework has been formally adopted by the California Department of Public Health for application to its decision-making process ( BARHII, 2015).

HEALTH PROFESSIONAL EDUCATION AND COLLABORATION

Karen Yoder (2006) developed a framework for service learning in dental education that could be applied to all health professions. Its focus is on planning, implementing, and evaluating service learning. It also allows educators to differentiate between service learning and other forms of community engagement, such as volunteerism, community service, internships, and field education, that may or may not include all the elements of true service learning ( Furco, 1996). True service learning entails an ongoing synergistic effect between learning and service that involves active participation in thoughtfully organized service experiences deigned to meet the actual needs of the community. It also includes structured time for reflection and integration of the service into basic science and clinical courses ( Chokshi, 2010; O'Brien et al., 2014; Yoder, 2006). The goal of service learning is to better prepare health professionals to work and partner effectively with diverse populations and communities, and to equip learners with competencies for interacting with other sectors, particularly within health policy.

As seen in Figure 3-6, service learning is placed in the center of the framework to signify an equal balance between service and learning and between the learner and the recipient of the service. The framework is structured around the four categories of scholarship, partnership, programs, and growth, each of which is further divided into two or three different but complementary components. In total, the framework encompasses ten essential components that are explained in Box 3-1.

Interprofessional education is key for helping health professionals learn to work with other professions and sectors. A previous Institute of Medicine (IOM) committee-the Committee on Measuring the Impact of Interprofessional Education on Collaborative Practice and Patient Outcomes-developed a model of interprofessional education (see Figure 3-7). This model depicts interprofessional education as ongoing and developing over time during a health professional's career, including both formal and informal education, as well as all stages of professional development (foundational education, graduate education, and continuing professional development). It includes four interrelated components: a learning continuum; the outcomes of learning; individual and population health outcomes; system outcomes such as organizational changes, system efficiencies, and cost-effectiveness; and the major enabling and interfering factors that influence implementation and overall outcomes ( IOM, 2015, p. 28).

The Cooperative Extension (the Extension) developed a National Framework for Health and Wellness (see Figure 3-8) that is based on the National Prevention Council Action Plan of the U.S. Department of Health and Human Services ( HHS, 2012). The HHS strategy identifies four areas for prevention efforts: (1) healthy and safe community environments, (2) clinical and community preventive services, (3) empowered people, and (4) elimination of health disparities ( HHS, 2012). These areas are captured in the center of the Extension's framework, in the overall goal to "increase the number of Americans who are healthy at every stage of life" ( ECOP Task Force, 2014).

The Extension's framework also is based on the social-ecological model of Urie Bronfenbrenner (1979), which addresses the relationships among individual, community, and societal factors. That model is captured in the first ring of the framework, "healthy and safe environments" and "healthy and safe choices." The next ring depicts the Extension's six priority areas: health policy issues education; integrated nutrition, health, environment, and agriculture systems; health literacy; chronic disease prevention and management; positive youth development for health; and health insurance literacy. The outer ring identifies key partners with which to collaborate to achieve the Extension's goals: an engaged university system, health professionals, the education sector, the private sector, the public sector, engaged communities, community organizations, and clinical and community preventive services ( ECOP Task Force, 2014).

MONITORING AND EVALUATION

Figure 3-9 depicts a conceptual framework for measuring efforts to increase access to health workers in underserved areas. This framework builds on previous monitoring and evaluation efforts of WHO (2009) and parallels the WHO Commission's social, political, and economic context as illustrated in Figure 3-3. These contextual factors are rarely considered in evaluations of country-led initiatives to attract and retain qualified health workers in underserved areas. Huicho and colleagues (2010) proposed this framework to capture contextual factors and overcome evaluation challenges due to the complexity of interventions and the lack of previously published guidelines.

Based on a systems approach, this framework is divided into inputs (design and implementation), outputs, outcomes, and impact. For each of these divisions, the authors provide examples of indicators for evaluating success. Of particular interest for purposes of this report is the emphasis on education during the input phase, retention of workers as an output, worker performance as an outcome, and improved health status as a measurable impact ( Huicho et al., 2010).

Finally, THEnet created a comprehensive framework to aid schools in examining and learning how to improve health outcomes and health systems performance. This framework is designed to be useful at the individual school level, the network/partnership level, and the broader level. Its purpose is to help schools assess their social accountability, and it is structured around a series of questions under four sections, presented in Box 3-2 ( THEnet, 2015). The entire framework is accessible online ( THEnet, 2015).

BARHII (Bay Area Regional Health Inequities Initiative). A public health framework for reducing health inequities. 2015. [September 22, 2016]. http://barhii​.org/framework.

Bronfenbrenner U. The ecology of human development. Cambridge, MA: Harvard University Press; 1979.

Furco A. Expanding boundaries: Serving and learning. Taylor B, editor. Washington, DC: Corporation for National Service; 1996. pp. 2-6. (Service-learning: A balanced approach to experiential education).

HHS (U.S. Department of Health and Human Services). National Prevention Council Action Plan: Implementing the national prevention strategy. Washington, DC: HHS; 2012.

IOM (Institute of Medicine). Measuring the impact of interprofessional education on collaborative practice and patient outcomes. Washington, DC: The National Academies Press; 2015. [ PubMed: 26803876 ]

Raphael D, Brown I, Renwick R. Psychometric properties of the full and short versions of the quality of life instrument package: Results from the Ontario Province-Wide Study. International Journal of Disability, Development and Education. 1999;46(2):157-168.

Ryan-Nicholls K. Rural Canadian community health and quality of life: Testing a workbook to determine priorities and move to action. Rural Remote Health. 2004;4(2):278. [ PubMed: 15884999 ]

WHO (World Health Organization). Closing the gap in a generation: Health equity through action on the social determinants of health, final report. Geneva, Switzerland: WHO Commission on Social Determinants of Health; 2008. [ PubMed: 19385432 ]

WHO. Monitoring and Evaluation Working Group of the International Health Partnership and related initiatives (IHP+). Geneva, Switzerland: WHO; 2009. (Monitoring performance and evaluating progress in the scale-up for better health: A proposed common framework).

Yoder KM. A framework for service-learning in dental education. Journal of Dental Education. 2006;70(2):115-123. [ PubMed: 16478925 ]

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