Getting social: Public Health’s increasing awareness of the social determinants of health

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Even though the media and industry continue to tell us thatlifestyle choices are both a threat to and the salvation of ourhealth,thereisagrowingconsensusinPublicHealthresearchthathealthandlongevityaresubstantiallydeterminedbynon-medical and non-behavioural factors (Raphael 2006,Richter&Hurrelmann2009). Most of today's health problems canbe traced back to the social conditions in which we live andwork. The report of the WHO Commission on SocialDeterminants of Health is a new milestone in documentingthis shift in perspectives (CSDH 2008). Accordingly, healthand health inequalities are increasingly understood as theresult of an interdependent process of contextual conditions(such as governance and policy), socioeconomic position,health care systems and life circumstances (Starfield 2007).These social determinants influence a broad set of anindividual’s resources as well as biological, psychologicaland behavioural reactions that further shape health. Each ofthese factors contributes to the explanation of health andillness, and constitutes a complex dialogue between structureand agency that is increasingly being rewritten by PublicHealth research. The contributions in the current issue of theJournal of Public Health exemplify the increasing awarenessof Public Health researchers by focussing on welfare stateregimes, social inequalities, psychosocial resources andvarious aspects of health care.Several papers in this issue deal explicitly with the widerdeterminants of health: The first article from Hurrelmann etal. takes a broad perspective and introduces an analysis ofthe impact of different welfare state regimes on populationhealth and health inequalities. The authors present anencompassing overview of the existing social policy andpublic health literature, and provide a framework thatoutlines potential pathways linking welfare policy, livingconditions and population health. The proposed theoreticalapproach on the association between welfare state regimesund health facilitates the understanding of health inequal-ities within and between countries. Using a macro-levelapproach, Chan analyses the impact of demographicchange, economic conditions and health care supply oninfant mortality in Singapore. He shows that the level ofinfant mortally is directly reduced by health care provision,which, in turn, is affected by the level of economic hardship(income per capita and inflation rate) and demographicchanges (marriage level, female education level, birth rate).Stroebele et al. take a closer look at contextual conditionsof individual health by assessing variety and pricing ofselected foods in different socioeconomic districts in Berlin,Germany. Interestingly, when directly comparing thenumber of grocery stores, the variety of fresh fruits andvegetables being offered, and food prices in low vs. highsocioeconomic districts, the authors found no differencesthat would account for health inequalities. Baiden et al.study the association between satisfaction with housing andthe ability to cope with daily demands in Accara, Ghana.Their findings indicate that satisfaction with housing islower among higher age groups, crowded and compoundhouseholds, and less educated people. Taking these andother indicators of housing and socioeconomic conditionsinto account, the ability to cope with daily demands issignificantly reduced for people who are dissatisfied with