Abstract
Social determinants of health can be understood as the social conditions in which individuals live and work; conditions that are shaped by the distribution of power, income and resources, as much on a global and national level as on a local level. Social determinants of cardiovascular diseases are found largely outside the healthcare and preventative healthcare systems; but it is important to think in terms of chains of cause and effect, which enable us to see these determinants at work within the system of curative and preventative care, including the management of traditional risk factors. Taking a dynamic perspective on these social determinants of health, and in particular viewing them in a biological and epidemiological context, emphasizes the fact that intervention as early in life as possible is desirable in order to prevent cardiovascular diseases. It is important to act early, before childhood adversities in these critical periods are permanently or irrevocably recorded in the body. In terms of behaviour, focussing health education on adults runs counter to the fact that, with age, it is increasingly difficult to change our behaviour and to overcome biological damage already inflicted. In an area where attention has long been focussed on individual risk factors, underlining the fact that these factors act from infancy allows us to highlight the collective influences on the development of these diseases. Reflecting on health determinants in this way suggests that perhaps the population strategy proposed by Geoffrey Rose may lead to an increase in social inequalities if the modest decrease in risk factors, for example in terms of nutrition, involves the population categories initially most privileged.
Highlights
The relationship between cardiovascular diseases (CVD) and risk factors such as high blood pressure, cholesterol, smoking, diabetes and physical inactivity has been the subject of extensive study, resulting in an abundance of literature
We suggest that social determinants should be juxtaposed with traditional risk factors acting directly on CVD, and be examined as underlying determinants of some CVDs, and, as factors acting along causal chains, influencing the incidence and management of traditional risk factors as well as the management of acute coronary events
There are three issues that highlight the fact that it is essential we improve our knowledge of cardiovascular disease determinants: firstly, social inequalities in health have not disappeared over recent decades, if anything they have increased; secondly, dramatic increases in CVD incidence have been observed after certain rapid social changes, such as in Eastern Europe in the nineties, after the fall of the Soviet Union; and an increase in the incidence of CVD has been observed among some disadvantaged groups.[1]
Summary
The relationship between cardiovascular diseases (CVD) and risk factors such as high blood pressure, cholesterol, smoking, diabetes and physical inactivity has been the subject of extensive study, resulting in an abundance of literature. A recent study presents additional arguments in favour of the causality of this relationship and suggests that several mechanisms are involved.[13] In this study, unfavourable working conditions were measured using the “job strain questionnaire” (Karasek’s questionnaire) The results of this analysis of the Whitehall II study confirm this association and note, for the first time, a dose-effect relationship between exposure to job strain and the onset of coronary heart disease: the longer the period of exposure, the higher the incidence (+40% for one period of exposure, +68% for two periods). This study reminds us of the need to define the elements of workplace organisation that put an individual in a situation in which they may develop “chronic stress” and reinforces the causal link with new arguments, in particular the dose-effect relationship It notes that there are multiple mechanisms at work, acting directly at a biological level or indirectly via health behaviour. Negative social interactions were found to be related to higher blood pressure levels, whereas, among men, at any rate, having supportive co-workers had the inverse effect.[18]
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