Social determinants driving health inequalities

Focussing on lifestyle interventions or individual behaviour fails to acknowledge the role of social determinants in health inequalities. Victim blaming is not the solution.

Where you live, your level of education, employment, income and race have all been shown to be correlated with a range of health outcomes, including oral health. That fact that health is influenced by a range of factors including social, economic, commercial and environmental, as well as individual factors such as genetics and behaviour, is a matter of fact, not opinion. Or at least it should be – because the evidence is overwhelming clear. And yet there are many who continue to argue that it is only individual behaviours that are the key drivers in poor health outcomes, and that social determinants play little or no role. To wit – if people just brushed their teeth and ate less sugar, they wouldn’t have dental disease.

The extension of that line of thinking is that individuals should therefore be held accountable for their own health to the extent that considerations of funding for healthcare are contingent on this premise of individual responsibility. The argument goes something like this: Health resources are scarce and expensive. We don’t want to increase taxes to fund dental care. We therefore need to ration what care is publicly available. Since dental diseases are caused by individual choice and behaviour, people should be accountable for their own health costs. Ergo, dental care should not be publicly funded.

Disease causation is complex. We want it to be simple:

Sugar + bacteria = tooth decay. It’s what we were taught in dental school.

Sugar. What we eat. Choice. Behaviour.

Bacteria. How we clean (or don’t). Choice. Behaviour.

So our model of disease prevention? Measures that focus on people ‘choosing’ to eat less sugar and brush more or better. Individual responsibility.

Yet people don’t exist in a vacuum. We are influenced as much by nurture as we are by nature. Again, that is not contestable. It is a gross simplification to assume that people are always in a position to make ‘healthy’ choices.

Imagine Sarah, who is living with low income and experiencing financial distress. The cost of housing, food and energy are increasing, and she has precarious employment. She cares about her health, and wants to prioritise healthy eating, but she also knows that she has to be careful with money because of her financial situation. Inexpensive healthy food is not available where she lives, so she has the difficult decision to either choose inexpensive but unhealthy food or choose healthy expensive food which puts her financial stability at risk. As a result of her choices, she ends up experiencing tooth decay. Is she responsible for this outcome? How much choice did she really have, if the option of cheap healthy food was actually not available to her? Many people like Sarah are forced to make these difficult choices, balancing their financial position with the need to pay for food, energy and housing. And for many more, they don’t have the luxury of choice.

There is an implicit assumption in the ‘individual responsibility’ model that people are fully cognisant of the risks associated with their behaviours, and that they are able to adequately weigh those risks when making decisions about their health. Assessing risk is difficult at the best of times. It’s hard to make decisions now about possible outcomes that occur long into the future. Even harder when there are many competing financial pressures. There is also for many people an element of gambling when it comes to their health. Causation is not a strictly linear 1:1 relationship. Not every smoker gets lung cancer. Some people with good diets still develop tooth decay. People play the health lottery, thinking ‘this bad outcome won’t happen to me.’ So the idea that someone can overcome the negative impacts of poverty simply by making better choices is both ill-informed and counterproductive.

Health is a complex interplay of factors, none of which can be solely explained away by individual choice or personal responsibility. And that is not to say that we shouldn’t focus on education and behaviour change. Those are important too – it’s not a binary either/or. But a single-minded and myopic focus on individual behaviours ignores the impact of social factors that play an important role. Ignoring these social factors means that disparities in health outcomes are likely to persist, regardless of the actions taken to address individual behaviours.

Whilst social determinants models usually focus on the link between factors related to social disadvantage and their influence on poor health outcomes, it’s worth reflecting on the converse – that many of the determinants of good health are associated with social advantage – education, wealth and secure employment. People who advocate loudly for the individual behaviour model should perhaps reflect on their own advantage and position of privilege if we are going to tackle social inequities and ensure that everyone is able to achieve the best possible health outcomes. Because that is our role as health practitioners.