Social work theory · Volume C: Ecological & Contextual
Social determinants of health
The social determinants of health are the conditions in which people are born, grow, live, work and age, and the wider distribution of power, money and resources that shapes those conditions.
1. What it is
The social determinants of health are the conditions in which people are born, grow, live, work and age, and the wider distribution of power, money and resources that shapes those conditions (Commission on Social Determinants of Health [CSDH], 2008). The framework holds that most differences in health between social groups are produced by social and economic arrangements. Health care and individual behaviour matter, but they explain a smaller share of population health than income, education, employment, housing and social position (Marmot, 2005). Because these conditions are socially produced, the resulting differences are regarded as avoidable and unfair. For social work, the framework provides an evidence-based explanation of why disadvantage and ill health cluster together and a mandate to act on the conditions of daily life.
Health inequities and the social gradient. Health inequalities are measurable differences in health between groups. Health inequities are those differences that are avoidable and unjust (CSDH, 2008). The Whitehall studies of British civil servants showed a social gradient: health worsens at each step down the occupational hierarchy, not only among the poorest (Marmot et al., 1991). The gradient means that disadvantage affects the whole population in graded ways.
WHO Commission on Social Determinants of Health (2008). The Commission was established by the World Health Organization in 2005 and chaired by Michael Marmot. Its final report, Closing the Gap in a Generation, made three overarching recommendations: improve daily living conditions; tackle the inequitable distribution of power, money and resources; and measure and understand the problem and assess the impact of action (CSDH, 2008; Marmot et al., 2008). Its conceptual framework distinguished structural determinants, such as social class, gender, ethnicity, governance and policy, from intermediary determinants, such as material circumstances, psychosocial factors, behaviours and the health system (Solar & Irwin, 2010).
Michael Marmot. Marmot is the epidemiologist most closely associated with the framework. His work links social position to health through material deprivation and through psychosocial pathways such as control over one’s life, social participation and chronic stress (Marmot, 2005, 2015). He argues that health inequities are a measure of social justice.
Dahlgren and Whitehead’s rainbow model. Dahlgren and Whitehead (1991) represented the determinants of health as concentric layers around the individual. At the centre are age, sex and constitutional factors. Surrounding layers include individual lifestyle factors; social and community networks; living and working conditions (such as education, work, unemployment, water and sanitation, health care services, housing and food production); and, at the outer layer, general socioeconomic, cultural and environmental conditions. The model shows that individual behaviour is shaped by the layers around it, and it remains one of the most widely used teaching diagrams in public health.
Proportionate universalism. Proportionate universalism was proposed in the Marmot Review of health inequalities in England, Fair Society, Healthy Lives (Marmot et al., 2010). It holds that actions to reduce the gradient should be universal, but with a scale and intensity proportionate to the level of disadvantage. Purely targeted programs miss most of the gradient and can stigmatise, while purely universal programs may benefit the advantaged most. Carey et al. (2015) developed a framework for applying the principle to policy design and service delivery.
Australian evidence. Australian data show the same patterns. The Australian Institute of Health and Welfare (AIHW, 2021) reports that people in the highest socioeconomic areas live more years in full health and that people in remote and very remote areas carry a higher burden of disease than those in major cities. Analysis reported in the Aboriginal and Torres Strait Islander Health Performance Framework 2017 estimated that social determinants such as employment, income, education and housing accounted for 34% of the health gap between Indigenous and non-Indigenous Australians, and selected health risk factors for 19% (Australian Health Ministers’ Advisory Council [AHMAC], 2017). These findings locate the health gap in historical and structural conditions, including the effects of colonisation and racism.
2. Historical development
| Period | Development |
|---|---|
| 1840s | Chadwick, Engels and Virchow link disease to poverty, housing and working conditions |
| 1974–1976 | Lalonde Report (Canada) and McKeown’s analysis question the dominance of medical care in explaining population health |
| 1978–1980 | Whitehall study findings on the occupational gradient; the Black Report on health inequalities in Britain |
| 1986 | WHO Ottawa Charter for Health Promotion names peace, shelter, education, food and income as prerequisites for health |
| 1991 | Dahlgren and Whitehead’s rainbow model; Whitehall II study published |
| 2005–2008 | WHO Commission on Social Determinants of Health reports |
| 2010 | Marmot Review introduces proportionate universalism |
| 2010s–2020s | Health equity frameworks adopted in Australian policy and Aboriginal and Torres Strait Islander health planning |
The social determinants framework grew from nineteenth-century public health and social medicine, which traced epidemics to overcrowding, sanitation and poverty. In the twentieth century, medical advances shifted attention to individual treatment until evidence such as the Black Report (Townsend & Davidson, 1982) and the Whitehall studies showed that inequalities persisted despite universal health care. Social epidemiology then developed as a distinct field that measured how social position becomes embodied in health (Marmot, 2005).
The framework became an independent and global agenda through the CSDH, which brought research, policy and human rights together. Social work had always worked with the material conditions of clients’ lives, and the framework gave this tradition a shared language with health and public policy. It now informs hospital, community health, Aboriginal community-controlled and primary care social work in Australia, where social workers are often the professionals tasked with addressing the social needs behind health presentations (Connolly & Harms, 2015).
3. Practical guidance
The framework directs attention beyond the presenting health problem to the conditions that produce it.
- Assess social conditions routinely. Ask about income, housing, food security, employment, education, transport, safety and social connection in health and community assessments. These conditions are relevant clinical information (CSDH, 2008).
- Act on daily living conditions. Secure income support entitlements, housing applications, concessions and material aid. Practical resources often improve health more directly than counselling alone.
- Use the rainbow model in formulation. Locate a client’s difficulties across individual, community, living and working, and structural layers to avoid attributing problems solely to lifestyle choices (Dahlgren & Whitehead, 1991).
- Apply proportionate universalism in program design. Offer services to all while increasing intensity, outreach and resources for those with greater need, for example through sustained home visiting within universal maternal and child health services (Marmot et al., 2010).
- Recognise cultural and historical determinants. For Aboriginal and Torres Strait Islander clients, connection to culture, Country and community is a determinant of health, and racism and colonisation are structural causes of ill health (AHMAC, 2017).
- Collect and use data. Record unmet social needs and patterns in service data to support advocacy and evaluation.
- Advocate at the structural level. Contribute evidence to policy submissions on income support, housing and health equity, consistent with the AASW Code of Ethics (2020).
4. Critical evaluation
Strengths. The framework rests on a large body of epidemiological evidence and has broad international endorsement. It shifts explanation from individual blame to social arrangements and offers a common language for health, welfare and policy sectors (Marmot, 2015). It fits closely with social work’s commitment to social justice and human rights (Ife, 2012). Concepts such as the social gradient and proportionate universalism have clear policy implications.
Limitations. Critics argue that the framework identifies structural causes but is often implemented through programs that target individual behaviour, a problem sometimes called lifestyle drift. Its language of “determinants” can understate agency, culture and collective resistance. Layered models such as the rainbow can present determinants as separate levels and obscure the political and economic processes that link them (Solar & Irwin, 2010). Social workers also have limited power to change upstream determinants within individual casework.
Overall importance. The social determinants framework is now a central reference point for health and social policy. For social work it provides empirical support for the profession’s long-standing attention to poverty, housing and inequality, and it connects direct practice with policy and advocacy. It also links to the risk factor (C7), social capital (C3) and community and environmental (C8) frameworks in this family.
5. References
- Australian Association of Social Workers. (2020). Code of ethics. AASW.
- Australian Health Ministers’ Advisory Council. (2017). Aboriginal and Torres Strait Islander Health Performance Framework 2017 report. AHMAC.
- Australian Institute of Health and Welfare. (2021). Australian burden of disease study 2018: Key findings. AIHW.
- Carey, G., Crammond, B., & De Leeuw, E. (2015). Towards health equity: A framework for the application of proportionate universalism. International Journal for Equity in Health, 14, Article 81. https://doi.org/10.1186/s12939-015-0207-6
- Commission on Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. World Health Organization.
- Connolly, M., & Harms, L. (2015). Social work: From theory to practice (2nd ed.). Cambridge University Press.
- Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote social equity in health. Institute for Futures Studies.
- Ife, J. (2012). Human rights and social work: Towards rights-based practice (3rd ed.). Cambridge University Press.
- Marmot, M. (2005). Social determinants of health inequalities. The Lancet, 365(9464), 1099–1104. https://doi.org/10.1016/S0140-6736(05)71146-6
- Marmot, M. (2015). The health gap: The challenge of an unequal world. Bloomsbury.
- Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., & Geddes, I. (2010). Fair society, healthy lives: The Marmot Review. The Marmot Review.
- Marmot, M., Friel, S., Bell, R., Houweling, T. A. J., & Taylor, S. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. The Lancet, 372(9650), 1661–1669. https://doi.org/10.1016/S0140-6736(08)61690-6
- Marmot, M. G., Smith, G. D., Stansfeld, S., Patel, C., North, F., Head, J., White, I., Brunner, E., & Feeney, A. (1991). Health inequalities among British civil servants: The Whitehall II study. The Lancet, 337(8754), 1387–1393. https://doi.org/10.1016/0140-6736(91)93068-K
- Solar, O., & Irwin, A. (2010). A conceptual framework for action on the social determinants of health (Social Determinants of Health Discussion Paper 2). World Health Organization.
- Townsend, P., & Davidson, N. (Eds.). (1982). Inequalities in health: The Black report. Penguin.