Review 193
The Social Dimension of Adolescent Health: Challenges for Paediatric Research and Practice Die soziale Dimension der Gesundheit in der Adoleszenz: Herausforderungen für die pädiatrische Foschung und Praxis
Authors
M. Richter1, D. Körholz2
Affiliations
1
Key words ▶ adolescence ● ▶ social inequalities ● ▶ socioeconomic position ● ▶ explanation ● ▶ health ● ▶ risk behavior ●
Abstract
Zusammenfassung
Innumerable studies have shown that socioeconomic inequalities have a serious impact on mortality and morbidity. Disease and premature mortality are thus embodied expressions of the conditions under which we live and work. The increasing discussion of adolescence as an independent stage of life has generated a growth of interest in the social determinants of young people’s health. The review outlines that a large part of the prevailing diseases in adolescence are strongly influenced by social, economic and political determinants and analyses which determinants and mechanisms are responsible that social inequalities get under the skin and cause adverse health. Paediatrics offers a central interdisciplinary link between the natural and social sciences to better understand how we biologically incorporate our lived experience and thus create social patterns of health and illness not only in societies but also between societies. Such research could contribute to further sensitise clinical and therapeutic practice on the social determinants of health and to integrate them in daily routine processes, such as anamnesis and therapy.
Unzählige Studien haben aufzeigen können, dass soziale Ungleichheiten einen gravierenden Einfluss auf die Mortalität und Morbidität ausüben. Krankheit und frühzeitige Sterblichkeit sind damit verkörperte Expressionen der Bedingungen, unter denen wir leben. Im Zuge des steigenden Interesses an der Lebensphase „Adoleszenz“ ist auch die Bedeutung sozialer Determinanten für die gesundheitliche Lage der Heranwachsenden in den Fokus der wissenschaftliche Auseinandersetzung geraten. Der Beitrag skizziert, dass ein großer Teil der aktuell vorherrschenden Krankheiten in der Adoleszenz maßgeblich durch soziale, ökonomische und politische Faktoren beeinflusst wird und geht der Frage nach, welche Determinanten und Mechanismen dafür verantwortlich sind, dass soziale Ungleichheiten unter die Haut kommen und krank machen. Die Kinder- und Jugendmedizin bietet eine interdisziplinäre Schnittmenge zwischen Natur- und Sozial wissenschaften, um besser als bislang die Prozesse und Einflüsse zu verstehen, wie wir unsere gelebte Erfahrung biologisch verkörpern und so gesellschaftliche Muster der Verteilung von Gesundheit und Krankheit sowohl innerhalb als auch zwischen Gesellschaften generieren. Eine derartig ausgerichtete Forschung kann auch dazu beitragen, die klinische und therapeutische Praxis stärker als bislang für soziale Faktoren zu sensibilisieren und sie stärker in den Anamneseprozess und Therapiealltag zu integrieren.
Bibliography DOI http://dx.doi.org/ 10.1055/s-0035-1549976 Published online: June 12, 2015 Klin Padiatr 2015; 227: 193–198 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0300-8630 Correspondence Prof. Matthias Richter Institute of Medical Sociology Martin Luther University Halle-Wittenberg Magdeburger Strasse 8 06112 Halle Germany Tel.: + 49/345/557 1166 Fax: + 49/345/557 1165 [email protected]
Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Halle, Germany Department of Pediatrics, Martin Luther University Medical Center, Halle, Germany
▼
Introduction
▼
It is increasingly acknowledged that non-medical and non-behavioural factors significantly determine not only individual health but also the health status of entire societies [13, 17, 41, 53]. A large part of the current burden of disease can be attributed to the social conditions in which peo-
▼
ple are born, grow, work, and age and which in turn are shaped by the distribution of money, power, and resources at global, national, and local levels [9, 42, 68]. Innumerable studies have provided clear and persuasive evidence that social inequalities have a profound influence on health and longevity [2, 40, 61, 69]. In all countries for which data is available, people with lower socio-
Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
Downloaded by: University of British Columbia. Copyrighted material.
Schlüsselwörter ▶ Adoleszenz ● ▶ Soziale Ungleichheiten ● ▶ Sozialer Status ● ▶ Erklärung ● ▶ Gesundheit ● ▶ Risikoverhalten ●
2
economic position (SEP) die earlier and are more often affected by adverse health compared to individuals with higher socioeconomic positions – a phenomenon which has also been described as the status syndrome [43]. In line with studies from other countries, findings for Germany show that people with lower education, occupation, and income have a lower life expectancy and suffer more often from disease in their anyway shorter life than pupils with a more favourable SEP [19, 32, 33, 61]. For example, in Germany, the difference between the highest and lowest income groups in average life expectancy at birth is 8 years for women and 11 years for men [30]. Several authors have argued that socioeconomic position is probably the most powerful single contributor to premature mortality and morbidity worldwide [86]. Adolescence is a transitional period in which opportunities for health are great and future patterns of adult health are established [23, 49, 57]. Research and monitoring of young people’s health and well-being is particularly important during profound societal changes, demanding school environments, increasing inequalities, and changing family structures [46]. While health inequalities in adulthood have been a key interest of public health research for more than 30 years now, less is known about the pattern of health inequalities among young people, especially in Germany [7, 8, 10, 73, 80]. For some time, adolescence did not seem to provide anything of particular interest for the genesis of socioeconomic inequalities in health [56, 83]. This lack of research is particularly surprising, as evidence of a relationship between socioeconomic position and health early in life would be a matter of concern and would constitute a particular challenge for health and social policy. Only recently a growing interest and global focus on adolescent health emerged and scholars increasingly argued that understanding and enhancing young people’s health needs a focus that takes into account upstream factors, from an individual’s risk or protective factors to the social patterns and structures that shape people’s opportunities to grow up and stay healthy [24, 51, 72, 75, 84]. For example, the Lancet recently published a series of reports on adolescent health, which have also highlighted the role of social determinants in adolescent health as well as implications for action [65, 80]. The Lancet has also initiated a Commission on Adolescent Health and Wellbeing, which aims to report in 2015 [50]. In addition, UNICEF [77] published a prominent report on ‘The State of the World’s Children 2011. Adolescence: An Age of Opportunity’. The recent publication of a WHO report on inequalities in young people’s health has further generated a growth of interest in the effects of social determinants on adolescent health [11]. The aim of this review paper is to outline the current discussion on the social determinants of health in adolescence and to enhance the awareness of the social dimension of young people’s health in paediatric research and practice. The review discusses the key findings on how social inequalities are literally embodied and, thus, how they produce societal patterns of the distribution of health and disease. A special attention is given to different determinants and mechanisms in the production and reproduction of social inequalities in health, trying to explain how society gets under the skin and causes adverse health.
Socioeconomic inequalities in adolescent health
▼
The research on social determinants of health has focused for a long time on the working population and the first years of life. Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
The existing evidence on socioeconomic inequalities in perinatal and child health has clearly showed a pronounced social gradient in several health outcomes [7, 32, 35]. Most studies looked at socioeconomic differences in infant mortality and morbidity in early life. For example, infants of mothers with a low socioeconomic position have a higher risk of premature mortality, low birth weight, congenital anomalies, and preterm delivery [21, 36, 62]. Consistent inequalities in child health are also found for infections and psychomotor disorders as well as limitations in cognitive development, hospital admissions, and severe injuries [55], for Germany: [20, 32]. Social inequalities in health among adolescents have been discussed far less frequently and in less depth compared to those of adults [8, 56, 72, 81]. Nevertheless, the existence and pattern of health inequalities in adolescence has been the focus of much debate [72, 83]. A complex picture has emerged in different studies, with strong patterning of health outcomes according to socioeconomic position in some cases and a lack of such in equalities in others [10, 72, 83]. Socioeconomic inequalities have been found for several indicators of ill health, e. g., injuries and violent deaths, symptom load and multiple complaints, mental health problems, overweight and obesity [18, 27, 31, 34, 37, 54, 66, 81]. However, it needs to be acknowledged that these social gradients are much smaller compared to any other part of the life course [78, 84, 85]. Interestingly, the existing findings indicate a variation with the severity of the disease. While less severe diseases show less variation by socioeconomic position, the differences increase with the level of severity, e. g., for injuries and chronic diseases [44, 83]. Stronger inequalities are generally found for girls. Girls seem to be more vulnerable to the influences of social inequalities compared to boys [56, 66, 74]. Further, several studies showed that family-based measures of socioeconomic position, such as income and occupational level of parents, are less often and less strongly associated with health [28, 54, 59]. More pronounced inequalities are found for students’ own educational level (type of school), current academic achievement, and subjective socioeconomic position [24, 51, 52]. So far, the mechanisms that are responsible for this effect have rarely been studied. The relationship between socioeconomic position and risk behaviour in adolescence is just as inconsistent and contradictory as it is for premature mortality and morbidity [26, 56]. Pronounced and consistent socioeconomic differences are found for nutrition, tooth brushing, physical activity, and sedentary behaviour [1, 76, 82, 87]. This suggests that stronger socioeconomic differences exist for behaviours, which are learned in early childhood when parental influences are much stronger than in adolescence. A weaker effect is found for those behaviours that do not start until adolescence (e. g., tobacco, alcohol and illegal substance use), suggesting that other determinants may have a greater effect on substance use compared to SEP [8, 22, 26, 76]. While risk behaviour in childhood is highly influenced by the parents, the influence of peers and youth culture increases with age. Both have shown to be significant predictors of adolescents’ risk behaviour [57, 83]. Such process may decrease the influence of the family background and might result in a homogenising effect of socioeconomic differences in risk behaviour. Adolescent health is becoming increasingly important from a life course perspective. Several studies have shown that the origins of poor adult health and health inequalities in later life can be traced to circumstances that precede current socioeconomic position and living conditions [25, 55]. However, although adoles-
Downloaded by: University of British Columbia. Copyrighted material.
194 Review
cent health is known to be related to earlier determinants [71], less emphasis has been placed on how adolescent and future health is also the product of biological and social experiences that are specific to this phase of life [3, 65]. The complex nature of socioeconomic inequalities in health during adolescence underlines the potential to provide a better understanding of the origins of socioeconomic differences in adult health and possible pathways by which health inequalities are produced and re-produced. It is also important in its own right, since programmes designed to improve the health of young people need to address the potential importance of socioeconomic determinants.
Explaining socioeconomic inequalities in adolescent health
▼
The different ways in which social determinants affect health are undoubtedly complex and multi-layered [13, 58]. Compared to risk behaviours or clinical measures, these structures are largely invisible. This might be one of the reasons why despite considerable research efforts, it is still difficult to explain the processes that cause social inequalities in health [14, 15, 42]. The debate on the explanation of socioeconomic differences in adult health has identified behavioural, psychosocial, and material factors as important explanatory approaches [61]. All 3 approaches postulate that a differential distribution of determinants across socioeconomic groups explains socioeconomic inequalities in health. Behavioural factors include, for example, smoking, a poor diet, and lack of physical activity. The psychosocial perspective emphasises an unequal distribution of psychosocial factors, such as social resources, social support, and level of control while the materialist explanation focuses on the role of structural and material living circumstances (e. g., employment status or housing conditions). So far, little is known about potential factors and mechanisms that influence the relationship between socioeconomic position and health in adolescence [16, 56]. Most of the well-known determinants of health inequalities in adulthood had little time to exert their health damaging effects on young people. However, evidence suggests that the explanatory factors outlined above are also relevant for children and adolescents. Already during childhood, behavioural factors are associated with various undesirable health outcomes. Findings from the cross-national ‘Health Behaviour in School-aged Children (HBSC)’ study, for example, showed that different health behaviours among 11- to 15-year-old explain up to 25 % of the social gradient in self-rated health [61]. In addition, the family, school, and the peer group comprise central socialising contexts for young people. Potential psychosocial stressors capable of compromising health and leading to adverse health are primarily found in these social contexts [35]. The family also represents the environment, which might expose children and adolescents to material disadvantage. Although there are some findings on the health-damaging consequences of various psychosocial aspects of school, peer groups, and family not much is known about their contribution to the explanation of socioeconomic differences in health in adolescence. Some studies have however shown that children and adolescents from families with low socioeconomic position are more disadvantaged in terms of material wealth, family situation, housing circumstances, and peer relations, which in turn are associated with adverse health [10, 35]. These young people often have fewer individual and social resources to cope with
these demands. For example, in the German KiGGS study, adolescents from the lowest socioeconomic group with good resources showed less health problems compared to their low SEP peers with fewer resources [32]. In addition to a positive family climate and parental support, personal resources such as selfesteem and control beliefs turned out to be especially relevant. Few studies have systematically analysed the relative importance of different explanatory pathways in childhood and adolescence. Findings by Richter et al. [60] showed that socioeconomic in equalities in self-rated health were largely explained by material, psychosocial, and behavioural factors among German adolescents. Material factors contributed most to differences in selfrated health because of their direct and indirect effect (through psychosocial and behavioural factors). Using the cross-national HBSC Study, Moor et al. [45] found that this effect is largely universal across European and North-American countries. Recently, a number of studies have shown that health and health inequalities in adulthood are determined not only by individual material, psychosocial and behavioural factors, but also by factors at the macro-level (societal level), such as welfare state characteristics, national income, income inequality, and public health spending. These studies were mostly interested in investigating how social contexts create social stratification and assign individuals to different social positions [9, 60, 70]. The ‘context’ here is broadly defined to “include all social and political mechanisms that generate, configure and maintain social hierarchies, including: the labour market, the educational system, political institutions and other cultural and societal values” [70]. Richter et al. [60] found that welfare state regimes are associated with the overall level of subjective health in adolescence. Adolescents in the Eastern and Anglo-Saxon welfare regimes had higher prevalences of fair/poor self-rated health and health complaints compared to adolescents in the Scandinavian and Bismarckian regime.
Systematic approaches to explain socioeconomic inequalities in health
▼
The findings given above show that health and illness are sideproducts of the social organization of societies. Several general conceptual frameworks were proposed, which try to summarize different levels of influences on health and health inequalities, from levels proximal to the individual to factors quite distal from the individual, such as economic and political systems [6, 39, 47]. Even though the frameworks differ in terms of complexity and style, they all share the assumption that health is the result of a web of different social influences. The WHO ‘Commission on the ▶ Fig. 1) developed one of the most Social Determinants of Health’ ( ● cited models on the explanation of social inequalities in health. The model assumes that the effect of socioeconomic position on health causes the unequal distribution of health and well-being, i. e., that a lower position causes a greater risk for adverse health. However, socioeconomic position does not have a direct effect on health but operates through a set of intermediary and interlinked determinants (material conditions; psychosocial circumstances; behavioural and/or biological factors). The set of socioeconomic positions is itself formed by social, economic, and political mechanisms (contextual determinants) that generate, configure, and maintain social hierarchies, including the labour market, educational system, political institutions, and other cultural and societal values. According to country and configuration, the health system can also play a key role as it influences Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
Downloaded by: University of British Columbia. Copyrighted material.
Review 195
196 Review
Socioeconomic and political context
Fig. 1 Conceptual framework of the WHO “Commission on Social determinants of Health”. (Source: adapted according to CSDH 2008) Social position Material cicumstances
Governance
Social cohesion Education
Policy (macroeconomic, social, health)
Occupation
Cultural and societal norms and values
Ethninicty
Income Gender
Psychosocial factors Behaviours
Distribution of health and well-being
Biological factors
Health care system
Discussion
▼
The social conditions in which we live and grow up not only create or favour a predisposition for disease, but also cause disease directly and influence the course of the disease. This statement, which was formulated by Alfred Grotjahn already in 1923 [4], has not lost anything of its conciseness and is still up-to-date. Clues for current and changing population patterns of health and illness (and thus for social inequalities in health) are mainly to be found in the social, material, and ecological contexts in which we are born and develop and not in the dominating etiological hypotheses that consider decontextualised and disembodied risk behaviour and genes [29]. Children and adolescents are born into a specific socioeconomic environment that strongly influences the possibilities of young people to achieve and sustain good health as well as a high level of well-being [56, 80]. Adolescence is a period of rapid development when young people acquire new capacities and face new challenges. When they move on to secondary school, young people are confronted with new and more complex socialising influences from various areas, influences that play a mediating role between the social structure and the adolescent. In no other developmental period, health, behaviour, and the social environment are changing so rapidly while at same time, important neurological, cognitive, and physical changes occur [65]. Even though studies on health inequalities among children and adolescents are less numerous compared to studies among adults, the existing findings indicated clearly that social inequalities have severe consequences for health and longevity already in young people. The chances for a long and healthy life are compromised already at the start, and the odds that social and health-related disadvantages continue and accumulate throughout the life course increase. However, it is remarkable that no consistent picture of social inequalities is found in adolescent health, unlike in adults. Generally, some evidence suggest that certain aspects of adolescent health are more sensitive towards the social determinants of health. Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
Challenges in basic research on adolescent health
Considering the preventive potential inherent to young people, it will be crucial to increase research efforts to describe and explain health inequalities in adolescence. Several authors argued that adolescence may be a second critical period for tackling social inequalities in current and future health [71, 80]. Paediatrics plays a key role in this context. It offers a central interdisciplinary link of different research paradigms to better understand how society gets under the skin. Two major challenges can be identified in this context. The first relates to putting adolescence up on the agenda of paediatric research and practice, the second relates to a broader understanding of adolescent health, including its social determinants. Advocating a more holistic understanding of adolescent health is an important further step for including adolescent health, as a marginalised subspecialty, in mainstream global health agendas [65, 79]. Though general paediatrics has been more active in incorporating social aspects of health compared to other fields in medicine, it is still largely dominated by natural sciences thinking. The findings on the embodiment of social inequalities, which are largely informed by research in the field of medical sociology and social epidemiology, could be considered much stronger in mainstream paediatric research. On the other hand, medical sociology should approach paediatric research more directly and involve it pro actively in developing and testing research questions. Task of such a paradigmatic alliance would be to build on previous risk and protective factor models of adolescent health and to develop developmental transactional models that take into account person-environment interaction and its multi-level, multi-dimensionality, and multi-directionality over the whole life course [12, 25, 79]. This calls for thinking in terms of the full range of questions and explanatory factors – spanning multiple domains, levels, and time. It also requires that paediatrics and medical sociology are reciprocally more aware of the literature in order to further develop joint frameworks and conceptual models as well as measurements and research designs. Another task of such a biopsychosocial as well as explicitly social research on adolescent health would be to focus on the question how social influences are embodied in physiological characteristics and thus exert an influence on health as well as how they are reflected in social inequalities in health [29, 38, 64]. This would provide new insights on how social conditions form a) the expression of biological features and b) societal patterns of health and disease. This, for example, also includes work on epigenetic mechanisms in children and adolescents [67]. First findings, for example, showed that the extent of DNA methylation, one of the
Downloaded by: University of British Columbia. Copyrighted material.
health directly as well as indirectly through the intermediary factors. The role of the health system becomes particularly relevant for the issue of access and plays an important role in mediating the differential consequences of illness in people’s lives. Finally, the model also takes into account that adverse health – especially in case of weak social security systems – can influence socioeconomic position (social selection).
Review 197
Clinical research challenges in adolescent health
So far, existing studies mostly looked at the role of socioeconomic position for the genesis of adverse health while few studies have analysed the impact of social determinants on healthcare provision in adolescence. Findings for adults suggest that disadvantaged people suffer not only from a higher burden of disease but also from poorer access to and quality of health care. Thus, one promising research avenue for paediatric research would be to focus on possible socioeconomic inequalities in clinical settings: For example, to analyse whether inequalities in patientreported outcomes such as functioning, well-being or social participation exist during and/or after treatment. Social inequalities in the access and quality of health care present another important example which has rarely been analysed in young people. Similar, socioeconomic differences in the patient-doctor relationship as well as adherence were rarely studied in this age group. As a first step descriptive studies are indicated followed by studies trying to unravel possible mechanisms which link family SEP to the respective outcomes. This could include quantitative as well as qualitative research designs. Based on this work, targeted consequences for practical medicine can be derived [63]. The clinical and therapeutic practice must be more aware of socioeconomic influences and is requested to further integrate them in daily routine processes, such as anamnesis, treatment, and therapy. For example, next to medical diagnostic more attention could be paid to a social diagnosis of young patients and their families in order to assess whether the proposed therapy can be realised. This could help to identify high-risk groups and to apply targeted strategies to increase adherence and competence in young patients from lower socioeconomic groups. Moreover, a closer collaboration of the involved disciplines is indicated in order to evaluate and develop corresponding treatment concepts. Generally, there is a strong need to translate findings from health inequalities research into clinical practice. The extent to which such an interdisciplinary research can be established as a counterweight to a strong molecular biological-reductionist medicine is unclear. We support the claim of the WHO Commission on the Social Determinants of Health regarding the increased need to measure the problem, to evaluate action, to develop a workforce that is trained in the social determinants of health, and to raise public awareness about the social determinants of health. We are hoping that our findings offer ideas for an increased discussion of the determinants and mechanisms of health inequalities in paediatric research and practice.
Contributor’s statement
▼
M. Richter wrote the first draft of the paper. D. Körholz edited and revised the manuscript. All authors read and approved the final manuscript.
Conflict of interest: The authors have no conflict of interest to disclose.
References
1 Bergström E, Hernell O, Persson LA. Cardiovascular risk indicators cluster in girls from families of low socio-economic status. Acta Paediatr 1996; 85: 1083–1090 2 Bleich SN, Jarlenski MP, Bell CN et al. Health inequalities. trends, progress, and policy. Annu Rev of Public Health 2012; 33: 7–40 3 Blum RW, Bastos Francisco IPM et al. Adolescent health in the 21st century. Lancet 2012; 379: 1567–1568 4 Borgers D, Steinkamp G. Sozialepidemiologie – Gesundheitsforschung zu Krankheit, Sozialstruktur und gesundheitsrelevanter Handlungsfähigkeit. In: Schwenkmezger P, Schmidt LR, Borgers D (Eds.). Lehrbuch der Gesundheitspsychologie. 18 Tabellen. Enke, Stuttgart: 1994 5 Borghol N, Suderman M, McArdle W et al. Associations with early-life socio-economic position in adult DNA methylation. Int J Epidemiol 2012; 41: 62–74 6 Brunner EJ, Marmot MG. Social organization, stress, and health. In: Marmot MG, Wilkinson RG (Eds.). Social determinants of health. Oxford University Press, Oxford: 2006 7 Chen E, Martin AD, Matthews KA. Socioeconomic status and health. Do gradients differ within childhood and adolescence? Soc Sci Med 2006; 62: 2161–2170 8 Chen E, Matthews KA, Boyce WT. Socioeconomic differences in children’s health. how and why do these relationships change with age? Psychol Bull 2002; 128: 295–329 9 CSDH WH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: WHO 2008 10 Currie C, Nic Gabhainn S, Godeau E et al. Inequalities in Young People’s Health. HBSC International Report from the 2005/2006 Survey. World Health Organization (WHO), Copenhagen: 2008 11 Currie C, Zanotti C, Morgan A et al. Social determinants of health and well-being among young people. Health Behaviour in School-aged Children (HBSC) study. international report from the 2009/2010 survey. Health Policy for Children and Adolescents, No. 6. WHO Regional Office for Europe, Copenhagen: 2012 12 Denny K, Brownell M. Taking a social determinants perspective on children’s health and development. Can J Public Health 2010; 101: (Suppl 3): S4–S7 13 Diderichsen F, Andersen I, Manuel C et al. Health inequality–determinants and policies. Scand J Public Health 2012; 40: 12–105 14 Diez-Roux AV. Conceptual approaches to the study of health disparities. Annu Rev of Public Health 2012; 33: 41–58 15 Dowler E, Spencer N. Challenging health inequalities. From Acheson to ‚choosing health‘. Policy Press, Bristol: 2007 16 Due P, Krølner R, Rasmussen M et al. Pathways and mechanisms in adolescence contribute to adult health inequalities. Scand J Public Health 2011; 39: 62–78 17 Elo IT. Social Class Differentials in Health and Mortality: Patterns and Explanations in Comparative Perspective. Annu Rev Sociol 2009; 35: 553–572 18 Frederick CB, Snellman K, Putnam RD. Increasing socioeconomic disparities in adolescent obesity. Proc Natl Acad Sci USA. 2014; 111: 1338–1342 19 Geyer S. Manifestation, Erklärung und Reduzierung gesundheitlicher Ungleichheiten. Ethik Med 2010; 22: 249–262 20 Geyer S, Peter R. Unfallbedingte Krankenhausaufnahmen von Kindern und Jugendlichen in Abhängigkeit von ihrem sozialen Status–Befunde mit Daten einer nordrhein-westfälischen AOK. Gesundheitswesen 1998; 60: 493–499 21 Gissler M, Rahkonen O, Järvelin MR et al. Social class differences in health until the age of seven years among the Finnish 1987 birth cohort. Soc Sci Med 1998; 46: 1543–1552 22 Goodman E, Huang B. Socioeconomic status, depressive symptoms, and adolescent substance use. Archives of pediatrics & adolescent medicine 2002; 156: 448–453 23 Gore FM, Bloem Paul JN et al. Global burden of disease in young people aged 10-24 years: a systematic analysis. Lancet 2011; 377: 2093–2102 24 Hagquist CE. Health inequalities among adolescents. the impact of academic orientation and parents’ education. Eur J Public Health 2007; 17: 21–26 25 Halfon N. Socioeconomic influences on child health: building new ladders of social opportunity. JAMA 2014; 311: 915–917 26 Hanson MD, Chen E. Socioeconomic status and health behaviors in adolescence. A review of the literature. J Behav Med 2007; 30: 263–285 27 Holstein BE, Currie C, Boyce WT et al. Socio-economic inequality in multiple health complaints among adolescents. International comparative study in 37 countries. Int J Public Health 2009; 54: 260–270
Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
Downloaded by: University of British Columbia. Copyrighted material.
key epigenetic mechanisms, varies with income and education [5]. A recent study also showed that parental education was positively associated with child leukocyte telomere length and that children whose parents never attended college had shorter telomeres, roughly equivalent to 6 years of additional aging [48].
28 Koivusilta LK, Rimpela AH, Kautiainen SM. Health inequality in adolescence. Does stratification occur by familial social background, family affluence, or personal social position? BMC public health 2006; 6: 110 29 Krieger N. Epidemiology and the people’s health. Theory and context. Oxford University Press, New York: 2012 30 Kroll LE, Lampert T. Soziale Unterschiede in der Lebenserwartung. Datenquellen in Deutschland und Analysemöglichkeiten des SOEP = Socioeconomic differences in life expectancy. MDA 2009; 3: 3–30 31 Laflamme L, Engström K, Huisman M. Is there equalisation in socioeconomic differences in the risk of traffic injuries in childhood? A study of three cohorts of Swedish school children. Int J Adolesc Med Health 2004; 16: 253–263 32 Lampert T, Kroll LE. Armut und Gesundheit. GBE kompakt 5/2010. www.rki.de/gbe-kompakt (Stand: 01.12.2010) 2010; 33 Lampert T, Kroll LE, Kuntz B et al. Gesundheitliche Ungleichheit. WZB, Destatis 2011 34 Lampert T, Kurth B. Sozialer Status und Gesundheit von Kindern und Jugendlichen. Ergebnisse des Kinder- und Jugendgesundheitssurveys (KiGGS). Deutsches Ärzteblatt 2007; 43: 2944–2949 35 Lampert T, Richter M. Gesundheitliche Ungleichheit bei Kindern und Jugendlichen. In: Richter M, Hurrelmann K (Eds.). Gesundheitliche Ungleichheit. Grundlagen, Probleme, Perspektiven. VS Verlag für Sozialwissenschaften, Wiesbaden: 2009 36 Law C. Mother, fetus, infant and family. socio-economic inequalities. In: Gordon D, Shaw M, Dorling D et al. (Eds.). Inequalities in Health – the evidence. Polity Press, Bristol: 1999 37 Levin KA, Currie C, Muldoon J. Mental well-being and subjective health of 11- to 15-year-old boys and girls in Scotland, 1994-2006. Eur J Public Health 2009; 19: 605–610 38 Loi M, Del Savio L, Stupka E. Social Epigenetics and Equality of Opportunity. Public Health Ethics 2013; 6: 142–153 39 Mackenbach JP. Health inequalities: Europe in Profile. An independent expert report commissioned by the UK presidency of the EU. Department of Health, London: 2006 40 Mackenbach JP, Stirbu I, Roskam AR et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med 2008; 358: 2468–2481 41 Marmot M, Allen JJ. Social determinants of health equity. Am J Public Health 2014; 104: (Suppl 4): S517–S519 42 Marmot MG, Wilkinson RG. Social determinants of health. Oxford: Oxford University Press 2006 43 Marmot MG. Status syndrome. How your social standing directly affects your health and life expectancy. Bloomsbury Press, London: 2004 44 Mielck A, Reitmeir P, Wjst M. Severity of childhood asthma by socioeconomic status. Int J Epidemiol 1996; 25: 388–393 45 Moor I, Rathmann K, Stronks K et al. Psychosocial and behavioural factors in the explanation of socioeconomic inequalities in adolescent health: a multilevel analysis in 28 European and North American countries. J Epidemiol Community Health 2014; 68: 912–921 46 Mortimer JT, Larson R. The changing adolescent experience. Societal trends and the transition to adulthood. Cambridge University Press, Cambridge, UK, New York: 2002 47 Najman JM. A General Model of the Social Origins of Health and WellBeing. In: Eckersley R, Dixon J, Douglas RM (Eds.). The social origins of health and well-being. Cambridge University Press, Cambridge, UK, New York, NY, USA: 2001 48 Needham BL, Fernandez JR, Lin J et al. Socioeconomic status and cell aging in children. Soc Sci Med 2012; 74: 1948–1951 49 Patton GC, Coffey C, Cappa C et al. Health of the world’s adolescents: a synthesis of internationally comparable data. Lancet 2012; 379: 1665–1675 50 Patton GC, Ross DA, Santelli JS et al. Next steps for adolescent health: a Lancet Commission. Lancet 2014; 383: 385–386 51 Piko BF, Fitzpatrick KM. Socioeconomic status, psychosocial health and health behaviours among Hungarian adolescents. Eur J Public Health 2007; 17: 353–360 52 Quon EC, McGrath JJ. Subjective socioeconomic status and adolescent health: a meta-analysis. Health Psychol 2014; 33: 433–447 53 Raphael D. Social determinants of health. present status, unanswered questions, and future directions. Int J Health Serv 2006; 36: 651–677 54 Reiss F. Socioeconomic inequalities and mental health problems in children and adolescents: a systematic review. Soc Sci Med 2013; 90: 24–31 55 Richardson LJ, Hussey JM, Strutz KL. A life course perspective on maternal and child health. In: Kotch JB (Ed.). Maternal and Child Health: Programs, Problems, and Policy. Jones & Bartlett, Sudbury, MA: 2013 56 Richter M. Gesundheit und Gesundheitsverhalten im Jugendalter. Der Einfluss sozialer Ungleichheit. VS Verlag für Sozialwissenschaften, Wiesbaden: 2005
Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
57 Richter M. Risk behaviour in adolescence: Patterns, determinants and consequences. Wiesbaden: VS-Verlag 2010 58 Richter M. Verkörperte Ungleichheiten: Herausforderungen für die psychosomatische Medizin. Psychother Psychosom Med Psychol 2013; 63: 19–25 59 Richter M, Lampert T. Verkörperte Ungleichheiten. Die Rolle multipler Statusindikatoren für das Gesundheitsverhalten im Jugendalter. ZSE 2008; 28: 174–190 60 Richter M, Moor I, van Lenthe FJ. Explaining socioeconomic differences in adolescent self-rated health. The contribution of material, psychosocial and behavioural factors. J Epidemiol Community Health 2012; 691–697 61 Richter M, Hurrelmann K. Gesundheitliche Ungleichheit. Grundlagen, Probleme, Perspektiven, Wiesbaden. VS Verlag für Sozialwissenschaften, 2009 62 Roberts H. What works in reducing inequalities in child health? Policy Press, Bristol, Chicago, IL: 2012 63 Roberts J, Sanci L, Haller D. Global adolescent health: is there a role for general practice? Br J Gen Pract 2012; 62: 608–610 64 Rosenbach F, Richter M, Pförtner T. Sozioökonomischer Status und inflammatorische Biomarker für Herz-Kreislauf-Erkrankungen. Wie wirken Bildung, Beruf und Einkommen? Herz 2014 65 Sawyer SM, Afifi RA, Bearinger LH et al. Adolescence: a foundation for future health. Lancet 2012; 379: 1630–1640 66 Schreier HMC, Chen E. Health Disparities in Adolescence. In: Steptoe A (Ed.). Handbook of Behavioral Medicine. Springer Science + Business Media, LCC, New York: 2010 67 Schreier HMC, Roy LB, Frimer LT et al. Family chaos and adolescent inflammatory profiles: the moderating role of socioeconomic status. Psychosom Med 2014; 76: 460–467 68 Scrambler G. Health inequalities. Soc Health Illn 2012; 34: 130–146 69 Siegrist J, Marmot MG. Social inequalities in health: new evidence and policy implications. Oxford: Oxford University Press 2006 70 Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. World Health Organization, Geneva: 2007 71 Spencer N. Reducing child health inequalities: what's the problem? Arch Dis Child 2013; 98: 836–837 72 Spencer NJ. Social equalization in youth. evidence from a cross-sectional British survey. Eur J Public Health 2006; 16: 368–375 73 Starfield B, Riley AW, Witt WP et al. Social class gradients in health during adolescence. J Epidemiol Community Health 2002; 56: 354–361 74 Torsheim T, Currie C, Boyce WT et al. Material deprivation and self-rated health. a multilevel study of adolescents from 22 European and North American countries. Soc Sci Med 2004; 59: 1–12 75 Torsheim T, Currie C, Boyce WT et al. Country material distribution and adolescents’ perceived health. multilevel study of adolescents in 27 countries. J Epidemiol Community Health 2006; 60: 156–161 76 Tuinstra J, Groothoff JW, Van den Heuvel WJ et al. Socio-economic differences in health risk behavior in adolescence. do they exist? Soc Sci Med 1998; 47: 67–74 77 UNICEF. State of the world’s children 2011. adolescence – an age of opportunity. United Nations Children’s Fund, New York, NY: 2011 78 Vallejo-Torres L, Hale D, Morris S et al. Income-related inequality in health and health-related behaviour: exploring the equalisation hypothesis. J Epidemiol Community Health 2014; 68: 615–621 79 Viner RM, Barker M. Young people’s health: the need for action. BMJ 2005; 330: 901–903 80 Viner RM, Ozer EM, Denny S et al. Adolescence and the social determinants of health. Lancet 2012; 379: 1641–1652 81 Von Rueden U, Gosch A, Rajmil L et al. Socioeconomic determinants of health related quality of life in childhood and adolescence: results from a European study. J Epidemiol Community Health 2006; 60: 130–135 82 Wardle J, Jarvis MJ, Steggles N et al. Socioeconomic disparities in cancer-risk behaviors in adolescence. baseline results from the Health and Behaviour in Teenagers Study (HABITS). Prev Med 2003; 36: 721–730 83 West P. Health inequalities in the early years. is there equalisation in youth? Soc Sci Med 1997; 44: 833–858 84 West P, Sweeting H. Evidence on equalisation in health in youth from the West of Scotland. Soc Sci Med 2004; 59: 13–27 85 Wickrama KAS, Noh S, Elder GH. An investigation of family SES-based inequalities in depressive symptoms from early adolescence to emerging adulthood. Adv Life Course Res 2009; 14: 147–161 86 Williams RB. Lower Socioeconomic Status and Increased Mortality. Early Childhood Roots and the Potential for Successful Interventions. JAMA 1998; 279: 1745–1746 87 Xie B, Gilliland FD, Li Y et al. Effects of ethnicity, family income, and education on dietary intake among adolescents. Prev Med 2003; 36: 30–40
Downloaded by: University of British Columbia. Copyrighted material.
198 Review
The Social Dimension of Adolescent Health: Challenges for Paediatric Research and Practice Die soziale Dimension der Gesundheit in der Adoleszenz: Herausforderungen für die pädiatrische Foschung und Praxis
Authors
M. Richter1, D. Körholz2
Affiliations
1
Key words ▶ adolescence ● ▶ social inequalities ● ▶ socioeconomic position ● ▶ explanation ● ▶ health ● ▶ risk behavior ●
Abstract
Zusammenfassung
Innumerable studies have shown that socioeconomic inequalities have a serious impact on mortality and morbidity. Disease and premature mortality are thus embodied expressions of the conditions under which we live and work. The increasing discussion of adolescence as an independent stage of life has generated a growth of interest in the social determinants of young people’s health. The review outlines that a large part of the prevailing diseases in adolescence are strongly influenced by social, economic and political determinants and analyses which determinants and mechanisms are responsible that social inequalities get under the skin and cause adverse health. Paediatrics offers a central interdisciplinary link between the natural and social sciences to better understand how we biologically incorporate our lived experience and thus create social patterns of health and illness not only in societies but also between societies. Such research could contribute to further sensitise clinical and therapeutic practice on the social determinants of health and to integrate them in daily routine processes, such as anamnesis and therapy.
Unzählige Studien haben aufzeigen können, dass soziale Ungleichheiten einen gravierenden Einfluss auf die Mortalität und Morbidität ausüben. Krankheit und frühzeitige Sterblichkeit sind damit verkörperte Expressionen der Bedingungen, unter denen wir leben. Im Zuge des steigenden Interesses an der Lebensphase „Adoleszenz“ ist auch die Bedeutung sozialer Determinanten für die gesundheitliche Lage der Heranwachsenden in den Fokus der wissenschaftliche Auseinandersetzung geraten. Der Beitrag skizziert, dass ein großer Teil der aktuell vorherrschenden Krankheiten in der Adoleszenz maßgeblich durch soziale, ökonomische und politische Faktoren beeinflusst wird und geht der Frage nach, welche Determinanten und Mechanismen dafür verantwortlich sind, dass soziale Ungleichheiten unter die Haut kommen und krank machen. Die Kinder- und Jugendmedizin bietet eine interdisziplinäre Schnittmenge zwischen Natur- und Sozial wissenschaften, um besser als bislang die Prozesse und Einflüsse zu verstehen, wie wir unsere gelebte Erfahrung biologisch verkörpern und so gesellschaftliche Muster der Verteilung von Gesundheit und Krankheit sowohl innerhalb als auch zwischen Gesellschaften generieren. Eine derartig ausgerichtete Forschung kann auch dazu beitragen, die klinische und therapeutische Praxis stärker als bislang für soziale Faktoren zu sensibilisieren und sie stärker in den Anamneseprozess und Therapiealltag zu integrieren.
Bibliography DOI http://dx.doi.org/ 10.1055/s-0035-1549976 Published online: June 12, 2015 Klin Padiatr 2015; 227: 193–198 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0300-8630 Correspondence Prof. Matthias Richter Institute of Medical Sociology Martin Luther University Halle-Wittenberg Magdeburger Strasse 8 06112 Halle Germany Tel.: + 49/345/557 1166 Fax: + 49/345/557 1165 [email protected]
Institute of Medical Sociology, Martin Luther University Halle-Wittenberg, Halle, Germany Department of Pediatrics, Martin Luther University Medical Center, Halle, Germany
▼
Introduction
▼
It is increasingly acknowledged that non-medical and non-behavioural factors significantly determine not only individual health but also the health status of entire societies [13, 17, 41, 53]. A large part of the current burden of disease can be attributed to the social conditions in which peo-
▼
ple are born, grow, work, and age and which in turn are shaped by the distribution of money, power, and resources at global, national, and local levels [9, 42, 68]. Innumerable studies have provided clear and persuasive evidence that social inequalities have a profound influence on health and longevity [2, 40, 61, 69]. In all countries for which data is available, people with lower socio-
Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
Downloaded by: University of British Columbia. Copyrighted material.
Schlüsselwörter ▶ Adoleszenz ● ▶ Soziale Ungleichheiten ● ▶ Sozialer Status ● ▶ Erklärung ● ▶ Gesundheit ● ▶ Risikoverhalten ●
2
economic position (SEP) die earlier and are more often affected by adverse health compared to individuals with higher socioeconomic positions – a phenomenon which has also been described as the status syndrome [43]. In line with studies from other countries, findings for Germany show that people with lower education, occupation, and income have a lower life expectancy and suffer more often from disease in their anyway shorter life than pupils with a more favourable SEP [19, 32, 33, 61]. For example, in Germany, the difference between the highest and lowest income groups in average life expectancy at birth is 8 years for women and 11 years for men [30]. Several authors have argued that socioeconomic position is probably the most powerful single contributor to premature mortality and morbidity worldwide [86]. Adolescence is a transitional period in which opportunities for health are great and future patterns of adult health are established [23, 49, 57]. Research and monitoring of young people’s health and well-being is particularly important during profound societal changes, demanding school environments, increasing inequalities, and changing family structures [46]. While health inequalities in adulthood have been a key interest of public health research for more than 30 years now, less is known about the pattern of health inequalities among young people, especially in Germany [7, 8, 10, 73, 80]. For some time, adolescence did not seem to provide anything of particular interest for the genesis of socioeconomic inequalities in health [56, 83]. This lack of research is particularly surprising, as evidence of a relationship between socioeconomic position and health early in life would be a matter of concern and would constitute a particular challenge for health and social policy. Only recently a growing interest and global focus on adolescent health emerged and scholars increasingly argued that understanding and enhancing young people’s health needs a focus that takes into account upstream factors, from an individual’s risk or protective factors to the social patterns and structures that shape people’s opportunities to grow up and stay healthy [24, 51, 72, 75, 84]. For example, the Lancet recently published a series of reports on adolescent health, which have also highlighted the role of social determinants in adolescent health as well as implications for action [65, 80]. The Lancet has also initiated a Commission on Adolescent Health and Wellbeing, which aims to report in 2015 [50]. In addition, UNICEF [77] published a prominent report on ‘The State of the World’s Children 2011. Adolescence: An Age of Opportunity’. The recent publication of a WHO report on inequalities in young people’s health has further generated a growth of interest in the effects of social determinants on adolescent health [11]. The aim of this review paper is to outline the current discussion on the social determinants of health in adolescence and to enhance the awareness of the social dimension of young people’s health in paediatric research and practice. The review discusses the key findings on how social inequalities are literally embodied and, thus, how they produce societal patterns of the distribution of health and disease. A special attention is given to different determinants and mechanisms in the production and reproduction of social inequalities in health, trying to explain how society gets under the skin and causes adverse health.
Socioeconomic inequalities in adolescent health
▼
The research on social determinants of health has focused for a long time on the working population and the first years of life. Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
The existing evidence on socioeconomic inequalities in perinatal and child health has clearly showed a pronounced social gradient in several health outcomes [7, 32, 35]. Most studies looked at socioeconomic differences in infant mortality and morbidity in early life. For example, infants of mothers with a low socioeconomic position have a higher risk of premature mortality, low birth weight, congenital anomalies, and preterm delivery [21, 36, 62]. Consistent inequalities in child health are also found for infections and psychomotor disorders as well as limitations in cognitive development, hospital admissions, and severe injuries [55], for Germany: [20, 32]. Social inequalities in health among adolescents have been discussed far less frequently and in less depth compared to those of adults [8, 56, 72, 81]. Nevertheless, the existence and pattern of health inequalities in adolescence has been the focus of much debate [72, 83]. A complex picture has emerged in different studies, with strong patterning of health outcomes according to socioeconomic position in some cases and a lack of such in equalities in others [10, 72, 83]. Socioeconomic inequalities have been found for several indicators of ill health, e. g., injuries and violent deaths, symptom load and multiple complaints, mental health problems, overweight and obesity [18, 27, 31, 34, 37, 54, 66, 81]. However, it needs to be acknowledged that these social gradients are much smaller compared to any other part of the life course [78, 84, 85]. Interestingly, the existing findings indicate a variation with the severity of the disease. While less severe diseases show less variation by socioeconomic position, the differences increase with the level of severity, e. g., for injuries and chronic diseases [44, 83]. Stronger inequalities are generally found for girls. Girls seem to be more vulnerable to the influences of social inequalities compared to boys [56, 66, 74]. Further, several studies showed that family-based measures of socioeconomic position, such as income and occupational level of parents, are less often and less strongly associated with health [28, 54, 59]. More pronounced inequalities are found for students’ own educational level (type of school), current academic achievement, and subjective socioeconomic position [24, 51, 52]. So far, the mechanisms that are responsible for this effect have rarely been studied. The relationship between socioeconomic position and risk behaviour in adolescence is just as inconsistent and contradictory as it is for premature mortality and morbidity [26, 56]. Pronounced and consistent socioeconomic differences are found for nutrition, tooth brushing, physical activity, and sedentary behaviour [1, 76, 82, 87]. This suggests that stronger socioeconomic differences exist for behaviours, which are learned in early childhood when parental influences are much stronger than in adolescence. A weaker effect is found for those behaviours that do not start until adolescence (e. g., tobacco, alcohol and illegal substance use), suggesting that other determinants may have a greater effect on substance use compared to SEP [8, 22, 26, 76]. While risk behaviour in childhood is highly influenced by the parents, the influence of peers and youth culture increases with age. Both have shown to be significant predictors of adolescents’ risk behaviour [57, 83]. Such process may decrease the influence of the family background and might result in a homogenising effect of socioeconomic differences in risk behaviour. Adolescent health is becoming increasingly important from a life course perspective. Several studies have shown that the origins of poor adult health and health inequalities in later life can be traced to circumstances that precede current socioeconomic position and living conditions [25, 55]. However, although adoles-
Downloaded by: University of British Columbia. Copyrighted material.
194 Review
cent health is known to be related to earlier determinants [71], less emphasis has been placed on how adolescent and future health is also the product of biological and social experiences that are specific to this phase of life [3, 65]. The complex nature of socioeconomic inequalities in health during adolescence underlines the potential to provide a better understanding of the origins of socioeconomic differences in adult health and possible pathways by which health inequalities are produced and re-produced. It is also important in its own right, since programmes designed to improve the health of young people need to address the potential importance of socioeconomic determinants.
Explaining socioeconomic inequalities in adolescent health
▼
The different ways in which social determinants affect health are undoubtedly complex and multi-layered [13, 58]. Compared to risk behaviours or clinical measures, these structures are largely invisible. This might be one of the reasons why despite considerable research efforts, it is still difficult to explain the processes that cause social inequalities in health [14, 15, 42]. The debate on the explanation of socioeconomic differences in adult health has identified behavioural, psychosocial, and material factors as important explanatory approaches [61]. All 3 approaches postulate that a differential distribution of determinants across socioeconomic groups explains socioeconomic inequalities in health. Behavioural factors include, for example, smoking, a poor diet, and lack of physical activity. The psychosocial perspective emphasises an unequal distribution of psychosocial factors, such as social resources, social support, and level of control while the materialist explanation focuses on the role of structural and material living circumstances (e. g., employment status or housing conditions). So far, little is known about potential factors and mechanisms that influence the relationship between socioeconomic position and health in adolescence [16, 56]. Most of the well-known determinants of health inequalities in adulthood had little time to exert their health damaging effects on young people. However, evidence suggests that the explanatory factors outlined above are also relevant for children and adolescents. Already during childhood, behavioural factors are associated with various undesirable health outcomes. Findings from the cross-national ‘Health Behaviour in School-aged Children (HBSC)’ study, for example, showed that different health behaviours among 11- to 15-year-old explain up to 25 % of the social gradient in self-rated health [61]. In addition, the family, school, and the peer group comprise central socialising contexts for young people. Potential psychosocial stressors capable of compromising health and leading to adverse health are primarily found in these social contexts [35]. The family also represents the environment, which might expose children and adolescents to material disadvantage. Although there are some findings on the health-damaging consequences of various psychosocial aspects of school, peer groups, and family not much is known about their contribution to the explanation of socioeconomic differences in health in adolescence. Some studies have however shown that children and adolescents from families with low socioeconomic position are more disadvantaged in terms of material wealth, family situation, housing circumstances, and peer relations, which in turn are associated with adverse health [10, 35]. These young people often have fewer individual and social resources to cope with
these demands. For example, in the German KiGGS study, adolescents from the lowest socioeconomic group with good resources showed less health problems compared to their low SEP peers with fewer resources [32]. In addition to a positive family climate and parental support, personal resources such as selfesteem and control beliefs turned out to be especially relevant. Few studies have systematically analysed the relative importance of different explanatory pathways in childhood and adolescence. Findings by Richter et al. [60] showed that socioeconomic in equalities in self-rated health were largely explained by material, psychosocial, and behavioural factors among German adolescents. Material factors contributed most to differences in selfrated health because of their direct and indirect effect (through psychosocial and behavioural factors). Using the cross-national HBSC Study, Moor et al. [45] found that this effect is largely universal across European and North-American countries. Recently, a number of studies have shown that health and health inequalities in adulthood are determined not only by individual material, psychosocial and behavioural factors, but also by factors at the macro-level (societal level), such as welfare state characteristics, national income, income inequality, and public health spending. These studies were mostly interested in investigating how social contexts create social stratification and assign individuals to different social positions [9, 60, 70]. The ‘context’ here is broadly defined to “include all social and political mechanisms that generate, configure and maintain social hierarchies, including: the labour market, the educational system, political institutions and other cultural and societal values” [70]. Richter et al. [60] found that welfare state regimes are associated with the overall level of subjective health in adolescence. Adolescents in the Eastern and Anglo-Saxon welfare regimes had higher prevalences of fair/poor self-rated health and health complaints compared to adolescents in the Scandinavian and Bismarckian regime.
Systematic approaches to explain socioeconomic inequalities in health
▼
The findings given above show that health and illness are sideproducts of the social organization of societies. Several general conceptual frameworks were proposed, which try to summarize different levels of influences on health and health inequalities, from levels proximal to the individual to factors quite distal from the individual, such as economic and political systems [6, 39, 47]. Even though the frameworks differ in terms of complexity and style, they all share the assumption that health is the result of a web of different social influences. The WHO ‘Commission on the ▶ Fig. 1) developed one of the most Social Determinants of Health’ ( ● cited models on the explanation of social inequalities in health. The model assumes that the effect of socioeconomic position on health causes the unequal distribution of health and well-being, i. e., that a lower position causes a greater risk for adverse health. However, socioeconomic position does not have a direct effect on health but operates through a set of intermediary and interlinked determinants (material conditions; psychosocial circumstances; behavioural and/or biological factors). The set of socioeconomic positions is itself formed by social, economic, and political mechanisms (contextual determinants) that generate, configure, and maintain social hierarchies, including the labour market, educational system, political institutions, and other cultural and societal values. According to country and configuration, the health system can also play a key role as it influences Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
Downloaded by: University of British Columbia. Copyrighted material.
Review 195
196 Review
Socioeconomic and political context
Fig. 1 Conceptual framework of the WHO “Commission on Social determinants of Health”. (Source: adapted according to CSDH 2008) Social position Material cicumstances
Governance
Social cohesion Education
Policy (macroeconomic, social, health)
Occupation
Cultural and societal norms and values
Ethninicty
Income Gender
Psychosocial factors Behaviours
Distribution of health and well-being
Biological factors
Health care system
Discussion
▼
The social conditions in which we live and grow up not only create or favour a predisposition for disease, but also cause disease directly and influence the course of the disease. This statement, which was formulated by Alfred Grotjahn already in 1923 [4], has not lost anything of its conciseness and is still up-to-date. Clues for current and changing population patterns of health and illness (and thus for social inequalities in health) are mainly to be found in the social, material, and ecological contexts in which we are born and develop and not in the dominating etiological hypotheses that consider decontextualised and disembodied risk behaviour and genes [29]. Children and adolescents are born into a specific socioeconomic environment that strongly influences the possibilities of young people to achieve and sustain good health as well as a high level of well-being [56, 80]. Adolescence is a period of rapid development when young people acquire new capacities and face new challenges. When they move on to secondary school, young people are confronted with new and more complex socialising influences from various areas, influences that play a mediating role between the social structure and the adolescent. In no other developmental period, health, behaviour, and the social environment are changing so rapidly while at same time, important neurological, cognitive, and physical changes occur [65]. Even though studies on health inequalities among children and adolescents are less numerous compared to studies among adults, the existing findings indicated clearly that social inequalities have severe consequences for health and longevity already in young people. The chances for a long and healthy life are compromised already at the start, and the odds that social and health-related disadvantages continue and accumulate throughout the life course increase. However, it is remarkable that no consistent picture of social inequalities is found in adolescent health, unlike in adults. Generally, some evidence suggest that certain aspects of adolescent health are more sensitive towards the social determinants of health. Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
Challenges in basic research on adolescent health
Considering the preventive potential inherent to young people, it will be crucial to increase research efforts to describe and explain health inequalities in adolescence. Several authors argued that adolescence may be a second critical period for tackling social inequalities in current and future health [71, 80]. Paediatrics plays a key role in this context. It offers a central interdisciplinary link of different research paradigms to better understand how society gets under the skin. Two major challenges can be identified in this context. The first relates to putting adolescence up on the agenda of paediatric research and practice, the second relates to a broader understanding of adolescent health, including its social determinants. Advocating a more holistic understanding of adolescent health is an important further step for including adolescent health, as a marginalised subspecialty, in mainstream global health agendas [65, 79]. Though general paediatrics has been more active in incorporating social aspects of health compared to other fields in medicine, it is still largely dominated by natural sciences thinking. The findings on the embodiment of social inequalities, which are largely informed by research in the field of medical sociology and social epidemiology, could be considered much stronger in mainstream paediatric research. On the other hand, medical sociology should approach paediatric research more directly and involve it pro actively in developing and testing research questions. Task of such a paradigmatic alliance would be to build on previous risk and protective factor models of adolescent health and to develop developmental transactional models that take into account person-environment interaction and its multi-level, multi-dimensionality, and multi-directionality over the whole life course [12, 25, 79]. This calls for thinking in terms of the full range of questions and explanatory factors – spanning multiple domains, levels, and time. It also requires that paediatrics and medical sociology are reciprocally more aware of the literature in order to further develop joint frameworks and conceptual models as well as measurements and research designs. Another task of such a biopsychosocial as well as explicitly social research on adolescent health would be to focus on the question how social influences are embodied in physiological characteristics and thus exert an influence on health as well as how they are reflected in social inequalities in health [29, 38, 64]. This would provide new insights on how social conditions form a) the expression of biological features and b) societal patterns of health and disease. This, for example, also includes work on epigenetic mechanisms in children and adolescents [67]. First findings, for example, showed that the extent of DNA methylation, one of the
Downloaded by: University of British Columbia. Copyrighted material.
health directly as well as indirectly through the intermediary factors. The role of the health system becomes particularly relevant for the issue of access and plays an important role in mediating the differential consequences of illness in people’s lives. Finally, the model also takes into account that adverse health – especially in case of weak social security systems – can influence socioeconomic position (social selection).
Review 197
Clinical research challenges in adolescent health
So far, existing studies mostly looked at the role of socioeconomic position for the genesis of adverse health while few studies have analysed the impact of social determinants on healthcare provision in adolescence. Findings for adults suggest that disadvantaged people suffer not only from a higher burden of disease but also from poorer access to and quality of health care. Thus, one promising research avenue for paediatric research would be to focus on possible socioeconomic inequalities in clinical settings: For example, to analyse whether inequalities in patientreported outcomes such as functioning, well-being or social participation exist during and/or after treatment. Social inequalities in the access and quality of health care present another important example which has rarely been analysed in young people. Similar, socioeconomic differences in the patient-doctor relationship as well as adherence were rarely studied in this age group. As a first step descriptive studies are indicated followed by studies trying to unravel possible mechanisms which link family SEP to the respective outcomes. This could include quantitative as well as qualitative research designs. Based on this work, targeted consequences for practical medicine can be derived [63]. The clinical and therapeutic practice must be more aware of socioeconomic influences and is requested to further integrate them in daily routine processes, such as anamnesis, treatment, and therapy. For example, next to medical diagnostic more attention could be paid to a social diagnosis of young patients and their families in order to assess whether the proposed therapy can be realised. This could help to identify high-risk groups and to apply targeted strategies to increase adherence and competence in young patients from lower socioeconomic groups. Moreover, a closer collaboration of the involved disciplines is indicated in order to evaluate and develop corresponding treatment concepts. Generally, there is a strong need to translate findings from health inequalities research into clinical practice. The extent to which such an interdisciplinary research can be established as a counterweight to a strong molecular biological-reductionist medicine is unclear. We support the claim of the WHO Commission on the Social Determinants of Health regarding the increased need to measure the problem, to evaluate action, to develop a workforce that is trained in the social determinants of health, and to raise public awareness about the social determinants of health. We are hoping that our findings offer ideas for an increased discussion of the determinants and mechanisms of health inequalities in paediatric research and practice.
Contributor’s statement
▼
M. Richter wrote the first draft of the paper. D. Körholz edited and revised the manuscript. All authors read and approved the final manuscript.
Conflict of interest: The authors have no conflict of interest to disclose.
References
1 Bergström E, Hernell O, Persson LA. Cardiovascular risk indicators cluster in girls from families of low socio-economic status. Acta Paediatr 1996; 85: 1083–1090 2 Bleich SN, Jarlenski MP, Bell CN et al. Health inequalities. trends, progress, and policy. Annu Rev of Public Health 2012; 33: 7–40 3 Blum RW, Bastos Francisco IPM et al. Adolescent health in the 21st century. Lancet 2012; 379: 1567–1568 4 Borgers D, Steinkamp G. Sozialepidemiologie – Gesundheitsforschung zu Krankheit, Sozialstruktur und gesundheitsrelevanter Handlungsfähigkeit. In: Schwenkmezger P, Schmidt LR, Borgers D (Eds.). Lehrbuch der Gesundheitspsychologie. 18 Tabellen. Enke, Stuttgart: 1994 5 Borghol N, Suderman M, McArdle W et al. Associations with early-life socio-economic position in adult DNA methylation. Int J Epidemiol 2012; 41: 62–74 6 Brunner EJ, Marmot MG. Social organization, stress, and health. In: Marmot MG, Wilkinson RG (Eds.). Social determinants of health. Oxford University Press, Oxford: 2006 7 Chen E, Martin AD, Matthews KA. Socioeconomic status and health. Do gradients differ within childhood and adolescence? Soc Sci Med 2006; 62: 2161–2170 8 Chen E, Matthews KA, Boyce WT. Socioeconomic differences in children’s health. how and why do these relationships change with age? Psychol Bull 2002; 128: 295–329 9 CSDH WH. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: WHO 2008 10 Currie C, Nic Gabhainn S, Godeau E et al. Inequalities in Young People’s Health. HBSC International Report from the 2005/2006 Survey. World Health Organization (WHO), Copenhagen: 2008 11 Currie C, Zanotti C, Morgan A et al. Social determinants of health and well-being among young people. Health Behaviour in School-aged Children (HBSC) study. international report from the 2009/2010 survey. Health Policy for Children and Adolescents, No. 6. WHO Regional Office for Europe, Copenhagen: 2012 12 Denny K, Brownell M. Taking a social determinants perspective on children’s health and development. Can J Public Health 2010; 101: (Suppl 3): S4–S7 13 Diderichsen F, Andersen I, Manuel C et al. Health inequality–determinants and policies. Scand J Public Health 2012; 40: 12–105 14 Diez-Roux AV. Conceptual approaches to the study of health disparities. Annu Rev of Public Health 2012; 33: 41–58 15 Dowler E, Spencer N. Challenging health inequalities. From Acheson to ‚choosing health‘. Policy Press, Bristol: 2007 16 Due P, Krølner R, Rasmussen M et al. Pathways and mechanisms in adolescence contribute to adult health inequalities. Scand J Public Health 2011; 39: 62–78 17 Elo IT. Social Class Differentials in Health and Mortality: Patterns and Explanations in Comparative Perspective. Annu Rev Sociol 2009; 35: 553–572 18 Frederick CB, Snellman K, Putnam RD. Increasing socioeconomic disparities in adolescent obesity. Proc Natl Acad Sci USA. 2014; 111: 1338–1342 19 Geyer S. Manifestation, Erklärung und Reduzierung gesundheitlicher Ungleichheiten. Ethik Med 2010; 22: 249–262 20 Geyer S, Peter R. Unfallbedingte Krankenhausaufnahmen von Kindern und Jugendlichen in Abhängigkeit von ihrem sozialen Status–Befunde mit Daten einer nordrhein-westfälischen AOK. Gesundheitswesen 1998; 60: 493–499 21 Gissler M, Rahkonen O, Järvelin MR et al. Social class differences in health until the age of seven years among the Finnish 1987 birth cohort. Soc Sci Med 1998; 46: 1543–1552 22 Goodman E, Huang B. Socioeconomic status, depressive symptoms, and adolescent substance use. Archives of pediatrics & adolescent medicine 2002; 156: 448–453 23 Gore FM, Bloem Paul JN et al. Global burden of disease in young people aged 10-24 years: a systematic analysis. Lancet 2011; 377: 2093–2102 24 Hagquist CE. Health inequalities among adolescents. the impact of academic orientation and parents’ education. Eur J Public Health 2007; 17: 21–26 25 Halfon N. Socioeconomic influences on child health: building new ladders of social opportunity. JAMA 2014; 311: 915–917 26 Hanson MD, Chen E. Socioeconomic status and health behaviors in adolescence. A review of the literature. J Behav Med 2007; 30: 263–285 27 Holstein BE, Currie C, Boyce WT et al. Socio-economic inequality in multiple health complaints among adolescents. International comparative study in 37 countries. Int J Public Health 2009; 54: 260–270
Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
Downloaded by: University of British Columbia. Copyrighted material.
key epigenetic mechanisms, varies with income and education [5]. A recent study also showed that parental education was positively associated with child leukocyte telomere length and that children whose parents never attended college had shorter telomeres, roughly equivalent to 6 years of additional aging [48].
28 Koivusilta LK, Rimpela AH, Kautiainen SM. Health inequality in adolescence. Does stratification occur by familial social background, family affluence, or personal social position? BMC public health 2006; 6: 110 29 Krieger N. Epidemiology and the people’s health. Theory and context. Oxford University Press, New York: 2012 30 Kroll LE, Lampert T. Soziale Unterschiede in der Lebenserwartung. Datenquellen in Deutschland und Analysemöglichkeiten des SOEP = Socioeconomic differences in life expectancy. MDA 2009; 3: 3–30 31 Laflamme L, Engström K, Huisman M. Is there equalisation in socioeconomic differences in the risk of traffic injuries in childhood? A study of three cohorts of Swedish school children. Int J Adolesc Med Health 2004; 16: 253–263 32 Lampert T, Kroll LE. Armut und Gesundheit. GBE kompakt 5/2010. www.rki.de/gbe-kompakt (Stand: 01.12.2010) 2010; 33 Lampert T, Kroll LE, Kuntz B et al. Gesundheitliche Ungleichheit. WZB, Destatis 2011 34 Lampert T, Kurth B. Sozialer Status und Gesundheit von Kindern und Jugendlichen. Ergebnisse des Kinder- und Jugendgesundheitssurveys (KiGGS). Deutsches Ärzteblatt 2007; 43: 2944–2949 35 Lampert T, Richter M. Gesundheitliche Ungleichheit bei Kindern und Jugendlichen. In: Richter M, Hurrelmann K (Eds.). Gesundheitliche Ungleichheit. Grundlagen, Probleme, Perspektiven. VS Verlag für Sozialwissenschaften, Wiesbaden: 2009 36 Law C. Mother, fetus, infant and family. socio-economic inequalities. In: Gordon D, Shaw M, Dorling D et al. (Eds.). Inequalities in Health – the evidence. Polity Press, Bristol: 1999 37 Levin KA, Currie C, Muldoon J. Mental well-being and subjective health of 11- to 15-year-old boys and girls in Scotland, 1994-2006. Eur J Public Health 2009; 19: 605–610 38 Loi M, Del Savio L, Stupka E. Social Epigenetics and Equality of Opportunity. Public Health Ethics 2013; 6: 142–153 39 Mackenbach JP. Health inequalities: Europe in Profile. An independent expert report commissioned by the UK presidency of the EU. Department of Health, London: 2006 40 Mackenbach JP, Stirbu I, Roskam AR et al. Socioeconomic inequalities in health in 22 European countries. N Engl J Med 2008; 358: 2468–2481 41 Marmot M, Allen JJ. Social determinants of health equity. Am J Public Health 2014; 104: (Suppl 4): S517–S519 42 Marmot MG, Wilkinson RG. Social determinants of health. Oxford: Oxford University Press 2006 43 Marmot MG. Status syndrome. How your social standing directly affects your health and life expectancy. Bloomsbury Press, London: 2004 44 Mielck A, Reitmeir P, Wjst M. Severity of childhood asthma by socioeconomic status. Int J Epidemiol 1996; 25: 388–393 45 Moor I, Rathmann K, Stronks K et al. Psychosocial and behavioural factors in the explanation of socioeconomic inequalities in adolescent health: a multilevel analysis in 28 European and North American countries. J Epidemiol Community Health 2014; 68: 912–921 46 Mortimer JT, Larson R. The changing adolescent experience. Societal trends and the transition to adulthood. Cambridge University Press, Cambridge, UK, New York: 2002 47 Najman JM. A General Model of the Social Origins of Health and WellBeing. In: Eckersley R, Dixon J, Douglas RM (Eds.). The social origins of health and well-being. Cambridge University Press, Cambridge, UK, New York, NY, USA: 2001 48 Needham BL, Fernandez JR, Lin J et al. Socioeconomic status and cell aging in children. Soc Sci Med 2012; 74: 1948–1951 49 Patton GC, Coffey C, Cappa C et al. Health of the world’s adolescents: a synthesis of internationally comparable data. Lancet 2012; 379: 1665–1675 50 Patton GC, Ross DA, Santelli JS et al. Next steps for adolescent health: a Lancet Commission. Lancet 2014; 383: 385–386 51 Piko BF, Fitzpatrick KM. Socioeconomic status, psychosocial health and health behaviours among Hungarian adolescents. Eur J Public Health 2007; 17: 353–360 52 Quon EC, McGrath JJ. Subjective socioeconomic status and adolescent health: a meta-analysis. Health Psychol 2014; 33: 433–447 53 Raphael D. Social determinants of health. present status, unanswered questions, and future directions. Int J Health Serv 2006; 36: 651–677 54 Reiss F. Socioeconomic inequalities and mental health problems in children and adolescents: a systematic review. Soc Sci Med 2013; 90: 24–31 55 Richardson LJ, Hussey JM, Strutz KL. A life course perspective on maternal and child health. In: Kotch JB (Ed.). Maternal and Child Health: Programs, Problems, and Policy. Jones & Bartlett, Sudbury, MA: 2013 56 Richter M. Gesundheit und Gesundheitsverhalten im Jugendalter. Der Einfluss sozialer Ungleichheit. VS Verlag für Sozialwissenschaften, Wiesbaden: 2005
Richter M, Körholz D. The Social Dimension of … Klin Padiatr 2015; 227: 193–198
57 Richter M. Risk behaviour in adolescence: Patterns, determinants and consequences. Wiesbaden: VS-Verlag 2010 58 Richter M. Verkörperte Ungleichheiten: Herausforderungen für die psychosomatische Medizin. Psychother Psychosom Med Psychol 2013; 63: 19–25 59 Richter M, Lampert T. Verkörperte Ungleichheiten. Die Rolle multipler Statusindikatoren für das Gesundheitsverhalten im Jugendalter. ZSE 2008; 28: 174–190 60 Richter M, Moor I, van Lenthe FJ. Explaining socioeconomic differences in adolescent self-rated health. The contribution of material, psychosocial and behavioural factors. J Epidemiol Community Health 2012; 691–697 61 Richter M, Hurrelmann K. Gesundheitliche Ungleichheit. Grundlagen, Probleme, Perspektiven, Wiesbaden. VS Verlag für Sozialwissenschaften, 2009 62 Roberts H. What works in reducing inequalities in child health? Policy Press, Bristol, Chicago, IL: 2012 63 Roberts J, Sanci L, Haller D. Global adolescent health: is there a role for general practice? Br J Gen Pract 2012; 62: 608–610 64 Rosenbach F, Richter M, Pförtner T. Sozioökonomischer Status und inflammatorische Biomarker für Herz-Kreislauf-Erkrankungen. Wie wirken Bildung, Beruf und Einkommen? Herz 2014 65 Sawyer SM, Afifi RA, Bearinger LH et al. Adolescence: a foundation for future health. Lancet 2012; 379: 1630–1640 66 Schreier HMC, Chen E. Health Disparities in Adolescence. In: Steptoe A (Ed.). Handbook of Behavioral Medicine. Springer Science + Business Media, LCC, New York: 2010 67 Schreier HMC, Roy LB, Frimer LT et al. Family chaos and adolescent inflammatory profiles: the moderating role of socioeconomic status. Psychosom Med 2014; 76: 460–467 68 Scrambler G. Health inequalities. Soc Health Illn 2012; 34: 130–146 69 Siegrist J, Marmot MG. Social inequalities in health: new evidence and policy implications. Oxford: Oxford University Press 2006 70 Solar O, Irwin A. A Conceptual Framework for Action on the Social Determinants of Health. World Health Organization, Geneva: 2007 71 Spencer N. Reducing child health inequalities: what's the problem? Arch Dis Child 2013; 98: 836–837 72 Spencer NJ. Social equalization in youth. evidence from a cross-sectional British survey. Eur J Public Health 2006; 16: 368–375 73 Starfield B, Riley AW, Witt WP et al. Social class gradients in health during adolescence. J Epidemiol Community Health 2002; 56: 354–361 74 Torsheim T, Currie C, Boyce WT et al. Material deprivation and self-rated health. a multilevel study of adolescents from 22 European and North American countries. Soc Sci Med 2004; 59: 1–12 75 Torsheim T, Currie C, Boyce WT et al. Country material distribution and adolescents’ perceived health. multilevel study of adolescents in 27 countries. J Epidemiol Community Health 2006; 60: 156–161 76 Tuinstra J, Groothoff JW, Van den Heuvel WJ et al. Socio-economic differences in health risk behavior in adolescence. do they exist? Soc Sci Med 1998; 47: 67–74 77 UNICEF. State of the world’s children 2011. adolescence – an age of opportunity. United Nations Children’s Fund, New York, NY: 2011 78 Vallejo-Torres L, Hale D, Morris S et al. Income-related inequality in health and health-related behaviour: exploring the equalisation hypothesis. J Epidemiol Community Health 2014; 68: 615–621 79 Viner RM, Barker M. Young people’s health: the need for action. BMJ 2005; 330: 901–903 80 Viner RM, Ozer EM, Denny S et al. Adolescence and the social determinants of health. Lancet 2012; 379: 1641–1652 81 Von Rueden U, Gosch A, Rajmil L et al. Socioeconomic determinants of health related quality of life in childhood and adolescence: results from a European study. J Epidemiol Community Health 2006; 60: 130–135 82 Wardle J, Jarvis MJ, Steggles N et al. Socioeconomic disparities in cancer-risk behaviors in adolescence. baseline results from the Health and Behaviour in Teenagers Study (HABITS). Prev Med 2003; 36: 721–730 83 West P. Health inequalities in the early years. is there equalisation in youth? Soc Sci Med 1997; 44: 833–858 84 West P, Sweeting H. Evidence on equalisation in health in youth from the West of Scotland. Soc Sci Med 2004; 59: 13–27 85 Wickrama KAS, Noh S, Elder GH. An investigation of family SES-based inequalities in depressive symptoms from early adolescence to emerging adulthood. Adv Life Course Res 2009; 14: 147–161 86 Williams RB. Lower Socioeconomic Status and Increased Mortality. Early Childhood Roots and the Potential for Successful Interventions. JAMA 1998; 279: 1745–1746 87 Xie B, Gilliland FD, Li Y et al. Effects of ethnicity, family income, and education on dietary intake among adolescents. Prev Med 2003; 36: 30–40
Downloaded by: University of British Columbia. Copyrighted material.
198 Review
