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Theoretical and Conceptual Frameworks on Social Determinants of Health and Health Inequalities
Social (including economic) inequalities in health have long been documented and debated. Interest in studying social in uences on health and health inequalities dates back to at least 19th century. Some of the pioneering researchers include Rudolf Virchow, Friedrich Engels and Salvador Allende. Rudolf reported on the role of poverty and political economy in causing an epidemic of plague in Upper Prussia, while Friedrich explored the connection between high mortality and poor living conditions of the working class in England. Salvador showed the role of social and political factors in generating health inequalities in populations (Antonovsky, 1967; Jayasinghe, 2015; Krieger et al., 2010; Kunst et al., 1998).
Since the pioneering research, several theories have been advanced to explain the generation of health inequalities from the social contexts (Solar and Irwin, 2010). Recent expansion of the theories on the in uence of social factors on health and health inequality1 includes the works f Rose (2001) on causes of morbidity in individuals, Lieberson (1985) theory of fundamental causes, developed by Link and Phelan (1995), and extended by Lutfey and Freese (2005). Most of the recent theories use the term social determinants of health inequalities (SDHI) to denote economic contexts, social norms and social structures that impact health outcomes.
In the academic and policy-oriented literature, various pathways have been put forward to 1In this thesis, the terms – inequality, disparity and inequity – were used interchangeably in many instances.dene and summarise theories of social inequalities in health. Some of these pathways include social causation, social selection/mobility and a life course perspective. Theories on life course perspective posit that an array of factors across the life span, for instance poor educational
exposure in childhood, maternal malnutrition during pregnancy, determine inequality in morbidity and mortality trends observed over time (Beckeld and Krieger, 2009; Krieger, 2001).
On the other hand, social selection theories postulate that health determines socio-economic position, and not the other way round. Thus, healthier individuals, compared to less healthier individuals, will tend to move towards better socio-economic positions, leading to inequalities in health (Bartley and Plewis, 1997; Manor et al., 2003; West, 1991). However, some studies conclude that health selection cannot be regarded as the predominant explanation for health inequalities (Marmot et al., 1997; Smith and Morris, 1994) More pertinent to this thesis, social causation theories propound that a range of unevenly distributed material, psycho-social and behavioural factors give rise to inequalities in health.
Material factors include varying income levels and investments across structures that are benecial to the society. Psycho-social factors are the chronic stresses that arise from perceptions and experiences of personal status in an unequal society. Behavioural factors refer to lifestyles and attitudes that shape individual’s health, for example, the higher rates of unhealthy diets or smoking observed in poorer groups that lead to dierential rates of morbidity, diseases, mortality and general health status (Brunner, 2007; Brunner and Marmot, 2005; Davey Smith and Egger, 1996; Raphael, 2006).
1 Introduction
1.1 Theoretical and Conceptual Frameworks on Social Determinants of Health and
Health Inequalities
1.2 Empirical Literature on Social Determinants of Health and Health Inequality
1.3 Trends in Health Outcomes and Health-related Behaviour .
1.4 Social Determinants of Health Inequalities
1.5 Gender Inequalities in Health .
1.6 Summary
2 South African Trends in Health Outcomes and Health-related Behaviour: Evidence from Repeated Cross-Sectional Surveys
2.1 Introduction .
2.2 The data and methods .
2.3 A Description of the Trends .
2.4 Estimating the Trends .
2.5 Discussion and Conclusion .
3 Social Determinants of Health Inequalities in South Africa: A Decomposition Analysis
3.1 Introduction
3.2 Methodology .
3.3 Theoretical and Empirical Methods of Estimating Health Inequality .
3.4 Results
3.5 Discussion and Conclusion
4 Gender Dierentials in Health: A Dierences-in-Decompositions Estimate
4.1 Introduction
4.2 Data, Trends and Descriptive Analysis
4.3 Empirical Strategy .
4.4 Decomposition Results
4.5 Discussion
4.6 Limitations of the study
4.7 Conclusion .
5 Conclusion
References
A Appendix for Chapter 2
A.1 Descriptive statistics of Ill-health status, Public health care facility preferences
and Medical aid coverage .
A.2 Logit Marginal Eects of the Explanatory Variables on the Health Variables .
B Appendix for Chapter 3
B.1 Components of Asset Indices .
B.3 Oaxaca-type Decomposition of Change .
C Appendix for Chapter 4
C.1 Description of Social Grants in South Africa .
C.2 Weighted Means of the Explanatory and Health Variables
C.3 OLS Decompositions of the Gendered Health Dierential
C.4 Decomposition of Gender Gap in the Health Dierentials
