Guest editors' introduction: in pursuit of the social determinants of health: the evolution of health services research.
In developing this special issue of Health Services Research, we hoped to highlight for health services researchers the importance of factors that contribute to health beyond the health care delivery system, and to identify some promising policy directions for improving health. The submissions we received, and those that appear in this issue, reflect both the strengths and gaps in our field. We were gratified that submissions concerned the entire life cycle, from birth through old age; reflected a broad conceptualization of health, including mental health and oral health; and considered a wideranging list of potential determinants of health, including not only health care but also income and income distribution, racial/ethnic segregation, and discrimination, among others. They reflected some of the major strengths of our field, using state of the art methods to examine some difficult analytic issues. They also reflected some important cross-fertilization from fields such as social epidemiology, outlining the potential contributions of community and neighborhood factors to health. Finally, they challenged us to think about investments outside of health, such as in education, which might ultimately reap benefits in terms of population health improvements.
Also worth noting are issues not addressed by papers here, which suggest important directions for future work. Submissions dealt only peripherally with health behaviors and the contribution of the physical-chemical-biological environment, despite an emerging consensus that the growing epidemic of obesity (and concomitant lack of physical activity) will join tobacco as one of the greatest contributors to morbidity and mortality, and a recent report that a seemingly nonmedical factor such as the level of air pollution is highly correlated with Medicare expenditures (Fuchs and Frank 2002). Much research, policy, and practice regarding health behaviors has generally seen these behaviors as matters of individual choice, and has only begun to recognize the role of social determinants in shaping patterns of health behavior. Conversely, health behaviors have often been treated too cursorily in work on social determinants of health. A fuller interface between these two lines of work is much needed. Research and theory on social determinants of health has been even less connected to work on the health impact of the physical-chemical-biological environment and must become more so.
There were also no reports of demonstrations or policy experiments, even if unsuccessful, that attempted to address health behaviors or environmental interventions, or policy experiments in income or education policy that might be expected to have an impact on the health of the nation. Such experiments are important not only to bringing knowledge of social determinants of health to bear on improving the nation's health, but also in advancing scientific understanding of the complex interrelations among social determinants and between them and health. Careful research designs and analyses are essential to untangling the degree to which and ways that multiple determinants of health have their effects. Methods that are now mainstream in health services research, such as techniques to address selection bias, endogeneity, and multicollinearity, have a lot to offer in addressing some of these problems.
Those studying the social determinants of health are often accused of ignoring the contribution to health improvement of a wide array of health care services, which may in turn be conditioned by community as well as individual patient factors. Similarly, health services researchers often fail to understand that without recognizing and controlling for the important role played by social determinants, studies that estimate the impact of health care services on health improvement may suffer from omitted variables bias and overestimate the true marginal contribution of increased utilization. Observing simple correlations between any of the health indicators, social determinants, and utilization of health care services will not tell us what we ultimately need to know, which is, how do we best use our considerable resources to improve health.
Our understanding of these issues and their impact on health is still evolving and has a long way to go. As we look to the future, health services research will model with ever increasing precision the implications of a problem like obesity on health care costs, utilization, and even access to care for the coming tide of uninsured children with diabetes. We are heartened by the multidisciplinary perspectives offered in this issue, and hope that such cross-fertilization of ideas stimulates further evolution in the field of health services research. Nevertheless, to fully address these problems, the field needs to evolve into new ways of thinking as well as more sophisticated tools of inquiry. Although evolution is sometimes an imperceptibly slow process, we would hope that several years from now, a new special issue of this Journal will reflect such evolutionary change, and that a generation of investigators will have struggled with, and be able to report on, attempts to identify and address nonmedical determinants of health before they develop into raging epidemics, stripping the future delivery system of the resources necessary to truly improve the health of populations, and rendering concerns about the delivery of care truly secondary, if not extinct.
Acheson, D. 1998. Independent Inquiry into Inequalities in Health- Report of the Scientific Advisory Group. London: The Stationery Office.
Fuchs, V. R., and S. R. Frank. 2002. "Air Pollution and Medical Care Use by Older Americans: A Cross-Area Analysis." Health Affairs 21 (6): 207-14.
McGinnis, J. M., and W. H. Foege. 1993. "Actual Causes of Death in the United States." Journal of the American Medical Association 270 (18): 2207-12.
U.S. Department of Health and Human Services. 2001. Healthy People 2010 [accessed July 25, 2003]. Available at http://www.healthypeople.gov.
James S. House
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|Publication:||Health Services Research|
|Date:||Dec 1, 2003|
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