Question 1

What are the social determinants of health?

Accepted Answer

Social determinants of health (SDH) are the conditions in which people are born, grow, live, work and age — the social and economic circumstances that powerfully determine health outcomes. The main SDH domains: income and wealth; education; employment and working conditions; social protection systems; housing and living conditions; food security; early childhood development; social support networks; gender norms; and discrimination. These conditions shape health behaviours, access to services and biological responses to stress.

Question 2

How much do social factors affect health?

Accepted Answer

Social and economic conditions account for an estimated 30-55% of health outcomes — far more than the 20% attributed to clinical healthcare. A 10-15 year life expectancy gap between the richest and poorest areas of the same city (like Glasgow or London) is explained by social conditions. A child's chance of good health is more powerfully determined by their parents' income, education and neighbourhood than by any medical intervention they will receive.

Question 3

What is the social gradient in health?

Accepted Answer

The social gradient in health — first systematically documented in the Whitehall Studies of British civil servants by Sir Michael Marmot — shows that health follows a continuous gradient from top to bottom of the social hierarchy. Not just the poor have worse health than the rich — those in the middle have worse health than those above them. This gradient runs for heart disease, mental health, disability, life expectancy and almost every health outcome studied.

Question 4

What was the WHO CSDH?

Accepted Answer

The WHO Commission on Social Determinants of Health (CSDH), chaired by Sir Michael Marmot (2005-2008), was convened to synthesise global evidence on SDH and provide recommendations. Its landmark 2008 report "Closing the Gap in a Generation" concluded that social injustice is killing people on a grand scale. Its three main recommendations: improve daily living conditions (early childhood, housing, work conditions, social protection); address the inequitable distribution of power, money and resources; measure the problem and assess the impact of action.

Question 5

What is Health in All Policies?

Accepted Answer

Health in All Policies (HiAP) is a governance approach — endorsed by WHO and the EU — that systematically incorporates health considerations into decision-making across all sectors. Agricultural subsidies affect food choices; urban transport design affects physical activity; housing quality affects respiratory disease; educational attainment affects lifelong health. HiAP requires cross-sectoral mechanisms: inter-ministerial committees, health impact assessments, legislative requirements.

Question 6

How does education affect health?

Accepted Answer

Education is one of the most powerful social determinants of health. Higher educational attainment is associated with: longer life expectancy (7-10 years difference between university graduates and those without secondary education); lower rates of cardiovascular disease, diabetes, depression and obesity; higher health literacy; better health behaviours (lower smoking rates, healthier diet); access to safer occupations; and better navigating of health systems. Education's health effects extend across generations.

Question 7

How does poverty affect health?

Accepted Answer

Poverty operates on health through multiple pathways: material deprivation (inability to afford food, heating, healthcare); psychosocial stress (chronic activation of the stress response — elevated cortisol, inflammation); exposure to hazardous environments (pollution, violence, poor housing); barriers to health-promoting behaviours; and reduced access to services. Chronic poverty from early childhood has the most devastating long-term health consequences — disrupting brain development and setting health trajectories for life.

Question 8

What is proportionate universalism?

Accepted Answer

Proportionate universalism — a concept from the Marmot Review — argues that health inequalities are best reduced by universal policies (applied to all, not just the poorest) delivered with intensity proportionate to disadvantage. Pure universalism (one-size-fits-all) ignores that the middle of the social gradient also has worse health than the top. Pure targeting (services only for the poorest) misses the gradient and often stigmatises recipients. Proportionate universalism delivers more intensive support to more disadvantaged groups while maintaining universal access.

Question 9

What is the Marmot Review?

Accepted Answer

The Marmot Review for England (2010, updated 2020) — commissioned by the UK government and led by Sir Michael Marmot — is one of the most influential SDH policy documents globally. It documented the social gradient in English health; identified six policy objectives (early childhood, education, employment, income, communities, ill-health prevention); and found that despite SDG-era progress, health inequalities in England were not reducing. The 2020 update found they had widened. It coined proportionate universalism and inspired similar reviews globally.

Question 10

How do SDH relate to climate change?

Accepted Answer

Climate change and social determinants interact: communities with the weakest social conditions — poorest, most marginalised, least resilient — are the most vulnerable to climate impacts (extreme heat, flooding, food insecurity, displacement). They have the least adaptive capacity. Addressing SDH is therefore a climate adaptation strategy; conversely, climate change threatens to reverse decades of SDH progress by deepening poverty, food insecurity and displacement.

Question 11

How does GMJ News cover social determinants?

Accepted Answer

GMJ News frames health news through the lens of SDH — covering inequality in health outcomes, Marmot Review updates, WHO SDH Commission initiatives, Georgia's social gradient in health, and Health in All Policies implementation. SDH is central to PHIG's public health mission and the Georgian Medical Journal's health policy coverage.

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