A conceptual model for studies on social determinants of health in Brazilian municipalities

Melo, Francisco Carlos Carvalho de; Costa, Rodolfo Ferreira Ribeiro da; Corso, Jansen Maia Del

Acessibilidade / Reportar erro

Brasil

Español English

sumário « anterior atual seguinte »

Sumário

Original articles • Saude soc. 29 (2) • 2020 • https://doi.org/10.1590/S0104-12902020181094 copy

A conceptual model for studies on social determinants of health in Brazilian municipalities

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

The conceptual models of Social Determinants of Health (SDH) available in the literature, although useful for comprehending mechanisms that affect the results of the health system on the living conditions of the population, present limitations regarding their application in empirical studies and, consequently, in guiding public health policies. This occurs because the categories adopted by these models are not adequately represented by indicators of homogeneous variables subject to mathematical or statistical manipulations in a simple relation system. This study aims to help filling this gap by proposing an operationally applicable SDH conceptual model - reproducible as a mathematical or statistical model - to support studies and define strategies concerning public health. We resorted to the literature to review previously developed conceptual models, identifying a set of SDH and presenting recommendations and choice criteria. Then we located reliable data sources supplying indicators and variables listed in historic series and proposed an applicable conceptual model, which requires specific methods and tools for a systemic approach for operationalization.

Keywords:
Social Determinants of Health; SDH Conceptual Models; Systemic Approach

Document or author	Objectives	Suggested indicators
The Ottawa Charter for Health Promotion (1986), Canada, World Health Organization (WHO).	Built on the Alma-Ata Declaration, the charter identifies the “prerequisites for health,” which concern social structure, and organization and distribution of economic and social resources. It focuses on the health needs of industrialized countries, without disregard to other regions of the globe.	Peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice, and equity.
Dahlgren and Whitehead (1992DAHLGREN, G.; WHITEHEAD, M. Policies and strategies to promote social equity in health. Estocolmo: Institute for Future Studies, 1991.), Sweden (WHO).	It aims to stimulate debates among policy-makers and practitioners from various sectors. The authors formulated a four-level model of health determinants, represented in a rainbow form.	It identifies “living and working conditions” as contributors to health: agriculture and food production, education, work environment, unemployment, water and sanitation, health service, and housing.
International Centre for Health and Society (1996), London and New York.	It aims to identify the social bases for health, prosperity, and well-being.	Economic growth, income distribution, consumption, work organization, unemployment, family and social structure, education, and poverty.
Health Canada (1998), Canada.	It describes several determinants of health, many of which are social determinants of income, social status, and social support networks.	Education, employment and working conditions, physical conditions and social environments, genetics and biology, personal health, coping strategies and skills, healthy child development, health services, gender, and culture.
The University of York Conference organizers (2002), Canada.	The aims were: (1) to consider the conditions of the major SDH in Canada; (2) to explore their implications for the health of Canadians; and (3) to define policy guidelines for strengthening these SDH.	Aboriginal, early life, education, employment and working conditions, food security, gender, health services, housing, income and its distribution, security and social exclusion, and employment.
WHO’s European Office, United Kingdom.	It aims to raise issues for guiding policy-makers and public opinion.	Social class gradient (in health), stress, early life, social exclusion, work and unemployment, social support, drug addiction, food, and transportation.
Centers for Disease Control and Prevention (2006), United States.	It highlights SDH on socioeconomic status.	Transportation, housing, services access, discrimination (by gender, race, or class) and environmental or social stressors.

Fulop et al. (2001FULOP, N. et al. (Org.). Studying the organization and delivery of health services, research methods. Londres: Routledge Publishers, 2001. ); Mills (2012MILLS, A. Health policy and systems research: defining the terrain; identifying the methods. Health Policy and Planning, Londres, v. 27, p. 1-7, 2012. ); Gilson (2012GILSON, L. Health policy and systems research: a methodology reader. Genebra: World Health Organization, 2012. )	Exworthy (2008EXWORTHY, M. Policy to tackle the social determinants of health: using conceptual models to understand the policy process. Health Policy and Planning, Londres, v. 23, p. 318-327, 2008. )	Raphael (2009RAPHAEL, D. Social determinants of health: Canadian perspectives. 2. ed. Toronto: Canadian Scholars’ Press Inc., 2009. Disponível em: <Disponível em: https://bit.ly/39QTELn >. Acesso em: 7 abr. 2015. https://bit.ly/39QTELn... )	Craig et al. (2015CRAIG, W.; THOMAS, L. C.; MONROE, J. A. M. The value of the “system” in public health services and systems research. American Journal of Public Health, Oxford, v. 105, n. 2, p. 147-149, 2015. )
Regarding management level or geographical approach	Regarding strategy	Regarding the association with theory, common sense, and management structures	Regarding the focus on systemic thinking and health systems
(1) Micro: individual level within the health system. It comprises suppliers and patients, citizens, managers, and political elites, as well as the relationship among them.	(1) Intra-institutional and intersectoral partnerships are key to formulate and implement policies for SDH, despite being one among many competing priorities for policy-makers attention and resources.	(1) They must be consistent with the SDH existing formulations and comply with the literature empirical basis.	(1) The governmental public health (federal, state, tribal, and local and territorial agencies that function as a governmental entity for public health).
(2) Meso: local health system - often referred to as municipal or district health system - and organizations, such as hospitals. It comprises broader social, economic, and political structures.	(2) Identifying, monitoring, and analyzing epidemiological changes over time is important for political decision-making. However, routine data are usually unavailable, of poor quality, or collected during insufficient periods to help policy decision-making.	(2) They must be consistent with the lay public’s understanding of factors influencing health and well-being.	(2) The public health system or partnerships that contribute for public health.
(3) Macro: national health systems - although its influence by both national and international context is recognized.	(3) Decentralization, which promotion is mainly controlled by the government, may be deemed as a smaller threat to national policies formulation than globalization.	(3) They must be clearly aligned with government structures (e.g. ministries or secretariats). SDH must be considered relevant by both decision makers and citizens.	(3) Other systems and structural components comprised by public health infrastructure (i.e. information systems, work force).
		(4) They must comply with an active part of government policy.	(4) Systems science employed in exploring and understanding causal ties, complex dynamics, and interactions.

Domains	Indicator or variable	Source
Economic and socio-demographic	(1) Population	IBGE
	(2) Per capita income	IBGE
	(3) Employment and unemployment	Caged
Sanitation and environmental conditions	(4) Number of housings built with masonry	Siab
	(5) Number of housings with water supply	Siab
	(6) Number of housings with electric power	Siab
	(7) Number of housings with sanitary sewage	Siab
	(8) Number of housings with waste collection	Siab
Municipal financial management results	(9) Fiscal Management Index - own revenue	Firjan
	(10) Fiscal Management Index - personnel costs	Firjan
	(11) Fiscal Management Index - investment expense	Firjan
	(12) Fiscal Management Index - liquidity	Firjan
	(13) Fiscal Management Index - cost of debt	Firjan
Public expenditure	(14) Health expenditure	Siops
	(15) Social welfare expenditure	Finbra
	(16) Internal control expenditure	Finbra
	(17) Culture expenditure	Finbra
	(18) Education expenditure	Finbra
	(19) Housing expenditure	Finbra
	(20) Sanitation expenditure	Finbra
	(21) Work/capitation/job guidance expenditure	Finbra
	(22) City planning expenditure	Finbra
Health services assistance and production	(23) Live births with seven prenatal consultations	DataSUS
	(24) Vaccination coverage rate	DataSUS
	(25) Outpatient services production by area of residence	SAI
	(26) Hospital services production by area of residence	SIH
	(27) Family Health Strategy coverage (%)	DataSUS
	(28) Oral health coverage (%)	DataSUS
	(29) Health insurance beneficiaries (%)	DataSUS
Availability of health system structure	(30) Number of primary medical centers	CNES
	(31) Number of specialized medical centers	CNES
	(32) Number of hospital beds in the public sector	CNES
	(33) Number of hospital beds in the private sector	CNES
	(34) Number of hospital beds	CNES
	(35) Number of health establishments	CNES
Mortality	(36) Overall mortality rate	SIM
	(37) Infant mortality rate	SIM
	(38) Neonatal mortality rate	SIM
	(39) Deaths from preventable causes (< 5 years)	SIM
	(40) Deaths from preventable causes (5 to 74 years)	SIM
	(41) Deaths from external causes	SIM/Violence map

Faculdade de Saúde Pública, Universidade de São Paulo. Associação Paulista de Saúde Pública. Av. dr. Arnaldo, 715, Prédio da Biblioteca, 2º andar sala 2, 01246-904 São Paulo - SP - Brasil, Tel./Fax: +55 11 3061-7880 - São Paulo - SP - Brazil
E-mail: saudesoc@usp.br

Acompanhe os números deste periódico no seu leitor de RSS

[1] Correspondence Francisco Carlos Carvalho de Melo Av. Mota Neto, 350, Apartamento 1003. Mossoró, RN, Brasil. CEP: 59612-000