Almost 2,000 years ago, Galen (8) observed, "Both in importance and in time, health precedes disease. Therefore, we ought to consider first how health may be preserved and then how one may best cure disease." This statement leads us to ponder what the causal factors may be for disease and ill health. Oftentimes, epidemiology seeks to identify the risk factors for diseases and conditions. Elevated blood cholesterol or blood pressure is associated with an increased risk for cardiovascular disease. Based on such information, screenings are often called for to identify the individuals who may be at high risk for subsequent disease and they become appropriate candidates for outreach and interventions to reduce risk. However, it may be time to view the issue through a different lens. What if we were to consider, from a population health perspective, the underlying causal factors that cause the biological markers for subsequent disease (such as elevated cholesterol) to get closer to the sources of the problem? Here, for example, we examine the dietary behaviors of people as a more proximal cause of the disease, rather than the biological effect the diet itself has on blood lipid profiles.
Unfortunately, if we consider only the proximal factors for the risks, there may be an inappropriate and unjustified urge to blame individuals for the disease end points - that is, adopt the position that "if people were to just change their behavior, we wouldn't have the negative consequences of so much ill health including excess health care costs, lost productivity, and the like." Despite the modifiable nature of many behaviors, it is not always entirely an individual choice to change behavior. It probably makes sense to look even deeper.
After decades of research, it has become increasingly clear that individual choices are not necessarily the reason why people, for example, consume diets high in saturated fats, salt, and calories. Behaviors are actually tied quite closely to the nature of the policies that shape economic incentives for farmers, the food supply itself, the culture of the group, and affordability and accessibility of healthy food options, among other reasons. These may all be considered social circumstances that influence the behavior of individuals and populations. These behaviors, in turn, predispose them to risk factors that may be viewed as "signal events" for impending disease, ill health, lower functional status, and premature death. Let's consider these social circumstances that shape the behaviors that are the "causes of the causes."
Previously, this column has reported on the interconnectedness of the behaviors of individual employees and the influence of the company environment on them (4). The bidirectional interaction between individuals and their (corporate) community makes health both a personal good and a public good (3). The health status of both the individual and the larger community to which they belong is directly related to the emotional, psychological, physical, and financial well-being of both the employee and the company. Searching for actionable opportunities to change the underlying causes of the causes will produce the potential to improve health and economic outcomes for both employees and the company for which they work. The intention of this column is to consider the social determinants of health and to stimulate action that will lead to change in the social context in which employees function, thereby providing specific reference to the worksite setting.
WHAT ARE THE CAUSES OF THE CAUSES?
On behalf of the World Health Organization, Wilkinson and Marmot (10) summarized their work on the social determinants of health in 10 messages that could provide guidance for action. The resulting 10 most important social determinants of health are based on many different kinds of studies including cross-sectional analyses, short-term trials, and decades of cohort tracking that allowed for patterns of health and ill health to emerge. The recommendations are the result of many thousands of research reports from various scientific fields of study. The difficulties in assigning causality have been overcome by using evidence from intervention studies and natural experiments. Given that the context is the social circumstance, evidence accumulated through this kind of method is acceptable. For example, John Snow's (9) careful observation and reasoned judgment - as opposed to a randomized controlled trial - led to the discovery that contaminated water from the Broad Street pump was the cause of cholera outbreak in the Soho neighborhood of London in 1854. The Table presents a summary of the 10 leading social determinants of health.
The 10 social determinants of health influence the health behaviors, biological markers of disease, and ultimately disease and premature death (Figure). Because of this causal chain, intervening on the social determinants of health can have a profound impact on behaviors, risk factors, and illness at the worksite setting. In fact, all of the 10 determinants are readily addressed in the worksite. Organizational policy interventions will be the most relevant type of intervention. For example, providing adequate safety measures to protect worker health from toxic exposures is most effectively accomplished through policy-level measures and actions.
To consider how to address these social determinants and implement changes or interventions thoughtfully, a simple operational three-step process is proposed here:
"SEEING - PLANNING - DOING"
Social determinants may not be a frequently used term in the worksite. However, when companies consider their corporate culture, their human resources strategy, their organization of work, their cafeteria offerings, their compliance to Occupational Safety and Health Administration rules and regulations, their pay scales, and their occupational health and safety plans, they are very much considering the social determinants of health. As such, worker health protection and worker health promotion go hand in hand in addressing the causes of the causes. Along with other internal partners, worksite health promotion practitioners should stimulate coordinated action to address the causes of the causes. This three-step approach may prove helpful in doing so.
Step 1: Seeing
First, it is important to see what is creating problems and what the situation is like in its current form or state. To take this action step, it is important to observe without immediately acting on what is observed. Seeing represents a step during which judgment is suspended (6) so an objective set of impressions and observations may be gathered. Furthermore, it includes the formulation of a current state assessment that reflects the reality of the situation against which a plan may be formulated.
A variety of tools may be used to make sure a thorough assessment is completed. These tools can include a company-wide health assessment that provides insight into the risk factors and diseases present among the employees. It also includes indicators of psychosocial risk factors. In addition, an organizational environment assessment that addresses the psychosocial work environment will be important. Insights into how workers are managed, how much autonomy they have in their jobs, how much demand is placed upon them, and how they are rewarded and incentivized represent important aspects of assessment. Stress, regardless of its source, is a very powerful component of the psychosocial work environment, and several models have been proposed that relate to this. Among these are the job demand-control model (2) and the effort-reward imbalance model (7). Both of these models relate to the notion that control of one's destiny is one of the most important factors in the causes of disease and ill health in the context of the community. In this case, the community is the workplace. Here, the psychosocial work environment influences the risk of physical and mental illness.
Step 2: Planning
Once a thorough assessment is completed, a plan may be formulated that describes a thoughtful strategy for action. This phase, the planning step, includes the crystallization of a series of strategies and tactics that allow for the goals of the initiative to be achieved. In the context of addressing social determinants of health, strategies that address the factors outlined in the Table include, but are not limited to, community-based reviews of job pay scales, employer-sponsored social clubs, pregnancy health care benefit designs and maternity/paternity leave benefits, employer-sponsored volunteer support for homeless shelter aid, increased decision latitude for specific jobs, job-sharing policies, all-company smoking bans, healthy food access and subsidies in the corporate cafeteria, and benefit-integrated incentives for bike-to-work commuting, among others. The Table provides examples of intervention strategies that are aligned with each of the social determinants.
Planning for such action steps needs to be supported by leadership at all levels of the company. Data need to describe not only the health impact of policies, but also the expected productivity gains, estimated returns on investment for the company, and the overall business performance (5). Leadership is critical in this step because the choices for interventions and initiatives must be considered from a perspective that looks at the issues more broadly than just from a business setting. Pursuing opportunities to contribute to the socioeconomic development of the worksite community by engaging employees of the company is one way to connect an organization's business performance and worker health and well-being to the larger environment in which it is housed. For example, in Minnesota, the Itasca Project is a collaborative of Twin Cities chief executives officers and education leaders that is focused on several priorities to improve the region's economic competitiveness and its quality of life. Project initiatives include improving the financial fitness of individuals and families in the community, decreasing the region's socioeconomic disparities, improving early childhood education, and creating a world-class K-12 education system in Minnesota, among others (1).
Step 3: Doing
Execution of a thoughtful plan is crucial. To achieve the intended results, the planned practices, protocols, policies, and infrastructures need to be implemented, acted upon, and executed - in short, the work has to be done.
It is good practice to conduct pilot studies before full implementation of new practices, policies, and infrastructures. Pilot studies help identify unanticipated barriers or obstacles so that timely adjustments can be made before attempts to embed the proposed interventions into the larger organization. Pilots also represent a learning environment in which small tests of change can identify the peculiarities and idiosyncrasies of the company, community, and macroenvironment in which the new plan will be embedded.
In the doing step, active and engaged leadership is necessary because addressing the social determinants tends to be a population-based activity that will undoubtedly bring about qualitatively new properties that are unpredictable at the outset. This emergence of new properties is much like oxygen and hydrogen coming together to form water - we could not predict the emergence of a new property called wetness based on the knowledge that the bonding of the oxygen and hydrogen molecules creates H2O. Leadership will allow for navigation around newly emerged properties. This step is characterized by action that includes demonstrations of concept, measurement, publication, and communication of early experiences and results, relevant examples of how people are affected, invitations to describe experiences, and analysis and learning.
A SUPPORTIVE CULTURE
In the final analysis, companies that address the social determinants of health in the context of their business goals and their larger community stand to gain enormous benefits - both socially and economically. The health of workers is affected not only by their material circumstances but also by how much they are valued, appreciated, and rewarded. Social policy at work that pays attention to the social determinants of health will create a supportive environment at the worksite - currently referenced as a culture of health.