건강결정요인

서울대학교 보건대학원

조 성 일

목 차

• 역학에서의 건강결정요인 연구

• 건강결정모형

• 건강의 사회적 결정요인

• 사회역학

• 이론적 발전

• 실천

• 결론

역학의 사전적 정의Porte (2008): A Dictionary of Epidemiology

• 역학은 특정한 인구집단에서 건강관련 상태나 사건의 발생과 분포를 연구하는 학문으로서, 그러한 상태에영향을 주는 결정요인을 탐구하고그 지식을 건강문제 통제에 적용하는 것을 포함한다.

• The study of the occurrence and distribution of health-related states or events in specified populations, including the study of the determinants influencing such states, and the application of this knowledge to control the health problems.

3

Epidemiology

원인, 결정요인, 위험요인?

결정요인

위험요인

원인

Epidemiology

감염병의 역학적 모형

병원체숙주

환경

질병

5

건강결정모형

다요인(multifactorial) 모형

건강결정모형

Health Field Concept(Lalonde Report, 1974)

건강결정모형

Dahlgren & Whitehead, 1991

건강결정모형

Health Promotion Planning Model

(Green, 1991, 2005)

건강결정모형

Social Determinants of Health Framework(WHO, 2008)

건강결정모형

Demographic Transition: Causes?건강의 사회적 결정요인

What Caused the Transition?

• Largely, socioeconomic factors (Omran)

• Socioeconomic factors drive the changes in overall patterns of diseases

• Socioeconomic factors affect the patterns of individual diseases

건강의 사회적결정요인

건강의 사회적결정요인

What are the social factors associated with infectious diseases?

WHO (2005)

Causes of the causes (Rose G, The strategy of preventive medicine, 1992)

건강의 사회적결정요인

건강의 사회적결정요인

Social Epidemiology, Defined

• The branch of epidemiology that studies the social distribution and social determinants of states of health. (Berkman & Kawachi, 2000)

• The branch of epidemiology that considers how social interactions and collective human activitiesaffect health. (Oakes & Kaufman, 2006)

사회역학

Social Epidemiology:Guiding the Practice

• Social determinants (mechanism): science

• Disparity, inequality, inequity: policy

• Justice: ethics, philosophy

사회역학

Key Exposure Areas

• Socioeconomic position (SEP), social class

• Income inequality, poverty, wealth

• Working conditions, employment

• Social network, support, cohesion, capital

• Gender and race/ethnicity

사회역학

(JECH 2006)

Measuring Socioeconomic Position (SEP)사회역학

Health Disparity

• “Health disparities occur when one group of people has a higher incidence or mortality rate than another, or when survival rates are less for one group than another.”—NCI Center to Reduce Cancer Health Disparities, 2003 (46)

• “Health disparities are differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States.” —NIH Strategic Research Plan and Budget to Reduce and Ultimately Eliminate Health Disparities, Vol. 1, Fiscal Years 2002–2006

사회역학

Approaches to Reducing Obesity (Adapted from IOM, 2003)

obese

overweight

current distribution

future distribution

A. High risk intervention approach

B. Population approach: shifting the mean C. Population approach: reducing inequality

사회역학

Broad Theories

• Life course theory

• Ecosocial theory

• Complexity theory

이론적 발전

Life Course Approach

Ben-Shlomo & Kuh (IJE, 2002)

이론적 발전

Berkman (Ann Rev PH, 2009)

이론적 발전

WHO (2005)

이론적 발전

Life Course Approach to Active Ageing (WHO, 2002)이론적 발전

Ecosocial Theory

• A theoretical generalization of multi-level framework

• Seek to integrate social and biological reasoning and a dynamic, historical and ecological perspective to develop new insights into determinants of population distributions of disease and social inequalities in health.

• Embodiment: a concept referring to how we literally incorporate, biologically, the material and social world in which we live, from in utero to death. A corollary is that no aspect of our biology can be understood absent knowledge of history and individual and societal ways of living.

이론적 발전

Krieger (AJPH, 2008)

Complexity TheoryMore comprehensive & interdiciplinary generalization of generalization of multilevel concept

Strong mathematical and analytical tools

Applied to social sciences, biology, and engineering

이론적 발전

WHO Commission on Social Determinants of Health (2005-8)

(30 years)

1978 Alma-Ata Declaration

(30 years)

1948 WHO established

M. Marmot(UCL, London)

실천

WHO Report on Social Determinants of Health (2008)

The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system.

These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices.

The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.

Three overarching recommendations:1. Improve daily living conditions2. Tackle the inequitable distribution of power, money, and resources3. Measure and understand the problem and assess the impact of action

실천

실천

Summary

• Determinants of health in various perspectives

• Social determinants as the fundamental causes

• Expansion of research into broader context

• Contributions to the science of epidemiology

• Contributions to public health and the society