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Adolescence and the Social Determinants of Health Series Adolescent Health 2 Adolescence and the social determinants of health Russell M Viner, Elizabeth M Ozer, Simon Denny, Michael Marmot, Michael Resnick, Adesegun Fatusi, Candace Currie The health of adolescents is strongly aff ected by social factors at personal, family, community, and national levels. Lancet 2012; 379: 1641–52 Nations present young people with structures of opportunity as they grow up. Since health and health behaviours Published Online correspond strongly from adolescence into adult life, the way that these social determinants aff ect adolescent health April 25, 2012 are crucial to the health of the whole population and the economic development of nations. During adolescence, DOI:10.1016/S0140- 6736(12)60149-4 developmental eff ects related to puberty and brain development lead to new sets of behaviours and capacities that See Comment enable transitions in family, peer, and educational domains, and in health behaviours. These transitions modify pages 1564 and 1567 childhood trajectories towards health and wellbeing and are modifi ed by economic and social factors within countries, See Online/Comment leading to inequalities. We review existing data on the eff ects of social determinants on health in adolescence, and DOI:10.1016/S0140- present fi ndings from country-level ecological analyses on the health of young people aged 10–24 years. The strongest 6736(12)60531-5 determinants of adolescent health world wide are structural factors such as national wealth, income inequality, and This is the second in a Series access to education. Furthermore, safe and supportive families, safe and supportive schools, together with positive of four papers about and supportive peers are crucial to helping young people develop to their full potential and attain the best health in adolescent health the transition to adulthood. Improving adolescent health worldwide requires improving young people’s daily life with UCL Institute of Child Health, University College London, families and peers and in schools, addressing risk and protective factors in the social environment at a population London, UK level, and focusing on factors that are protective across various health outcomes. The most eff ective interventions are (Prof R M Viner PhD); Offi ce of probably structural changes to improve access to education and employment for young people and to reduce the risk Diversity and Outreach at of transport-related injury. University of California, San Francisco, CA, USA (E M Ozer PhD); Department of Introduction modifi able SDH is increasingly recognised by nations Paediatrics, University of Young people grow to adulthood within a complex and international agencies. In 2008, the report of the Auckland, Auckland, New web of family, peer, community, societal, and cultural WHO Commission on Social Determinants of Health Zealand (S Denny PhD); UCL Research Department of infl uences that aff ect present and future health and emphasised the importance of a life-course approach to Epidemiology and Public wellbeing. Over the past two decades, theorists have action on SDH.1 However, life-course approaches have Health, University College begun to argue that understanding and enhancing health needed a focus upstream from an individual’s risk or protective factors to the social patterns and structures Key messages that shape people’s chances to be healthy. Commonly • The social determinants of health are defi ned by the WHO Commission on the Social referred to as the social determinants of health (SDH) Determinants of Health as “the conditions in which people are born, grow, live, work approach, such work focuses on the social contexts that and age”; these conditions or circumstances are shaped by families and communities aff ect health and also the pathways by which social and by the distribution of money, power, and resources at worldwide, national, conditions translate into health eff ects. In assessing and local levels, and aff ected by policy choices at each of these levels. the so-called causes of the causes, work on SDH • Adolescence is a second sensitive developmental period in which puberty and rapid particularly focuses on how the causes of individual brain maturation lead to new sets of behaviours and capacities that trigger or enable problems relate to the causes of population incidence, transitions in family, peer, and educational domains, and in health behaviours. These how diff erences between individuals relate to diff erences transitions modify childhood trajectories towards health and wellbeing. between populations, and how social gradients and • Our analyses show that the strongest determinants of adolescent health are structural 1 cultural factors aff ect health outcomes. factors such as national wealth, income inequality, and access to education. WHO defi nes SDH as “the conditions in which people Furthermore, safe and supportive families, safe and supportive schools, together with are born, grow, live, work and age”, conditions or positive and supportive peers, are crucial to helping young people develop to their full circumstances that are shaped by families and com- potential and attain the best health in the transition to adulthood. munities and by the distribution of money, power, and • Improving adolescent health worldwide requires improving young people’s daily lives resources at global, national, and local levels and with families and peers and in schools, addressing risk and protective factors in the 1 aff ected by policy choices at each of these levels. The social environment at a population level, and focusing on factors that are protective 2 fi rst report in this Series on adolescent health shows across various health outcomes. one model of the overlapping spheres of infl uence of • The most eff ective interventions are probably structural changes to improve access social deter minants on young people, which could be to education and employment for young people and to reduce the risk of elaborated to incorporate further positive infl uences transport-related injury. Other crucial aspects are ensuring participation of young and assets that support adolescent health. The health people in policy and service development, and building capacity in personnel and burden associated with operation of these SDH, and data systems in adolescent health. the substantial potential for improving health through www.thelancet.com Vol 379 April 28, 2012 1641 Series London, London, UK thus far focused almost entirely on early childhood such as family or peers, through communities, to factors (Prof M Marmot PhD); determinants of later adult health.3,4 Adolescence, as a quite distal from the individual, such as economic Department of Pediatrics, key developmental stage in the life course, has been opportunities provided by the state. Since these models University of Minnesota, Minneapolis, MN, USA neglected in SDH research. deal with “the conditions in which people are born, grow, (Prof M Resnick PhD); Developmental theorists have long identifi ed adoles- live, work and age”, it is perhaps not surprising that Department of Commuity cence as a crucial period of psychological and biological published work contains competing models with a Health, College of Health change, second only to early childhood in the rate and complex and inconsistent array of concepts and terms Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria breadth of developmental change. During adolescence, (panel 2). We will use the conceptual framework of the (A Fatusi PhD); and Child and rapid development of the CNS and other biological WHO Commission on Social Determinants of Health to Adolescent Health Research systems interact with social development to entrain new identify two main levels at which determinants operate: Unit, University of St Andrews, Fife, UK (Prof C Currie PhD) behaviours and to allow many transitions important for an structural and proximal. individual to function as a productive adult (panel 1). Structural determinants are the fundamental structures Correspondence to: Prof Russell M Viner, Approaches to problems in adolescent health have moved that generate social stratifi cation, such as global and UCL Institute of Child Health, beyond traditional risk-factor reduction focused on the national economic, political, and social welfare systems, 30 Guilford Street, individual to emphasise the importance of enhancing and education systems. Proximal, also called intermediate, London WC1N 1EH, UK protective factors in young people’s lives. Such resiliency- determinants are the circumstances of daily life, from the [email protected] based approaches have focused on family and peer factors quality of the family environment and peer relationships, as important in protecting young people from harm, but through availability of food, housing, and recreation, to also emphasise that a successful and healthy transition access to education. Proximal deter minants are generated to adulthood needs promotion of positive social and by the social stratifi cation that results from structural emotional development as much as avoiding drugs, vio- determinants, but are also generated through cultural, lence, or sexual risk.6 However, despite extensive pub- religious, and community factors. These proximal deter- lished work on potentially malleable factors that act as risk minants establish individual diff erences in exposure and and protective factors across a range of adolescent-health vulnerability to health compromising factors that generate outcomes,7 there has been little systematic
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