Influencia de determinantes sociales en promoci³n y prevenci³n de salud

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Transcript of Influencia de determinantes sociales en promoci³n y prevenci³n de salud

  • 7/29/2019 Influencia de determinantes sociales en promocin y prevencin de salud


    The influence of social determinants on the use of

    prevention and health promotion services: Results of a

    systematic literature review

    Der Einfluss sozialer Determinanten auf die Inanspruchnahme vonManahmen der Prvention und Gesundheitsfrderung in Deutschland:Ergebnisse einer systematischen Literaturrecherche


    Background: The following analysis aims to determine whether differ-ences in the use of prevention and health promotion services in Germany

    Christian Janen1

    Stefanie Sauter2

    can be attributed to health inequality between different social statusChristoph Kowalski2groups measured by education, occupation and income and where

    certain improvements can be made in health promotion and preventionefforts and research to reduce those differences. 1 Department of Applied Social

    Sciences, Munich UniversityMethods: A systematic literature search was conducted using MedPilotto identify relevant articles published between 1998 and 2010 in the of Applied Sciences, Munich,

    GermanyMedline, Medizinische Gesundheit, CC Med, Deutsches rzteblatt andSozialmedizin (SOMED) databases, the Hogrefe, Karger, Krause and 2 Institute for Medical

    Sociology, Health ServicesPachermegg and Thieme publisher databases, the Cochrane Databaseof Systematic Reviews (CDSR), the Cochrane Database of Abstracts of Research and RehabilitationReviews of Effectiveness (DARE), and the Cochrane Central Register ofControlled Trials.

    Science, Faculty of HumanScience and Faculty ofMedicine, University of

    Cologne, Cologne, Germany

    Results: A total of 23 empirical studies on the topic of prevention,

    health prevention and social inequality met the criteria for inclusionin the review. 20 of the 23 reviewed studies provided relatively clearevidence of a significant association between higher social status andgreater use of prevention and health promotion services. According tothe reviewed studies, gender tends to have a greater effect on the useof prevention and health promotion services than characteristics ofvertical social inequality. No studies were found dealing with tertiaryprevention or using qualitative methods to explore their researchquestions.Conclusions: Overall, the review shows that there is sufficient evidencefor the relationship between social status and the use of preventionand health promotion services and that this association is both signifi-

    cant and relevant. There are, however, a few blind spots in researchon this topic, such as a lack of studies on tertiary prevention, especiallywith regards to prevention and health promotion services use amongmen, as well as general studies on health promotion among men andwomen. There is also a lack of published intervention studies demon-strating how to better reach the socially disadvantaged.

    Keywords: social determinants, education, occupation, income,prevention, health promotion, systematic review


    Hintergrund: Der vorliegende Beitrag untersucht den Einfluss sozialer

    Determinanten auf die Inanspruchnahme prventiver und gesundheits-frderlicher Leistungen in Deutschland. Damit soll ein Beitrag zur Be-antwortung der Frage geliefert werden, warum Morbiditt und Mortalittso stark nach sozialen Statusmerkmalen (Bildung, Beruf und Einkom-

    1/12GMS Psycho-Social-Medicine 2012, Vol. 9, ISSN 1860-5214

    Review ArticleOPEN ACCESSSpecial issue: Health care utilization in Germany: The NWInresearch network

  • 7/29/2019 Influencia de determinantes sociales en promocin y prevencin de salud


    men) eines Menschen differieren und wo im Bereich der Gesundheits-frderung und Prvention mgliche Verbesserungs- und notwendigeForschungspotentiale bestehen.Methoden: Hierzu wurde mittels Medpilot eine systematische Literatur-recherche fr den Zeitraum 19982010 in den Datenbanken Medline,

    Medizinische Gesundheit, CC Med, Deutsches rzteblatt, Sozialmedizin

    (SOMED), Hogrefe Verlag, Karger Verlag, Krause und PachermeggPublikations-Datenbank, Thieme Verlag, Cochrane Database of Syste-matic Rrviews (CDSR), Cochrane Database of Abstracts of Reviews ofEffectiveness (DARE), Cochrane Central Register of Controlled Trialsnach empirischen Untersuchungen zu dieser Thematik durchgefhrt.Ergebnisse: Zusammenfassend lsst sich sagen, dass 20 der 23 sogefundenen empirischen Untersuchungen eindeutig signifikante Effektehinsichtlich einer Zunahme der Inanspruchnahme prventiver odergesundheitsfrderlicher Leistungen mit zunehmendem sozialen Status,drei Studien zeigten keine eindeutigen Ergebnisse. Es zeigte sich, dassdas Geschlecht berwiegend grere Effektstrken hinsichtlich der In-anspruchnahme von Manahmen der Prvention und Gesundheitsfr-

    derung zeigt als Merkmale der vertikalen sozialen Ungleichheit. Eswurden berwiegend Manahmen der Sekundrprvention untersuchtund es konnte keine Studie gefunden werden, welche sich mit Tertir-prvention beschftigt oder eine qualitative Methodik bei der Untersu-chung der Forschungsfrage angewandt hat.Diskussion: Insgesamt kann festgestellt werden, dass der Zusammen-hang zwischen einem eher niedrigerem sozialen Status und der ehergeringeren Inanspruchnahme gesundheitsfrderlicher und prventiverLeistungen als hinreichend belegt, signifikant und relevant angesehenwerden. Trotzdemgibt es noch einige blinde Flecken in der Forschungs-landschaft in diesem Gebiet: So fehlen Studien im Bereich der Tertir-Prvention, speziell fr den Bereich der Prvention und Gesundheitsfr-derung bei Mnnern sowie allgemein Studien im Bereich der Gesund-

    heitsfrderung bei Mnnern und Frauen. Es fehlt zudem an publiziertenInterventionsstudien, die zeigen, wie sozial Benachteiligte besser erreichtwerden knnen.

    Schlsselwrter: soziale Determinanten, Bildung, Beruf, Einkommen,Prvention, Gesundheitsfrderung, systematische Literaturrecherche


    This review investigates the impact of social factors onthe use of prevention and health promotion services inGermany and, in doing so, attempts to help answer the

    questions as to why there are such strong differences inmorbidity and mortality based on individuals social statuscharacteristics (e. g. education, occupation, income) andwhere certain improvements can be made in health pro-motion and prevention efforts and research to reducethose differences.In social epidemiology research, social inequalityprimarily encompasses horizontal inequalities (age,gender, marital status, nationality) and vertical inequal-ities (occupation, education, income). This study focuseson vertical inequalities that is, on the differences in in-dividuals education, occupation and income character-

    istics. (For in-depth studies analyzing horizontal inequality,see [6], [53], [38], [43]). These characteristics are alsoreferred to as socioeconomic characteristics and are oftencombined to an index in order to describe an individuals

    social status [20], [36]. In this review, the terms socialstatus and social class are used synonymously since al-though the concept of social class differs in theoreticalmeaning from that of social status, it can also be seenas a categorized form of social status [18]. In addition to

    the individual indicators education, occupation, and in-come, each with their various limitations and strengths(for an overview, see [14], [36]), this review also exploresgender-related differences in services use, since signifi-cant differences between women and men have beenfound in previous research.Social inequality leads to unequal distribution of healthchances in populations. For example, the mean differencein mortality between members of the upper and lowersocial classes can range from four to ten years [46].Already in the early 1970s in Great Britain, Marmotidentified a typical phenomenon of modern industrialized

    countries: a social class gradient in health, such that thehigher the social position, the better the health of a per-son [35]. This gradient, which he termed a status syn-drome, means that not only the lowest social class is at

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    Janen et al.: The influence of social determinants on the use of ...

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    Figure 1: A complete recursive model of social and health inequality (based on [36] and modified by the authors)

    a disadvantage or that the poorest of the poor is affected.Rather, it implies that the gradient in health, in the formof an inverse gradient, cuts across society as a whole[33], [34], [46].Other groundbreaking studies conducted by [4], [15], and[23] in the U.S. observed that the distribution of relevantchronic diseases and the risk for premature death followa social gradient as well: the higher the social status ofa population group, the lower the groups morbidity andmortality. Evidence for this gradient has been providedin all industrialized countries, in which such studies havebeen conducted [9], [31], [33], [46]. Even though the size

    of the inequalities between classes may vary, internation-al research has shown that in all European countriespremature death rates become increasingly higher as wemove down the social status scale. The fact that thereare indications that these inequalities are increasing [32]shows just how relevant they are today. The finding thatthe mean difference in life expectancy between membersof the highest income group and lowest income group inGermany is 8.4 years for women and 10.8 years for men[27] clearly illustrates how relevant this issue is for healthpolicy and science in Germany in particular.Those most impacted by social status-based health in-

    equalities are young children and middle-aged adults.Fewer inequalit