Influencia de determinantes sociales en promoción y prevención de salud

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

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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

Abstract

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

Zusammenfassung

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


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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

Introduction

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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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 inequalities are observed during adolescence andold age [26]. There are also differences between genders.Mens health seems to be more impacted by social status measured at least in terms of level of education, occu-pation and income than womens health [5]. Noticeabledifferences have also been observed in the magnitudeof social inequality in health between countries, evenwithin relatively homogeneous regions, such as Europeancountries [32]. For instance, whereas social disparitieshave been found to be lower in Southern Europeancountries, these disparities are greater in EasternEuropean countries. Disparities have also been foundwith regard to different diseases: Among low statusgroups, there are considerably higher (twice as high orhigher) risks for heart attack, stroke, chronic liver disease,

angina pectoris (in women), diabetes mellitus (in women),chronic bronchitis (in men) and osteoporosis (in men).These groups are also at a greater risk (i.e., have at leasta significantly increased likelihood) for: hypertension anddepression; high cholesterol, chronic bronchitis, bronchialasthma, arthrosis and osteoporosis (in women); andangina pectoris, heart failure, diabetes mellitus, chronicrenal failure and arthritis (in men). Less pronounced socialdisparities can be also observed for most types of cancer,gastrointestinal diseases and neurological disorders. Alimited number of diseases are more prevalent in higherthan in lower social classes. These include allergies and

breast cancer [46].In Germany, medical sociological research on this topicgot a late start because restrictive data regulations hadlimited the amount of available data and because thefield of medical sociology did not catch up with interna-tional developments until late. Since 2000, however, thetopic has been examined in more depth and detail in ex-tensive collective volumes of articles [17], [36], [40], [57].Although various sociological models can be drawn uponto explain social differences in morbidity and mortality[19], Mielcks model for explaining health inequality [36]is probably the most comprehensive (see Figure 1). Ac-

cording to the model, less knowledge (e.g., obtainedthrough schooling or professional training), less power(e.g., position in the occupational hierarchy or controlover the work content, intensity and processes of others),less prestige (e.g., how society regards the occupation)and less money (income and wealth) lead to greaterhealth burdens at ones place of residence or work, tofewer coping resources, to poorer medical care and toless healthy behavior. This, in turn, increases the risk forillness and premature death. At the same time, themodel identifies other direct pathways between socialand health inequality, such that illness can lead to a socialdowngrade and such that there are also direct relation-ships between physical and social characteristics (e.g.,the parameters of the immune system or blood pressure).Despite this, not all dimensions of social inequality are




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of course influenced by dimensions of health inequalityand vice versa.This review aims to determine whether differences in theuse of prevention and health promotion services in Ger-many can be attributed to health inequality between dif-ferent social status groups. So far, no other systematic

reviews have been conducted to determine if any suchassociation exists despite the fact that there have beenmany complaints about the tendency of prevention effortsto focus on the middle class.In the following section, a brief description of the Germanhealth care system will be given. Only an overview of thesystem will be provided due to its complexity and espe-cially given that the system is subject to constant changeowing to current medical and economic developmentsas well as associated political decisions and legislativeamendments. Following the overview, the results of thesystematic review will be presented. The findings of the

reviewed empirical studies on socioeconomic differencesin the use of prevention and health promotion serviceswill be synopsized in tables and briefly analyzed in con-sideration of systematic viewpoints. The final section willdiscuss the reviews findings as well as the limitationsand strengths of the review methods.

Fundamental characteristics of theGerman health care system with afocus on health promotion andprevention

In Germany, the health care system forms the third pillarof the social welfare system alongside pension and un-employment insurance. The main tasks of the Germanhealth care system include health maintenance andpromotion as well as the prevention and treatment of ill-ness. The states job is to provide the proper regulatoryframework facilitating the exchange, negotiation and co-ordination processes needed for respective institutionsto allocate funds [45]. Compared to other countries,Germany has an above-average number of physicians,dentists, physical therapists, nursing staff and hospital

beds. Approximately 4.3 million people nearly 9% ofthe nations workforce were reportedly either directlyor indirectly employed in the German health care sector[1].Funding for the German health care system is primarilyprovided through insurance contributions. Nine out of tenGerman citizens approx. 70 million people are mem-bers of the countrys nearly 150 statutory health insur-ance funds. Only ten million are coveredby private healthinsurance funds. The cornerstone of the German statutoryhealth insurance system is the solidarity principle. Accord-ing to this principle, insurance contributions are basedon an insured individuals level of income rather than the

individuals gender, age or risk of illness. In the case ofprivate health insurance, premiums depend on thenumber of services covered by the particular insurance

policy and the overall health status, gender and age atentry of the policyholder [37].Inpatient care in Germany is delivered in preventive,curative and rehabilitation health facilities. Funding forboth hospitals and rehabilitation facilities is provided bypublic, private or non-profit sources. The increasing focus

of hospitals on economic efficiency is placing new de-mands on nursing staff, other therapeutic professionsand physicians. Although prevention strategies are be-coming just as important as health promotion strategies,overall expenditures for prevention, health promotion,health protection, health information and education,screening and health care services make up a mere0.53% of the nations health budget [55]. Preventionand health promotion are interventions that achievecompression of morbidity. In Germany, the main parti-cipants in these efforts are the Public Health Service, thestate business supervisory authorities, institutions

providing occupational accident insurance and those re-sponsible for occupational health and safety, as well asthe health insurance funds.According to the WHO [58], the term health promotionrefers to a set of strategies and methods implementedat different societal levels in an attempt to increasepeoples health resources and potentials. Types of healthpromotion measures include: 1) those aimed at modifyingand promoting individual health behavior and 2) thoseaimed at creating health-promoting environments (oftenreferred to as the "settings approach) through, for ex-ample, organizational development, community develop-ment, policy development or health-related education

measures. According to [50], prevention (Latinpraeveniere: to come before), unlike health promotion,involves activities aimed at avoiding, lessening the likeli-hood of or delaying harm to a persons health. Preventionmeasures can focus on the behavior of individuals orgroups (behavioral risk prevention) or can be geared to-ward modifying the biological, social or technical environ-ment (environmental risk prevention).As illustrated in Table 1 based on Leppin [29], preventionactivities can also take place on three different levels(primary, secondary, and tertiary) depending on the time,objective and target of the preventive intervention.

The terms prevention and health promotion oftenused to be used synonymously. Recently, however, a dif-ferentiated view has come to be taken. The fundamentaldistinctions made between health promotion measuresand prevention measures can be summarized as follows(Table 2): (Please note that this way of differentiatingbetween prevention and health promotion is an ideal typeand is, by all means, open to debate.) While health pro-motion measures tend to focus more on resources (e.g.,health loci of control or social support), preventionmeasures are geared toward health burdens (e.g., vaccin-ations against certain diseases such as measles, mumpsor rubella). Health promotion interventions tend to bedesigned and conducted by public health specialistswithout a specific problem, risk factor or disease in mind;that is, they usually promote health in general. Prevention




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Table 1: The differences between primary, secondary, and tertiary prevention based on the time, goal and target of the intervention

(according to [29])

Table 2: Criteria for distinguishing health promotion from prevention

interventions, on the other hand, are performed by med-ical experts to counter specificdiseases (see, for instance,the vaccination example given in the previous sentence).Health promotion measures encourage patients and cit-izens to play an active role in their own health. In the caseof preventive measures, however, they play a morepassive role when being protected from diseases.

Methods used in the systematicreview

Already in 2009, a systematic literature review was con-ducted to determine the extent to which social statuscharacteristics are associated with the use of serviceswithin the entire German health care system [18].32 studies were identified as having been publishedbetween 2000 and 2008. According to the results ofthese studies, the overall level of health care provided toall social status groups in Germany is relatively high, andhardly any differences were found in the curative or re-habilitative care received across status groups. Therewere, however, marked differences with regard to thegroups use of prevention and health promotion services,

suggesting that prevention and health promotion pro-grams aimed at influencing individuals use of such ser-vices, providing them with relevant health and diseaseinformation and impacting the way this information is

used must be tailored to less privileged social statusgroups in order to be at least somewhat better able toreduce existing health inequalities in the future. After all,a socially equitable health care system should be able toclaim, in future, that it continues to contribute to the re-duction of health inequality [18]. The findings of the 2009review indicate that certain changes need be made tothe German health care system. However, when makingthese changes, care should be taken to ensure that thesame level of high-quality care continues to be providedto all social groups.In light of the findings of the previous review, the present

review only focuses on the use of prevention and healthpromotion services using search terms only in regard tothe mentioned topics while the first review and its searchterms were in regard to the medical system in general.On March 22, 2011, a new literature search was conduct-ed using MedPilot to identify relevant articles publishedbetween 1998 and 2010 in the Medline, Medizinische

Gesundheit, CC Med, Deutsches rzteblatt and Sozialme-dizin (SOMED) databases, the Hogrefe, Karger, Krauseand Pachermegg and Thieme publisher databases, theCochrane Database of Systematic Reviews (CDSR), theCochrane Database of Abstracts of Reviews of Effective-

ness (DARE), and the Cochrane Central Register of Con-trolled Trials. The following combinations of search termswere used:




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gesundheit* AND deutsch* AND (einkommen* ORbildung* OR beruf* OR geschlecht*) AND (prvent* ORscreening* OR vorsorge* OR gesundheitsfrderung* ORfrherkennung*) AND (inanspruchnahme* OR nutzung*OR besuch*)OR

health* AND german* AND (income* OR education* ORprofession* OR occupation* OR gender* OR sex*) AND(prevent* OR "early detect*" OR "health promotion" ORscreening*) AND (utili?ation* OR use* OR usage*)

Retrieved papers met the inclusion criteria if they werepublished in English or German and reported empiricalfindings.

Results

After excluding duplicate hits, a total of 1,303 articleswere independently screened by two of the authors. Fol-lowing the same procedure used in the 2009 review, thearticles were screened to identify empirical studies pub-lished in either English or German. In the end, a total of23 empirical studies on the topic of prevention, healthprevention and social inequality met the criteria for in-clusion in the review. Table 3 presents the results of thesystematic review. Only study findings pertaining to edu-cation, occupation, income and gender are listed. In manyof the studies, additional factors were also found to beassociated with prevention and health promotion servicesuse.

As evidenced by the findings presented in Table 3, 20 ofthe 23 reviewed studies provided relatively clear evidenceof a significant association between higher social statusand greater use of prevention and health promotion ser-vices. (The results of the other three studies were not asconclusive as the others.) Evidence of this associationwas provided for almost the whole of Germany. Whereasonly one study was conducted exclusively with men, threewere conducted only with women. The majority of thestudies examined secondary prevention measures. Nostudies were found dealing with tertiary prevention orusing qualitative methods to explore their research

questions.

Discussion

The aim of this study was to examine social inequality inprevention and health promotion in Germany through asystematic review of literature. The choice of search termsplayed a major role in the review process. On the onehand, they had to be broad enough in order to identify allstudies on the reviews topic; on the other hand, they hadto be narrow enough to distinguish between relevant andirrelevant studies. Nevertheless, it is possible that some

studies (e.g., unpublished studies) may not have beenincluded. This should be taken into consideration wheninterpreting the reviews results.

Overall, the review shows that there is sufficient evidencefor the relationship between social status and the use ofprevention and health promotion services and that thisassociation is both significant and relevant. There are,however, a few blind spots in research on this topic,such as a lack of studies on tertiary prevention, especially

with regards to prevention and health promotion servicesuse among men, as well as general studies on healthpromotion among men and women. There is also a lackof published intervention studies demonstrating how tobetter reach the socially disadvantaged. Recently, how-ever, there have been concerted efforts in this area (e.g.,by the German Federal Ministry of Education and Re-search). Studies on tertiary prevention measures may nothave been identified due to the terms chosen for the lit-erature search. It is possible that these types of measuresare subsumed under the term rehabilitation. Accordingto the reviewed studies, gender tends to have a greater

effect on the use of prevention and health promotionservices than characteristics of vertical social inequality.This is in part due to the greater public awareness ofpreventive measures for women (e.g., breast vs. prostatecancer early detection) and does not take into considera-tion the degree to which the offered measures are neces-sary and under which circumstances they were used.According to the Andersen model, all of the determinantsof services use examined in this review (i.e., education,occupation, income and gender) may be categorized asindividual factors [2], [3]. Contextual factors have onlybeen examined in a few studies, the reason for this mostoften being that specific data on individual characteristics

are not available. For this reason, studies such as thatof [44] use data on average income in individual regionsand not on individual or household income. This particulartype of ecological analysis makes it difficult to derivecausal inferences, particularly since the individual char-acteristic is not (cannot be) controlled for. Though in someStudies (e.g. [11]) some inividual characteristics arecontrolled for (eg. school type attended) but other relevantvariables (e.g. class size or financial resources of theschool), are not. Although "type of school attended is anindividual characteristic for which data is collected fromindividual people, it must be assumed that schools con-

stitute important contexts of influence on the use of pre-vention andhealth promotion services and that the typeof school attended variable along with other variables,such as class size, financial resources, teachers qualifi-cations is just a relevant characteristic of these con-texts.A noteworthy outcome of this review is the wide range ofstudies identified through the selected search strategy.Not only did the strategy identify studies on cancerscreening and vaccination prevalence; it also identifiedone on the use of sunscreen. A (survey) study focusingonly on physical activity was also found (and not excluded)[7]. A different search strategy probably would haveidentified numerous other studies exploring physicalactivity, though not explicitly within context of prevention




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Table 3: A breakdown of the reviewed studies by area of interest, target population, region of study, and findings




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(Continued)Table 3: A breakdown of the reviewed studies by area of interest, target population, region of study, and findings




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(Continued)Table 3: A breakdown of the reviewed studies by area of interest, target population, region of study, and findings




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and health promotion. This example reveals one problemwith the methods used in this review.Another main limitation of the selected review methods,according to the authors, involves publication bias; thatis, only significant results tend to be published. This maymean that studies finding no differences by social status

were not published and therefore not identified duringthis review. As another form of publication bias, manypublishers tend to prefer quantitative methods overqualitative methods. As a result, this review tends tocapture only quantitative results. In addition, the searchterms used in this review may have been too narrow,which means that papers which cover aspects of (tertiary)prevention, such as patient self-help groups or rehabilita-tion, but did not use one of the terms in our searchstrategy, were not identified. Another important limitationto this review is the time lag involved in empirical studiesobserving changes occurring in real life. Often, the time

between planning a study and publishing its results canbe months or even years. The question then needs to beraised as to the extent to which the methods in this reviewprovide an accurate picture of the current state of healthcare in Germany. The review provides an update of themore general review from 2009 [18], confirming its find-ings. Including a number of additional study results, thereis now a convincing body of literature that shows an as-sociation between social status and prevention/healthpromotion.Despite its limitations, the review also has certainstrengths. The analysis and discussion have a clear em-pirical basis. The design of the methods used in the re-

view is also clear, understandable and for the most partobjective. The results of the review could also serve as abaseline measurement for future comparison. In tenyears, for example, a follow-up study could be conductedto determine whether health careinequalities have grown,remained the same or even been reduced.Health care expenditures will continue to rise in Germanyin the future. The countrys aging population, coupledwith its declining birth rate, is throwing the solidaritysystem more and more out of balance as older peopleoften create higher expenditures yet contribute less tothe health insurance system. The result is increasing

health care costs that will have to be borne by a decreas-ing number of employed citizens unless extensive struc-tural reforms are implemented. In light of the expectedincrease in the number of elderly and dependent citizensover the coming years, one of Germanys main tasks willbe to expand existing prevention and outpatient struc-tures. Additionally, health promotion and prevention ser-vices for the elderly will gain in importance alongside careand rehabilitation. A socially equitable health care systemshould be able to claim, in future, that it continues tocontribute to the reduction of health inequality [18].

Notes

Acknowledgements

The writing of this article was carried out as part of thescientific network project Utilization of health-related

services in Germany theoretical approaches, methodsand empirical results in medical sociology (NWIN). Theproject is funded by the Deutsche Forschungsgemein-schaft (German Research Foundation, grant no.: JA1849/1-1).

Competing interests

The authors declare that they have no competing in-terests.

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Corresponding author:

Prof. Dr. Christian Janen, M.A.

Department of Applied Social Sciences, Munich Universityof Applied Sciences, Am Stadtpark 20, 81243 Munich,[email protected]

Please cite as

Janen C, Sauter S, Kowalski C. The influence of social determinants

on the use of prevention and health promotion services: Results of a

systematic literature review. GMS Psychosoc Med. 2012;9:Doc07.

DOI: 10.3205/psm000085, URN: urn:nbn:de:0183-psm0000850

This article is freely available from

http://www.egms.de/en/journals/psm/2012-9/psm000085.shtml

Published:2012-10-25

Copyright

2012 Janen et al. This is an Open Access article distributed under

the terms of the Creative Commons Attribution License

(http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You

are free: to Share to copy, distribute and transmit the work, provided

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Influencia de determinantes sociales en promoción y prevención de salud

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