Q1. What are social determinants of health, and why do they produce health inequities?

Social determinants of health refer to the conditions in which people are born, grow, live, work,
and age, shaped by the distribution of money, power, and resources (Braveman, 2006).
According to the Dahlgren & Whitehead (1991) model, these determinants operate in layers:
individual factors, lifestyle behaviours, social and community networks, living and working
conditions, and broader socioeconomic, cultural, and environmental conditions.

These determinants create systematic health inequities because different social groups
experience vastly different exposures to risks and access to resources. For example,
socioeconomic status (SES) influences education, employment opportunities, housing quality,
neighbourhood safety, and access to healthcare. Mackenbach et al. (2008) demonstrated
consistent SES gradients in mortality across 22 European countries, showing lower SES groups
experience greater morbidity and early death.

Environmental exposures also produce inequities. Gee & Payne-Sturges (2004) showed that
racial and low-income communities are disproportionately exposed to pollution, poor air
quality, and environmental hazards, resulting in higher rates of asthma, cardiovascular disease,
and poor birth outcomes.

Social networks and social capital further mediate the link between poverty and health. Cattell
(2001) found that strong, dense networks protect mental and physical health, whereas
impoverished networks—common in marginalized neighbourhoods—exacerbate stress and limit
access to resources.

Psychologically, these determinants operate through chronic stress and allostatic load.
Long-term exposure to adversity produces biological wear-and-tear via sustained activation of
stress systems, contributing to hypertension, diabetes, depression, and immune dysfunction
(Yoshikawa et al., 2012). Poverty also shapes health behaviours—lower SES groups have higher
rates of smoking, alcohol-related mortality, and obesity (Wang & Lim, 2012).

In sum, social determinants produce health inequities because the context in which individuals
live determines their exposure to risks, opportunities, and resources across the lifespan, and
these contexts are unequally distributed across society.

Q2. What is social exclusion, and how does it affect mental and physical health?

Social exclusion is a dynamic process of being shut out from social, economic, political, and
cultural systems that structure participation in society (Walker & Walker, 1997, in Cattell,
2001). It involves far more than material poverty; it includes lack of social participation,
isolation, discrimination, and limited access to institutions. At its core, social exclusion
undermines social networks, leaving individuals cut off from emotional and instrumental
support.

A major mechanism through which social exclusion affects health is uncertainty of belonging.
Walton & Cohen (2007) demonstrated that minority students show large fluctuations in daily
belonging—about 60% of variance explained by daily adversity—while majority-group students’
belonging was stable. This “belonging uncertainty” leads individuals to interpret everyday
hassles as evidence that they do not belong, producing chronic vigilance, stress, and
performance impairment.

Long-term consequences are significant. Walton & Cohen (2011) showed that a brief social
belonging intervention dramatically improved academic achievement and even physical health
among minority students over several years. This illustrates that social identity threat and
exclusion have profound physiological and behavioural consequences.

Social exclusion also reduces social capital—the resources embedded within social networks.
Cattell (2001) found that homogeneous, dense networks support mental health through trust
and reciprocity, while fragmented networks increase stress, anxiety, and poor health
behaviours.

Biologically, exclusion activates the same neural networks associated with physical pain (social
pain theory), increasing cortisol and inflammatory markers. Chronic exclusion contributes to
depression, cardiovascular disease, sleep disturbances, and reduced immune functioning.

Thus, social exclusion harms health by undermining belonging, weakening social networks,
increasing stress physiology, degrading emotional well-being, and limiting access to structural
and interpersonal resources.

Q3. Through which pathways do social determinants influence health? Provide examples.

Social determinants influence health through psychological, behavioural, and

environmental/systemic pathways.

1. Psychological & Emotional Pathways

Chronic stress, uncertainty about belonging, and daily discrimination contribute to allostatic
load—the cumulative physiological burden of stress. Yoshikawa et al. (2012) show how
childhood poverty leads to long-term emotional and behavioural problems due to chronic stress
exposure and reduced parental capacity. Walton & Cohen (2007) explain how belonging
uncertainty amplifies minor adversities into major psychological threats.

2. Social Network & Social Capital Pathways

Social connections influence health through structural (size, density), functional (support), and
normative (shared norms) mechanisms. Lecture slides (p.8) show that social connection
improves lifestyle, psychological health, biomarkers, and medical adherence, reducing
morbidity and mortality.

Cattell (2001) demonstrated that social networks mediate the relationship between poverty and
mental health: dense networks protect; fragmented networks harm.

3. Behavioural Pathways

SES shapes health behaviours. Lower SES groups smoke more, exercise less, and consume
cheaper, calorie-dense foods. Wang & Lim (2012) found strong SES gradients in childhood
obesity. Behavioural norms in peer networks reinforce patterns: smoking, alcohol, drug use,
diet.

4. Environmental & Systemic Pathways

Environmental exposures (pollution, toxins, noise) disproportionately burden low-income and

minority communities (Gee & Payne-Sturges, 2004). Segregated neighbourhoods have fewer
healthcare facilities, fewer parks, worse schools, less fresh food, and higher crime. Krieger et al.
(2016) show that area-level SES predicts rates of STIs, TB, and violence.

5. Healthcare Access & Quality

Health systems themselves reproduce inequity. Mackenbach et al. (2008) show that mortality
differences from conditions “amenable to medical intervention” reveal uneven access and
quality.

Together, these pathways illustrate that health is shaped not just by behaviour but by the
systems and environments in which behaviours occur.

Q4. Describe how social capital mediates the relationship between poverty and health. Use
Cattell (2001).

Social capital refers to resources embedded within social networks, including trust, reciprocity,
support, and shared norms. Cattell (2001) argues that social capital mediates the link between
poverty and health by determining the quality of individuals’ social environments.

In disadvantaged neighbourhoods, networks tend to be fragmented, weak, and stressful,

reducing access to emotional support, job opportunities, child care, information, and health
resources. Lack of social trust increases fear and reduces community engagement, contributing
to poor mental health.

Two types of social capital matter:

1. Bonding (dense) networks

○ Provide emotional support and belonging.

 ○ Protective for mental health (reduce stress, loneliness).

2. Bridging (heterogeneous) networks

○ Connect individuals to new opportunities and higher SES groups.

○ Important for escaping poverty and gaining health resources.

Poverty reduces both forms. As a result, individuals face more stress, fewer coping resources,
and fewer pathways to health-promoting environments.

Thus, social capital explains how structural disadvantage translates into psychological stress,
poor health behaviours, and limited access to care.

Q5. How do poverty and early-life conditions shape long-term mental, emotional, and
behavioural health? Use Yoshikawa et al. (2012).

Yoshikawa et al. (2012) show that poverty profoundly affects children through three
mechanisms:

1. Family Economic Stress → Parenting & Home Environment

Low-income parents experience chronic stress, financial strain, and instability. This leads to:

● harsher or inconsistent parenting

● lower emotional warmth

● chaotic home environments

● reduced cognitive stimulation

These conditions impair children’s emotion regulation, executive function, and stress
physiology, predicting later mental health problems, behavioural dysregulation, and lower
academic achievement.
2. Environmental Exposures

Children in poverty are more exposed to:

● toxins (lead, air pollution)

● unsafe housing

● noise

● food insecurity

These exposures directly affect cognitive development, physical health, and stress systems.

3. Access to Services & Institutions

Low-SES families have worse access to:

● high-quality early childhood education

● healthcare

● safe neighbourhoods

Early access to financial support significantly reduces long-term harm, demonstrating the
importance of timing.

Conclusion:

Poverty in early childhood shapes biological, emotional, and behavioural systems, influencing
health across the lifespan. Early intervention is therefore crucial.

Q6. Describe how sense of belonging influences educational and health outcomes (Walton &
Cohen).

Walton & Cohen (2007, 2011) demonstrate that sense of belonging is a critical psychological
determinant of academic and health outcomes, especially for minority students.
Minority students experience “belonging uncertainty”—a chronic sensitivity to cues that signal
social rejection. In 2007, Walton & Cohen showed that belonging among minority students
fluctuates dramatically with daily adversity, whereas majority-group students maintain stable
belonging.

In 2011, a brief belonging intervention that framed early academic struggles as normal and
temporary produced long-lasting improvements in:

● GPA

● health (fewer doctor visits)

● well-being

● retention

This demonstrates that belonging influences stress physiology and self-efficacy, affecting both
academic behaviour and physical health.

The mechanism is that belonging uncertainty triggers cognitive load, hypervigilance, and
stress, which undermine learning, motivation, immune function, and mental health.

Q7. How can we address health inequity? Provide community-level and structural strategies.

Addressing health inequity requires multi-level interventions that target social, psychological,
and structural determinants.

Community & Group-Level Strategies

1. Increasing Autonomy in Groups (Koudenburg et al., 2017)

Group-based interventions succeed when participants feel included and autonomous.

This enhances self-efficacy and engagement in health behaviours.

2. Belonging Interventions (Walton & Cohen)

Reducing belonging uncertainty improves academic performance and health, especially

for marginalized groups.

3. Strengthening Social Capital

○ Creating community centres, peer mentoring, parent networks

 ○ Building connections across SES and ethnic groups (“bridging ties”)

4. Changing Norms

○ Peer-led health education

○ Community role models

○ Neighbourhood-based prevention programs

Structural / Policy Strategies

1. Poverty Reduction

○ Minimum wage, child benefits, income supplements

○ Early financial support reduces intergenerational poverty effects.

2. Education Reform

○ Funding schools in low-SES neighbourhoods

○ Early childhood education

○ Reducing school segregation

3. Reducing Residential Segregation

Gee & Saegert (2004) argue segregation is a major cause of racial health disparities
because it concentrates environmental hazards and poor infrastructure.

4. Improving Housing

○ Safe, non-crowded, mould-free housing

○ Better heating and ventilation

5. Healthcare Equity

○ Universal coverage

○ Clinics in underserved areas

○ Culturally competent care

 6. Environmental Policy

○ Reduce pollution in low-income neighbourhoods

○ Improve green spaces and walkability

7. Food Environment Reform

○ Zoning laws for fast food

○ Subsidizing healthy foods

Q8. How do environmental health disparities arise? Use Gee & Payne-Sturges (2004).

Environmental health disparities arise when marginalized communities are disproportionately

exposed to environmental hazards due to historical and structural forces such as racial
segregation, discriminatory housing policies, and economic inequality.

Gee & Payne-Sturges (2004) propose a framework where environmental exposures and
psychosocial stressors combine to produce cumulative health burden. Low-income and
minority neighbourhoods are more likely to be located near:

● highways

● industrial zones

● waste facilities

● heavy traffic

● poor air quality

Environmental exposures interact with psychosocial stress, amplifying health effects (e.g.,
asthma, hypertension). These communities also lack buffers such as green spaces, safe
sidewalks, or health facilities.

Thus, environmental disparities reflect structural inequality and contribute significantly to

health inequities.
WEEK 2 — SOCIAL DETERMINANTS OF HEALTH & SOCIAL EXCLUSION

1. WHAT ARE SOCIAL DETERMINANTS OF HEALTH?

(Learning Goal 1)

Definition (Braveman, 2006)

Social determinants of health are the conditions in which people are born, grow, live, work,
and age—shaped by the distribution of money, power, and resources—that affect health,
functioning, and quality-of-life outcomes.

These determinants explain WHY health inequities exist.

1.1 The Dahlgren & Whitehead (1991) Model — from Lecture Slides

On slide 31, Karlijn shows the famous “rainbow model.”

It visually explains layers of determinants:

1. Individual factors

○ age, sex, biological factors

2. Lifestyle behaviours

○ exercise, diet, smoking

○ heavily shaped by outer layers

3. Social & community networks

○ peer norms

○ family structure

○ social capital

4. Living & working conditions

○ housing, education, work environment, unemployment, water sanitation

 ○ neighbourhood opportunity structures

5. General socioeconomic, cultural & environmental conditions

○ policies, culture, discrimination, inequality

Exam sentence you can use:

“Health is shaped more by contexts than by choices. Lifestyle sits in the center of a
layered system influenced by social networks, institutions, and larger socioeconomic
structures.”

1.2 Specific Determinants Explained

1.2.1 Socioeconomic Status (SES)

SES = income + education + occupational class.

Why it matters:

● Higher SES → better access to healthcare, safer housing, healthier food, better
schools.

● Lower SES → chronic stress, risky jobs, toxic exposures, poorer health outcomes.

Mackenbach et al. (2008) found consistent SES health gradients across 22 European
countries:

● lower SES → higher mortality, more chronic disease.

Cunningham et al. (2005):

● HIV patients with higher SES had significantly better survival even with equal
medical treatment.

→ SES influences more than access—it shapes stress, nutrition, stability,

neighbourhood.

1.2.2 Education
Education reduces mortality and CVD and cancer risk because it:

● increases employment opportunities

● improves health literacy

● increases access to healthy environments

● shapes self-regulation and coping strategies

EXAM TIP:

Education is both a determinant and a pathway through SES.

(Higher SES → better education → higher SES in next generation.)

1.2.3 Neighbourhood & Place

Living in a disadvantaged area →

● more pollution

● fewer parks

● more fast food

● fewer pharmacies

● underfunded schools

● high crime → stress, decreased mobility

Gee & Payne-Sturges (2004) describe environmental health disparities:

● Race & SES determine exposure to toxins, noise, poor air, unsafe housing.

Slide 30 shows how physical structures and social structures influence health outcomes.

1.2.4 Psychological Factors (Stress, Allostatic Load)

Chronic stress = wear-and-tear on the body.

It leads to:
 ● hypertension

● diabetes

● depression

● immune dysfunction

Yoshikawa et al. (2012) show:

● Children in poverty experience chronic stress → affects emotional regulation,

behaviour, and long-term mental health.

1.2.5 Social Networks & Social Capital

This comes straight from lecture slides (pages 3–12).

Karlijn explains 3 levels of social influence:

1. Structural → Quantity/quality of ties

2. Functional → Emotional/instrumental support

3. Normative → What people around you do & approve

Holt-Lunstad & Smith (slide 8) show:

● Social connection → better lifestyle, psychological functioning, biomarkers →

lower morbidity & mortality.

Cattell (2001) shows:

● Social capital mediates links between poverty and health.

● Dense networks protect mental health.

● Heterogeneous networks provide resource access.

1.2.6 Parental Income & Parenting Styles

Low parental income →

 ● more stress

● harsher/inconsistent parenting

● less emotional regulation development

● poorer school performance

Key point:

The earlier families receive income support, the less long-term damage poverty causes.

2. WHAT IS SOCIAL EXCLUSION?

(Learning Goal 2)

Definition (Walker & Walker, 1997; in Cattell, 2001)

“A dynamic process of being shut out from the social, economic, political, and cultural
systems which determine social integration.”

Key features:

● Not just poverty → multidimensional marginalization

● Includes: lack of voice, discrimination, poor housing, weak networks

● Main psychological consequence: low sense of belonging

2.1 Evidence From Walton & Cohen

Walton & Cohen (2007)

● Minority students show huge day-to-day fluctuations in sense of belonging (~60%

variance explained by adversity).

● White students → belonging stable, unaffected by adversity.

Interpretation:

Marginalized groups interpret everyday hassles as evidence they “don’t belong,”

worsening stress and performance.

Walton & Cohen (2011)

A brief belonging intervention:

● improved GPA

● reduced doctor visits

● improved well-being

● effects lasted years

→ Social inclusion is a health intervention.

3. HOW DO SOCIAL DETERMINANTS & EXCLUSION INFLUENCE HEALTH?

(Learning Goal 3)

3.1 Psychological & Emotional Pathways

Chronic Stress / Allostatic Load

Poverty → chronic cortisol activation → inflammation, metabolic disease.
Supported by Yoshikawa et al. (2012).

Uncertainty of Belonging → chronic vigilance

Minority stress → hypervigilance → poorer cardiovascular, mental health.

Loneliness & Isolation

Lecture slides (p.7):

● Loneliness doubles Alzheimer’s risk

● Increases stroke risk

● More common in youth than elderly

 → Social connection is a biological necessity.

3.2 Social Networks & Social Capital

Cattell (2001):

● Dense networks protect mental health.

● Weak networks → stress, low support, fewer opportunities.

Lecture (page 8) shows a full systems model where:

● Social connection improves lifestyle, psychological health, biomarkers, medical

adherence, and reduces mortality.

3.3 Health-Related Behaviours

Smoking, alcohol, drug use

Low SES → higher prevalence

Why?

● Stress coping

● Norms in peer networks

● Lower access to cessation support

Diet & Nutrition

Wang & Lim (2012):

● In industrialized countries → low SES = higher childhood obesity

● In developing countries → high SES = higher obesity

→ SES interacts with food environment.

Violence, STIs, TB
Krieger et al. (2016):

Area-level SES predicts

● STI incidence

● TB

● violence

→ Health is geographically patterned.

3.4 Environmental / Structural Pathways

Exposure to Environmental Hazards

(Gee & Payne-Sturges, 2004)

● Low-SES & minority communities live near pollution sources.

● More traffic, poor air, noise pollution.

Healthcare Access & Quality

Low-SES communities have:

● fewer physicians

● fewer hospitals

● less preventive care

● more medical deserts

Mackenbach et al. (2008):

Many deaths are from conditions that are “amenable to medical intervention” → health
inequities driven by systemic access issues.
4. HOW CAN WE ADDRESS HEALTH INEQUITY & SOCIAL EXCLUSION?

(Learning Goal 4)

4.1 Community & Group-Level Interventions

Autonomy in groups (Koudenburg et al., 2017)

● Group inclusion increases autonomy → improves engagement in health

programs.

Belonging interventions (Walton & Cohen)

● Low-cost psychological interventions can change long-term academic & health

outcomes.

Peer Networks

(From lecture: peer norms, descriptive/injunctive norms)

● Peer-led health education works because peers are credible models.

4.2 Policy & Structural Interventions

✔ Poverty reduction

● Cash transfers

● Child benefits → reduce stress, improve health & academic outcomes

✔ Better education for all

● Early childhood programs

● De-segregated schools

● Funding for low-SES schools

✔ Reduce residential segregation

Gee & Saegert (2004): segregation = root cause of “racial” health disparities.
✔ Improve housing

● safe, mold-free, non-crowded homes

● heating, insulation, ventilation

✔ Improve healthcare access

● Universal coverage

● Clinics in underserved areas

✔ Strengthen social cohesion

● “Bridging ties” = networks that connect across SES, race, culture

● Prevents isolation & exclusion

✔ Nudging + policy packaging

● Structural change + behavioural tools (e.g., making healthy choices easier)

5. FULL DETAILED READING SUMMARIES (VERY EXAM-RELEVANT)

Braveman (2006)

— Health Equity Framework

● Defines health disparities

● Explains why health inequities are systemic

● Calls for monitoring SDH indicators

● Emphasizes structural drivers: power, resources

Exam use: foundational definition + explains unfairness.

Cattell (2001)

— Social Capital Mediates Poverty → Health

● Low-SES areas have low trust, weak networks

● Dense networks protect mental health

● Heterogeneous networks offer resource mobility

● Social exclusion breaks both forms of capital

Exam use: explains why networks matter beyond individual factors.

Cunningham et al. (2005)

— SES Predicts Survival in HIV

● Even with equal care, SES predicts mortality

● Mechanisms: stability, nutrition, mental health, stress

● Illustrates that health systems alone cannot eliminate inequity.

Gee & Payne-Sturges (2004)

— Environmental Exposures

● Health disparities = intersection of psychosocial & environmental exposures

● Minorities exposed more to toxins → poor health

 ● Policies must address built environment

Koudenburg et al. (2017)

— Autonomy in Groups

● Group interventions work when they support autonomy

● Feeling included → greater motivation, self-efficacy

● Crucial for marginalized communities

Krieger et al. (2016)

— Area-Based SES Indicators

● Geocoding reveals neighbourhood-level health disparities

● Useful for policy targeting (STIs, TB, violence)

● Shows health inequality as spatially patterned

Mackenbach et al. (2008)

— SES & Mortality in Europe

● Consistent SES gradient across 22 countries

● Health inequity exists even in welfare states

● Shows fundamental cause nature of SES

Walton & Cohen (2007, 2011)

— Belonging Interventions

● Minority students show unstable belonging

● Brief intervention normalizing adversity improves long-term outcomes

Wang & Lim (2012)

— Childhood Obesity & SES

● SES → obesity gradient differs by country development

● Shows structural food environment importance

Yoshikawa et al. (2012)

— Poverty & Child Development

● Poverty harms emotional, behavioural, mental health

● Mechanisms: chronic stress, low stimulation, harsh parenting

● Early intervention most effective

FINAL EXAM CHEAT-SENTENCE YOU CAN SAY IN TUTORIAL
“Social determinants of health operate across multiple layers—from individual factors to
social networks to structural conditions like housing, education, and income. Health
inequities arise from unequal exposure to resources and risks. Social exclusion damages
belonging, self-efficacy, and health. These processes affect psychological functioning,
health behaviours, and even biology (allostatic load). Addressing inequity requires
community-level interventions that build autonomy and belonging, and structural reforms
that reduce poverty, improve housing, and desegregate neighbourhoods.”