Health equity and inequality. Does social determinants matter?

Author's Information:

Dr. Gogos Christos

Public School of Higher Vocational Training of Veria, School of Spatial Planning and Development, Faculty of Engineering, Aristotle University of Thessaloniki, General Hospital of Veria, Greece. 

Orcid ID: https://orcid.org/0000-0002-8658-5980

Gogou Maria

School of Early Childhood Education, Faculty of Education, Aristotle University of Thessaloniki, Greece.

 Orcid ID: https://orcid.org/0009-0005-4821-8345

Vol 02 No 12 (2025):Volume 02 Issue 12 December 2025

Page No.: 1010-1018

Abstract:

Equality in health does not require the elimination of all differences, but rather the reduction of unfair and preventable inequalities that arise from socio-determined conditions. Social determinants of health play a central role in understanding health equity as factors that contribute positively or negatively to health, as well as in the social processes that shape inequalities in the distribution of resources among groups with different levels of power and social influence. The investigation of health inequalities resulted in the development of specific theories. The relevant literature was searched in the PubMed, Scopus, and Google Scholar databases using search terms such as: ‘health inequalities’, ‘health disparities’, ‘health equity’, ‘social determinants of health’, ‘socioeconomic gradient in health’, and ‘access to healthcare services’. The literature search was conducted in English for the period 2015 to 2025. The issue of inequality is linked to complex social and economic processes, which means we need to adopt targeted policies to promote social justice and universal health coverage. 

KeyWords:

Equality, Inequality, Interpretive approaches, Theories, Social determinants of health

References:

  1. Aday, L. A. (1993). Equity, accessibility, and ethical issues: is the U.S. health care reform debate asking the right questions? American Behavioral Scientist, 36(6), 724–740. https://doi.org/10.1177/0002764293036006005
  2. Arcaya, M. C., Arcaya, A. L., & Subramanian, S. V. (2015). [Inequalities in health: definitions, concepts, and theories]. Revista Panamericana de Salud Publica = Pan American Journal of Public Health, 38(4), 261–271. http://www.ncbi.nlm.nih.gov/pubmed/26758216
  3. Augustin, J., Andrees, V., Walsh, D., Reintjes, R., & Koller, D. (2023). Spatial Aspects of Health—Developing a Conceptual Framework. International Journal of Environmental Research and Public Health, 20(3). https://doi.org/10.3390/ijerph20031817
  4. Austad, S. N., & Fischer, K. E. (2016). Sex Differences in Lifespan. Cell Metabolism, 23(6), 1022–1033. https://doi.org/10.1016/j.cmet.2016.05.019
  5. Bartley, M. (2016). Health Inequality: An Introduction to Concepts, Theories and Methods. Cambridge (UK), PolityPress.
  6. Berwick, D. M. (2020). The Moral Determinants of Health. JAMA - Journal of the American Medical Association, 324(3), 225–226. https://doi.org/10.1001/jama.2020.11129
  7. Bibi, E., Mubashir, A., Khalid Ghori, A., & Bibi, A. (2023). Understanding the Concept of Health Inequality. IntechOpen. doi: 10.5772/intechopen.1003038
  8. Black, D., Morris, J.N., Smith, C. Townsend, P. (1988). The black report. In Townsend, P. and Davidson, N. (eds) Inequalities in health. Penguin Books.
  9. Blume, M., Rattay, P., Hoffmann, S., Spallek, J., Sander, L., Herr, R., Richter, M., Moor, I., Dragano, N., Pischke, C., Iashchenko, I., Hövener, C., & Wachtler, B. (2021). Health inequalities in children and adolescents: A scoping review of the mediating and moderating effects of family characteristics. International Journal of Environmental Research and Public Health, 18(15), 1–33. https://doi.org/10.3390/ijerph18157739
  10. Booker, C. L., Rieger, G., & Unger, J. B. (2017). Sexual orientation health inequality: Evidence from Understanding Society, the UK Longitudinal Household Study. Preventive Medicine, 101, 126–132. https://doi.org/10.1016/j.ypmed.2017.06.010
  11. Bourdieu, Ρ. (2018). Social Space and the Genesis of Appropriated Physical Space. International Journal of Urban and Regional Research, 42(1), 106–114. https://doi.org/doi.org/10.1111/1468-2427.12534.
  12. Bowen, F. R. (2023). Education is a Social Determinant of Health: School Nurses Level the Playing Field. Journal of School Nursing, 39(5), 343–344. https://doi.org/10.1177/10598405231191283
  13. Brachman, P. (1996). Epidemiology. In: Baron S, (ed).Medical Microbiology. 4th edition. University of Texas Medical Branch at Galveston.
  14. Braveman P, Krieger N, L. J. (2000). Health inequalities and social inequalities in health. Bulletin of the World Health Organization, 78, 232–234.
  15. Brocklehurst, R., & Costello, J. (2003). Health Inequalities: the Black Report and Beyond. In: Public Health and Society. Palgrave, London. https://doi.org/10.1007/978-1-4039-3744-5_3
  16. Buckingham, A. (1999). Is there an underclass in Britain? British Journal of Sociology, 50(1), 1–173. https://doi.org/10.1111/j.1468-4446.1999.00049.x
  17. Clarke, B., Ghiara, V., & Russo, F. (2019). Time to care: Why the humanities and the social sciences belong in the science of health. BMJ Open, 9(8), 1–4. https://doi.org/10.1136/bmjopen-2019-030286
  18. Crimmins, E., Kim, J. K. I., & Vasunilashorn, S. (2010). POPULATION HEALTH AND MORTALITY: Theoretical Incorporation of Biological Information. Health (San Francisco), 47, 41–64.
  19. Crimmins, E. M., Shim, H., Zhang, Y. S., & Kim, J. K. (2019). Differences between men and women in mortality and the health dimensions of the morbidity process. Clinical Chemistry, 65(1), 135–145. https://doi.org/10.1373/clinchem.2018.288332
  20. CSDH. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the commission on social determinants of health (CSDH).
  21. Dei, V., & Sebastian, M. S. (2018). Is healthcare really equal for all? Assessing the horizontal and vertical equity in healthcare utilisation among older Ghanaians. International Journal for Equity in Health, 17(1). https://doi.org/10.1186/s12939-018-0791-3
  22. Evans, T., & Peters, F. (2001). Ethical dimensions of health equity. In E. T. Et & Al. (Eds.), Challenging inequities in health: from ethics to action. New York, Oxford Press., University.
  23. Evans, R. G. (1974). Supplier Induced Demand: Some Empirical Evidence and Implications. In M. Percman (Ed.), The Economics of Health and Medical Care. London: Mc Millan.
  24. Fiorillo, D., & Sabatini, F. (2015). Structural social capital and health in Italy. Economics and Human Biology, 17, 129–142. https://doi.org/10.1016/j.ehb.2015.02.004
  25. Ford, J., Sowden, S., Olivera, J., Bambra, C., Gimson, A., Aldridge, R., & Brayne, C. (2021). Transforming health systems to reduce health inequalities. Future Healthcare Journal, 8(2), e204–e209. https://doi.org/10.7861/fhj.2021-0018
  26. Frohlich, K. L., & Potvin, L. (2008). Transcending the known in public health practice: The inequality paradox: The population approach and vulnerable populations. American Journal of Public Health, 98(2), 216–221. https://doi.org/10.2105/AJPH.2007.114777
  27. Graham, H. (2004). Social determinants and their unequal distribution: Clarifying policy understandings. Milbank Quarterly, 82(1), 101–124. https://doi.org/10.1111/j.0887-378X.2004.00303.x
  28. Hasty, J., Lewis, D. G., & Snipes, M. M. (2022). Introduction to Anthropology. https://openstax.org/details/books/introduction-anthropology?Book details
  29. Hoeeg, D., Christensen, U., Grabowski, D. (2020). Intrafamilial health polarisation: How diverse heath concerns be-come barriers to health behaviour change in families with preschool children and emerging obesity. Sociology of Health and Illness, 42, 1243–1258.
  30. Idler, E., Blevins, J., Kiser, M., & Hogue, C. (2017). Religion, a social determinant of mortality? A 10-year follow-up of the Health and Retirement Study. PLoS ONE, 12(12), 1–15. https://doi.org/10.1371/journal.pone.0189134
  31. Islam, M. M. (2019). Social determinants of health and related inequalities: Confusion and implications. Frontiers in Public Health, 7(FEB), 11–14. https://doi.org/10.3389/fpubh.2019.00011
  32. Jatta, S., Ian, B. S., & Robert, M. (2022). Inequalities in recovery or methodological artefact? A comparison of models across physical and mental health functioning. SSM - Population Health, 17. https://doi.org/10.1016/j.ssmph.2022.101067
  33. Jayasinghe, S. (2015). Social determinants of health inequalities: Towards a theoretical perspective using systems science. International Journal for Equity in Health, 14(1), 1–8. https://doi.org/10.1186/s12939-015-0205-8
  34. Jeanniere, A. (2008). Plato.
  35. Joe, W., Rudra, S., & Subramanian, S. V. (2015). Horizontal inequity in elderly health care utilization: Evidence from India. Journal of Korean Medical Science, 30, S155–S166. https://doi.org/10.3346/jkms.2015.30.S2.S155
  36. Kawachi, I., Subramanian, S. V., & Almeida-Filho, N. (2002). A glossary for health inequalities. Journal of Epidemiology and Community Health, 56(9), 647–652. https://doi.org/10.1136/jech.56.9.647
  37. Keenan, K., Kulu, H., & Cox, F. (2022). Editorial introduction: Social and spatial inequalities in health and mortality: The analysis of longitudinal register data from selected European countries. Population, Space and Place, 28(3), 1–10. https://doi.org/10.1002/psp.2411
  38. Krishnamoorthy, Y. (Ed.). (2024). Health Inequality - A Comprehensive Exploration. IntechOpen.
  39. Lago, S., Cantarero, D., Rivera, B., Pascual, M., Blázquez-Fernández, C., Casal, B., & Reyes, F. (2018). Socioeconomic status, health inequalities and non-communicable diseases: a systematic review. Journal of Public Health (Germany), 26(1). https://doi.org/10.1007/s10389-017-0850-z
  40. Lewis, Ο. (1966). The culture of poverty. Scientific American, 215(4), 19–25. https://doi.org/10.1080/15595692.2020.1733960
  41. Lypourlis, D. (2007). Politics III, IV Volume II (Tzioka Evangelou, P. Trans.). Zitros.
  42. Mackenbach, J.P., Meerding, W.J., & Kunst, & A.E. (2011). Economic Costs of Health Inequalities in the European Union. Economic Costs of Health Inequalities in the European Union., 65(5), 412–419.
  43. Malmusi, D. (2015). Immigrants’ health and health inequality by type of integration policies in European countries. European Journal of Public Health, 25(2), 293–299. https://doi.org/10.1093/eurpub/cku156
  44. Manti, P., Tselepi, H. (2000). Sociological and Psychological Approach to Hospitals and Health Services (Social and Cultural Aspects of Health and Illness) Volume A (in Greek). Hellenic Open University, Patra, Greece.
  45. Marmot, M., Allen, J., Boyce, T., Goldplatt, S. Morrison, J. (2020). Health equity in England: the Marmot review 10 years on. The Health Foundation. 368. https://www.health.org.uk/sites/default/files/upload/publications/2020/Health Equity in England_The Marmot Review 10 Years On_full report.pdf
  46. Marmot, M., Allen, J., Goldblatt, P., Boyce, T., Di McNeish, M., Grady, I. G. (2010). Fair Society Healthy Lives. The Marmot Review. Strategic review of health inequalities in England/post-2010. e Local Government Association. https://doi.org/10.7748/ns2010.10.25.6.30.p4603
  47. Matthews, D. (2015). PART 2 of 5: SOCIOLOGY IN NURSING. Social class and its influence on health. Nursing Times, 111(42), 20–21.
  48. McCartney, G., Collins, C., Mackenzie, M. (2013). What (or who) causes health inequalities: theories, evidence and implications? Health Policy, 113(3), 221–227. https://doi.org/doi: 10.1016/j.healthpol.2013.05.021.
  49. McCartney, G. et al. (2019). Defining health and health inequalities. Public Health, 172, 22–30. https://doi.org/10.1016/j.puhe.2019.03.023
  50. McCartney, G., Collins, C., & Mackenzie, M. (2013). What (or who) causes health inequalities: Theories, evidence and implications? Health Policy, 113(3), 221–227. https://doi.org/10.1016/j.healthpol.2013.05.021
  51. McKeown, T. (1979). The Role of Medicine: Dream, Mirage or Nemesis? Basil Blackwell.
  52. McKinlay, J. B. (1975). A Case for Refocussing Upstream—The Political Economy of Illness. In Applying Behavioral Science to Cardiovascular Risk, (A.J. Enelow and J.B. Henderson (Ed.)). American Heart Association.
  53. Mooney, G. (2000). Vertical equity in health care resource allocation. Health Care Analysis, 8(3), 203–215. https://doi.org/10.1023/A:1009439917796
  54. Mostafavi, F., Piroozi, B., Mosquera, P., Majdzadeh, R., & Moradi, G. (2020). Assessing horizontal equity in health care utilization in Iran: A decomposition analysis. BMC Public Health, 20(1), 1–9. https://doi.org/10.1186/s12889-020-09071-z
  55. Navarro, V., Muntaner, C., Borrell, C., Benach, J., Quiroga, Á., Rodríguez-Sanz, M., Vergés, N., & Pasarín, M. I. (2006). Politics and health outcomes. Lancet, 368(9540), 1033–1037. https://doi.org/10.1016/S0140-6736(06)69341-0
  56. Nielsen, S., & Lubman, D. I. (2022). Time to address addiction treatment inequality in hospital settings. The Lancet Public Health, 7(1), e6–e7. https://doi.org/10.1016/S2468-2667(21)00260-7
  57. O’Donnell O, van Doorslaer E, Wagstaff A, L. M. (2008). Analysing health equity using household survey data: a guide to techniques and their implementation. In Southern Medical Journal (Vol. 72, Issue 5). The World Bank. https://doi.org/10.1097/00007611-197905000-00031
  58. Oliver A Cookson R. (2000). Towards Multidisciplinary Research. Health Economics, 9(7), 565–566.
  59. Oncini, F. (2020). Cuisine, health and table manners: food boundaries and forms of distinction among primary school children. Sociology, 54(3), 626– 642.
  60. Outka, G. (1975). Social justice and equal access to health care. Perspectives in Biology and Medicine, 18(2), 185–202. https://doi.org/10.1353/pbm.1975.0008
  61. Popay, J., Whitehead, M., Ponsford, R., Egan, M., & Mead, R. (2021). Power, control, communities and health inequalities I: Theories, concepts and analytical frameworks. Health Promotion International, 36(5), 1253–1263. https://doi.org/10.1093/heapro/daaa133
  62. Reid S. (2019). The rural determinants of health: using critical realism as a theoretical framework. Rural Remote Health, 19(3), 5184. https://doi.org/doi: 10.22605/RRH5184.
  63. Rolfe, S., Garnham, L., Godwin, J., Anderson, I., Seaman, P., & Donaldson, C. (2020). Housing as a social determinant of health and wellbeing: Developing an empirically-informed realist theoretical framework. BMC Public Health, 20(1), 1–19. https://doi.org/10.1186/s12889-020-09224-0
  64. Rose, G. (1985). Sick Individuals and Sick Populations. International Journal of Epidemiology, 14, 32–38.
  65. Rudolph, L., Caplan, J., Ben-Moshe, K., & Dillon, L. (2013). Health in all Policies. A Guide for State and Local Governments.
  66. Ruger, J. P. (2004). Ethics of the social determinants of health. Lancet, 364(9439), 1092–1097. https://doi.org/10.1016/S0140-6736(04)17067-0
  67. Schenkman, S., & Bousquat, A. (2021). From income inequality to social inequity: impact on health levels in an international efficiency comparison panel. BMC Public Health, 21(1), 1–17. https://doi.org/10.1186/s12889-021-10395-7
  68. Scholz, N. (2020). Addressing health inequalities in the European Union : concepts, action, state of play : in-depth analysis (Issue February). https://doi.org/10.2861/567478
  69. Shi, Z., & Wu, C. (2020). Early life adversity and health inequality: a dual interaction model. Journal of Chinese Sociology, 7(1). https://doi.org/10.1186/s40711-020-00121-y
  70. Siegrist, J. (2020). Health inequalities: The role of work and employment. European Journal of Public Health, 30(4), 620. https://doi.org/10.1093/eurpub/ckaa006
  71. Singata, M., Tranmer, J., & Gyte, G. M. L. (2014). Europe PMC Funders Group. 11, 1–59. https://doi.org/10.1002/14651858.CD003930.pub2.Restricting
  72. Solar O. Irwin A. A. (2010). Conceptual Framework for Action on the Social Determinants of Health. Social Determinants of Health Discussion Paper 2 (Policy and Practice). (2010).
  73. Stringhini, S., Carmeli, C., Jokela, M., Avendaño, M., Muennig, P., Guida, F., Ricceri, F., D’Errico, A., Barros, H., Bochud, M., Chadeau-Hyam, M., Clavel-Chapelon, F., Costa, G., Delpierre, C., Fraga, S., Goldberg, M., Giles, G. G., Krogh, V., Kelly-Irving, M., … Tumino, R. (2017). Socioeconomic status and the 25 × 25 risk factors as determinants of premature mortality: a multicohort study and meta-analysis of 1·7 million men and women. The Lancet, 389(10075), 1229–1237. https://doi.org/10.1016/S0140-6736(16)32380-7
  74. Sturgeon, S. (2007). Normative Judgement. Philosophical Perspectives, 21, 569–587. https://www.jstor.org/stable/
  75. Sundmacher, L., Scheller-Kreinsen, D., & Busse, R. (2011). The wider determinants of inequalities in health: A decomposition analysis. International Journal for Equity in Health, 10(1), 30. https://doi.org/10.1186/1475-9276-10-30
  76. Sutton, M. (2002). Vertical and horizontal aspects of socio-economic inequity in general practitioner contacts in Scotland. Health Economics, 11(6), 537–549.
  77. Thomson, L. J., Gordon-Nesbitt, R., Elsden, E., & Chatterjee, H. J. (2021). The role of cultural, community and natural assets in addressing societal and structural health inequalities in the UK: future research priorities. International Journal for Equity in Health, 20(1), 1–15. https://doi.org/10.1186/s12939-021-01590-4
  78. United Nations. (2015). Transforming our world: the 2030 Agenda for Sustainable Development. https://documents-dds-ny.un.org/doc/UNDOC/GEN/N15/291/89/PDF/N1529189.pdf?OpenElement
  79. United Nations. (2019). World Population Prospects 2019: Highlights (ST/ESA/SER.A/423). https://population.un.org/wpp/Publications/Files/WPP2019_Highlights.pdf
  80. Van Bergen, A. P. L., Wolf, J. R. L. M., Badou, M., De Wilde-Schutten, K., IJzelenberg, W., Schreurs, H., Carlier, B., Hoff, S. J. M., & Van Hemert, A. M. (2019). The association between social exclusion or inclusion and health in EU and OECD countries: A systematic review. European Journal of Public Health, 29(3), 575–582. https://doi.org/10.1093/eurpub/cky143
  81. Van Le, T., Vu, T. T. M., Mai, H. T., Nguyen, L. H., Truong, N. T., Hoang, C. L., Nguyen, S. H., Nguyen, C. T., Nguyen, B. C., Tran, T. H., Tran, B. X., Latkin, C. A., Ho, C. S. H., & Ho, R. C. M. (2019). Social determinants of stigma and discrimination in vietnamese patients with chronic hepatitis B. International Journal of Environmental Research and Public Health, 16(3). https://doi.org/10.3390/ijerph16030398
  82. Wang, J., & Geng, L. (2019). Effects of socioeconomic status on physical and psychological health: Lifestyle as a mediator. International Journal of Environmental Research and Public Health, 16(2). https://doi.org/10.3390/ijerph16020281
  83. Whitehead, M. (1992). The concepts and principles of equity and health. International Journal of Health Services, 22(3), 429–445. https://doi.org/10.2190/986L-LHQ6-2VTE-YRRN
  84. WHO. (1946). Constitution of the World Health Organization. https://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf
  85. WHO. (2003). Social determinants of health: the solid facts. 2nd edition. https://apps.who.int/iris/bitstream/handle/10665/326568/9789289013710-eng.pdf?sequence=1&isAllowed=y
  86. WHO. (2007). Concepts and principles for tackling social inequities in health: Levelling up Part 2. WHO Regional Office for Europe.
  87. WHO. (2009). Sixty-second World Health Assembly. In 2009 (Issues 18-22 May). http://apps.who.int/gb/ebwha/pdf_files/WHA62-REC1/WHA62_REC1-en.pdf
  88. WHO. (2011). Rio Political Declaration on Social Determinants of Health. http://www.who.int/sdhconference/declaration/Rio_political_declaration.pdf
  89. WHO. (2013a). Arguing for Universal Health Coverage. https://apps.who.int/iris/bitstream/handle/10665/204355/9789241506342_eng.pdf?sequence=1&isAllowed=y
  90. WHO. (2013b). Health 2020 A European policy framework and strategy for the 21st century. https://www.drugsandalcohol.ie/20480/1/Health2020-Long.pdf
  91. WHO. (2014). What you need to know about Health in All Policies. https://cdn.who.int/media/docs/default-source/mca-documents/rmncah/health-in-all-policies-key-messages-en.pdf?sfvrsn=a4982d1_
  92. WHO. (2016). Social protection, income and health inequities. Final report of the Task Group on GDP, Taxes, Income and Welfare Review of social determinants of health and the health divide in the WHO European Region. http://www.euro.who.int/pubrequest
  93. WHO. (2021). It’s time to build a fairer, healthier world for everyone, everywhere. https://cdn.who.int/media/docs/default-source/world-health-day-2021/health-equity-and-its-determinants.pdf?sfvrsn=6c36f0a5_1&download=true