Editorial
Social determinants of health and their impact on internal medicine
Determinantes sociales de la salud y su impacto en la medicina interna
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Montserrat Chimeno Viñas, P. Pérez-Martínez" "autores" => array:2 [ 0 => array:3 [ "nombre" => "M. Montserrat" "apellidos" => "Chimeno Viñas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "P." "apellidos" => "Pérez-Martínez" "email" => array:1 [ 0 => "pabloperez@uco.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Complejo Asistencial de Zamora, Zamora, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Determinantes sociales de la salud y su impacto en la medicina interna" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The World Health Organization (WHO) defines the social determinants of health as “the conditions in which people are born, grow, work, live, and age”. Therefore, the concept of “health inequalities” refers to the impact of factors such as wealth, education, occupation, racial or ethnic group, urban or rural residence, and social conditions from the place where one lives or works on the distribution of health and disease in the population.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The different health-related opportunities and resources that people have according to their social class, sex, neighborhood, or ethnicity, among other factors, determine a person’s level of health.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In recent years, it has been shown that these social determinants play an important role in the possible development of chronic noncommunicable diseases by increasing morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These determinants include, among others, economic stability, neighborhood safety, working conditions, environmental hazards (such as air pollution or noise), level of education, and access to quality health care. A good example of this is cardiovascular diseases, the leading cause of death in Spain. A lower socioeconomic status or having a precarious job is a predictor of greater risk of cardiovascular disease and, along the same lines, recent evidence suggests that having a lower education level is associated with greater inequality in overall cardiovascular mortality in Spain, especially in mortality due to ischemic heart disease and heart failure in young women.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In addition, the structural/socioeconomic, environmental, and psychosocial factors that are most associated with cardiovascular diseases as well as the biological mechanisms that contribute to disease pathogenesis—such as inflammation, impaired immune function, and cellular aging—have been defined.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">An interesting point for consideration is the impact of the social determinants of health on sick individuals attended by internal medicine specialists. Our specialty entails comprehensive, continuous care and, from this point of view, whatever may happen to the patient is not outside the scope of our activity. This encompasses the implementation of prevention and health promotion measures, the diagnosis and treatment of disease, as well as the psychosocial aspects of their environment in order to improve individuals’ quality of life. At present, aging and the increase in survival has clearly conditioned not only the chronicity of diseases but also their multimorbidity and progressive complexity. Internists do not simply treat diseases in an isolated manner, rather they approach the disease from the individual’s perspective, both in an inpatient and outpatient setting. From this comprehensive care approach, the social determinants presented by each of the diseases individually are manifested in a more intense and complicated way in these patients and entail exponentially increased difficulty.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Returning to the previous example, a person who only has cardiovascular disease is not the same as a person with cardiovascular disease as well as other comorbidities who lives alone and has a low income.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This highly complex example is clearly influenced by social determinants of health. Similar situations are encountered in internists’ day-to-day work and undoubtedly also occur in generalist specialties.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Therefore, each and every one of the social determinants, which directly influence our view of each specific disease, constitute additional factors within the complexity of a pluripathological patient and most of the time have a “cascade” effect rather than acting in isolation. Nevertheless, there are a series of social determinants that stand out significantly in internal medicine patients: socioeconomic status, educational level, and lifestyle habits influenced by the patient’s environment and neighborhood, among others.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Poverty and a low level of education condition the approach to all diseases that internists face on a daily basis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Despite social assistance, there are still many families without resources and they sometimes have no possibility of obtaining them due to a lack of knowledge or lack of initiative and support. Poverty leads to very precarious general living conditions: scarcity or low quality of food, hygiene, treatment access and adherence, etc., in addition to a greater probability of living in less healthy environments, having a precarious job, etc. On top of such a complex scenario as this is the low level of education and health literacy that these people usually have, which hinders initiatives and strategies to improve these conditions.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Population aging has also brought about other pressing problems: lack of family and social support, unwanted loneliness, cognitive impairment, disability, and dependency.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Evidently, higher social classes also have social determinants that condition their health: environments with easy access to alcohol, tobacco, and other types of drugs or an intense social life that leads to excessive calorie consumption and sedentary lifestyles, which predispose them to a greater burden of disease.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There are multiple aspects that can improve health inequalities and are aligned with the goals of the United Nations (UN) 2030 Agenda for Sustainable Development, which pursue equality among people, health and well-being, quality education, protecting the planet, and ensuring prosperity.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> At present, although there are some plans aimed at reducing socioeconomic inequalities in health, there are very few examples of interventions that take them into account, probably due to the scant interest that this problem has sparked among physicians so far. Since the main causes of health disparities lie in the socioeconomic and cultural diversity of population groups, the specialty of internal medicine must lead and implement initiatives that allow for detecting the impact of social determinants in our patients, guaranteeing quality care and a health system without inequities that is sustainable and efficient.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Addressing health inequalities in the European Union – Concepts, action, state of play – In-depth analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "N. 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