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Despite the fact that some disease-processes are linked to unmodifiable causes (e.g., biological sex, genetic or inheritable aspects), the health status of individuals and populations is highly dependent on the social, economic and psychosocial environments, the conditions in which people were born, and the experiences over their life-course. These factors are labeled as the social determinants of health (SDOH) or the "causes of the "causes" 1. sdoh include individual factors such as education, place of residence, employment status, income or housing, and aggregated factors such as access to transportation, quality of the health care system, public safety, social cohesion and support, and national and international trade policies 1,2, which shape, directly and indirectly, the health outcomes and trajectories of individuals. These socioeconomic conditions at individual, neighborhoods, country and global level account for many systematic health (morbidity and mortality) disparities between and within population groups that are unfair and evitable (known as health inequities). The inequalities and injustices due to social conditions are even more pressing and damaging among economically and socially excluded groups, such as poor individuals, of those people experiencing homelessness, substance use disorders, incarceration, and sex workers 3.
Colombia, with around 50 million inhabitants, is among the countries in the Americas region and the world with the biggest gap between individuals and/or population groups seated at the top (wealthier individuals) and those placed on the bottom of the social and wealth ladder 4. This situation reflects the disparities and inequalities in the Colombian context, which involves not only the economic dimension but also other life dimensions such as educational, social participation, and access to physical and natural resources 5. The country has also experienced significant socio-de-mographic and epidemiological changes in the last decades. Firstly, there is the demographic transition, with a decrease of the fertility rate from four children in 1980 to less than two children in 2017, and a rise of life expectancy from 65 to 75 years in the last 35 years 6, which has resulted in rapid ageing of the population.
Secondly, Colombia is also experiencing a rapid urbanization process, where the population living in an urban area increased from 56.6% in 1970 to 80.78% in 2018 7. People are increasingly moving to the already overcrowded urbes, such as Bogotá or the main cities of the Colombian Departments, looking for employment and educational opportunities. Thirdly, the country has been convulsed over the last decades by drug wars, the guerrillas, paramilitaries, and bad governance, which resulted in massive murders and disappearances, forcing over seven million Colombian persons to become internally displaced 8-10. The above factors have contributed to exacerbating the socioeconomic gap in Colombia, which in turn reflects disparities and inequities in health across and within social groups and Colombian departments.
We observed some increasing efforts to address the social determinants of Health in Colombia such as the "Plan Decenal de Salud Pública, 2012-2021", "Plan Nacional de Salud Rural", and the creation of the Observatory for Measuring Health Inequalities and Equity Analysis (Observatorio para Medición de Desigualdades y Análisis de Equidad en Salud, odes Colombia). Yet, there is a need to join multi-sector, multilevel, and long-term efforts and commitments to address the unmet social and health need of Colombian people to enhance a healthier, sustainable and peaceful Colombian society. Academics and researchers have also been taken some steps in building evidence on the socioeconomic realities and its effects on the health of different population groups in the Colombian context, while other authors have discussed the potential policy frameworks that could help to address the health inequalities derived from the social inequalities in Colombia 11.
However, limited evidence and studies have been conducted to both build facts on the effects of the socioeconomic, physiological and psychosocial circumstances on different health statuses of Colombian individuals and population groups, as well as on the evaluation of the policies and actions implemented to address both health and social inequalities at different levels. For example, in December 2019, we searched for published evidence in PubMed using the "Social Determinants of Health" [Mesh] AND "Colombia" [Mesh] for the last 10 years. Only 24 hits were found, and of these only 12 articles were directly related to health outcomes (mainly regarding children's health such as mortality, birthweight, and growth) or health equity-related policies or initiative considering the SDOH 11,12. Other studies published and indexed outside main academic health search engines showed some advances in assessing the health disparities and inequities in Colombian context 13, but there is also a paucity of these types of studies in the last five years. Thus, more efforts and research and policy agenda are needed to raise the evidence (facts) and debate regarding SDOH and associated health inequalities and inequities in Colombia; and to build a consensus across academic and researchers, health services providers, and decision-makers to address these issues.
Why investigating and addressing social determinants of health is so crucial for Colombia?
The first importance of investigating and addressing SDOH is for improving health and reducing health disparities in Colombia. Previous research has demonstrated that social conditions are the main drivers of illnesses and population health outcomes 2. While biological and genetic factors predisposed individuals or populations, social determinants such as risky behaviors (overdrinking and smoking, diet, exercise), which are often rooted in social and economic disadvantages or more structural social determinants, are primarily associated with the onset of an illness, accident, chronic disease or other poor health outcomes. The social determinants are factors that reinforce, precipitate, and perpetuate health risks and adverse health outcomes. Thus, addressing SDOH will improve health outcomes at the country and individual levels; particularly among population groups living in the most disadvantaged conditions 14.
Secondly, addressing the social determinants of health is about promoting healthy environments/ cities in Colombia. Living in a healthy and safe environment, which allows individuals and people to perform all the functions of life and developing to their maximum potential, is a concern for everyone, particularly, every Colombian citizen. Research and debate on SDOH in Colombia should go further than identifying the social determinants, but to understand how to promote a healthy environment, while addressing health inequalities among individuals, population groups, and geographical areas such as between urban and rural settings as well as between Colombian states (departmentos). Such debate needs to incorporate health considerations into decision making across sectors and policy areas.
Thirdly, tackling the determinants of health is a foundational investment in one of the most important of human capital and well-being of the Colombian population, such as health. There is a large body of evidence showing that health and education are two of the main pillars for a country to be competitive in the global economy. A healthy (and educated) population will be skilled and able to perform high quality, creative, and productive work over a long lifetime, and to reach their fullest potential. Hence, removing social barriers to access to high-quality health care services, and since early life through the overall life course, would set a strong foundation for sustained and inclusive economic growth in Colombia.
Finally, addressing the SDOH is a fulfillment of the right of every Colombian. Since 1946, the World Health Organization constitution includes "...the highest attainable standard of health as a fundamental right of every human being" 15; and so, for every Colombian citizen, regardless of their age, gender or sexual orientation, race, or social position or class. It is fundamental to understand the social barriers limit mainly marginalized and disadvantaged people from enjoying a healthy life. These populations are not only the most exposed to hazard risks and unhealthy environments, they also face more obstacles to accessing health care, socioeconomic opportunities (e.g., employment, education, housings, access to natural resources and land) and be active participants in building their own social and economic well-being, as well as that of their local communities. Thus, investigating and addressing the social conditions and the derived social and health disparities and inequities in Colombia is warranted.
What needs to be done?
Evidence-based research is a central element to inform actions needed and to lead policy decisions 16 to address the social determinants of health in Colombia. These determinants continually evolve over time and place and are affected by several factors such as new legislation, national budgetary policy decisions, population age structure, cultural factors and new lifestyles, migration, global market, climate change and so on. New causes of diseases or disease severity are also evolving.
Evidence-based research to capture these changes and update and create new knowledge is crucial. While we acknowledge health research capacity is on the rise in Colombia in the last two decades, as in some few other countries in Latin America (e.g., Argentina, Brazil, Chile, and Peru) 17, research infrastructure, human capacity, and research funding remain very diverse and challenging in Colombia.
There is also the need to diversify health research by extending the areas of study or interest, the targeted populations, the usage health administrative health data, the usage of different biomarkers including genetics and epigenetics data, the utilization new analytical techniques, implementations of social research interventions, and develop research collaborations across and within universities and research centers, at national and international level.
Bridging research and health policy
There is a need to engage in a meaningful debate, a real dialogue including researchers, experts, clinicians and health professionals, health authorities and other decision-makers around social and health concerns and potential solutions 16,18 in the Colombian context. Such dialogue should also integrate community organizations and leaders, local government and parliament representatives to create public awareness and engagement, which can generate local actions to better address the health disparities and inequities based on local and international evidence. Establishing and developing knowledge translation networks are deemed necessary, firstly to put social determinants and health inequalities on social and public agenda; secondly, to keep evaluating the impact of interventions, programs and policies on health.
Integrating SDoH in the daily practice and service provision
Social determinants as the leading causes of health risks and diseases should, therefore, be included in the daily clinical practice and social services delivery 19,20. First, SDOH should be made a core study area across the Colombian educational system, beginning from primary school to university studies. It should be specifically included in the health and allies' health professional curriculums, to move from a dominated biomedical model to a more comprehensive model, where structural factors and those of socioeconomic origins are recognized, assessed, managed, and addressed when preventing diseases, and promoting and caring for the health of individuals and population groups. Furthermore, team-based health and inter-professional communication approach will help to treat and manage individuals affected by the SDOH and provide them with a more multidisciplinary and multisector care plan and rehabilitation. Also, the systematic screening and collection of information regarding the social conditions at individual, local and structural levels to which individual and population groups are exposed over the different life course phases (prenatal, pregnancy, childhood, adolescence, young and late adulthood) 21, will inform appropriate caring plans and services, but as well evidence-based policy and interventions. Finally, engage with the local communities and individuals in identifying their pressing and unmet health and social needs, as well as in developing and planning the healthcare plans and solutions, not only will this enhance their self-care, but will also bring efforts to increase the social inclusion and health for all, without discrimination or socioeconomic, gender, race, or geographical distinctions. Since having better health, well-being and social opportunities is a right for all Colombian inhabitants, and, therefore, a commitment to the health, social, economic, and policy-related professionals and policymakers.
Knowledge translation (KT) 16 is a fundamental means for acting on and communicating facts regarding SDOH and the potential interventions, policies, instruments and guidelines that can be applied in the Colombian context to tackle the health disparities and inequities. The KT process should not only be aimed to target academic audience, but also it should include the public and communities who are those directly affected by the SDOH. When translating knowledge, it is also essential to speak the communities and policies language to be sure the critical message is passed and understood, and, therefore, put into practice.
In summary, putting the social determinants of health in the educational, health care, socioeconomic, research, and policy agendas in the Colombian context is necessary to reduce the health disparities and inequalities between and within pupation groups and to enhance much more cohesive, productive, and healthier current and future Colombians generations.
