9 General introduction From a biomedical perspective to a focus on the social determinants of health A wealth of research has indicated that our health and opportunities are not solely determined by our genetic, biological or medical characteristics, but rather depend on the direct and indirect impacts of social, economic, cultural and environmental conditions. These conditions in which people are born, grow, live, work, and age are called the Social Determinants of Health (SDOH) (26). Several studies have also proved the importance of (clustered) SDOH for outcomes during pregnancy or childbirth, being focused on factors such as area deprivation or socio-economic status with underlying concepts such as income, occupation and education (27-37). The SDOH framework provides an overview of the structural elements that shape the SDOH, their interrelatedness and the mechanisms by which social determinants generate health inequities (26). Although the medical sector also faces the consequences of unfavourable SDOH, many of the underlying elements and possible solutions fall outside their scope, posing a challenge to reduce health inequities within the medical sector alone (8). The SDOH can have an impact at various stages of our lives: during the first thousand days, childhood, adolescence and adulthood. According to models of life course health development, our health development is a dynamic, complex and non-linear process that results from different exposures over the life course (7, 38, 39). Both negative (e.g. food or housing insecurity) and positive (e.g. positive school environment) contexts and experiences can lead to different health trajectories (8, 38). The life course theory emphasizes that health differences mainly result from exposures during critical periods in early development, which subsequently accumulate throughout the course of one’s life. The National Academies of Sciences, Engineering, and Medicine (NASEM) used the above insights in their report ‘Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity’ (8). Their conceptual model shows various elements that shape children’s health and development during the life course, from conception into adulthood (Figure 1). The development and health of children is presented in the inner purple circle. In the direct environment of children are the factors that directly influence their daily experiences and patterns, such as family cohesion, caregiver well-being and nurturing (dark pink circle). These factors are shaped by the SDOH (pink circle). These SDOH, in turn, are influenced by the outer level: the socioeconomic and political drivers such as policies and laws that distribute resources and opportunities among the population (grey circle). The distribution of resources and opportunities is often disproportionate, based on characteristics such as race, gender or social class. The model provides opportunities for interventions to enhance individual and population health, as well as health equity, from micro to macro levels. Moreover, the model provides a powerful call for practice and policy to prioritize investments in improving preconception and perinatal health, since early life experiences can shape health and well-being across an entire lifetime for parents themselves, but these risks and protective factors can also be transmitted to their children. As these children grow into adulthood and potentially become parents themselves, this can lead to new cycles of inequity or resilience. Because of the intergenerational aspect, 1
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